Medi-Cal Update

Pharmacy | March 2020 | Bulletin 963

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1. The Medi-Cal Learning Portal Will Soon Be Upgraded

The Medi-Cal Learning Portal (MLP) will soon be upgraded and users will experience a new look, feel and navigational changes. The MLP is hosted using a commercial off-the-shelf software application that automates the administration, tracking and reporting of training events. The MLP publishes training material and curriculum on the internet and manages the training programs for the provider and billing communities.

The functions of the upgraded MLP are easy to navigate, and users will have logical, straight-forward access to much of what they need. The new MLP enables a blended approach to learning, combining classroom delivery, business and technical workshops, virtual classrooms, e-learning and one-on-one mentoring.

The refreshed Medi-Cal Learning Portal page will continue to be accessible from either its original location or from the Outreach & Education page of the Medi-Cal website. There will be no changes to how users will reach the upgraded MLP.

With some of the new or improved features, users will be able to:

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2. Medi-Cal Pharmacy Provider Self-Attestation Period Now Closed

The online attestation portal for fee-for-service Medi-Cal pharmacy providers seeking the higher of two professional dispensing fees as part of the reimbursement changes for covered outpatient drugs closed at 11:59 p.m. on February 29, 2020. No additional attestations will be accepted.

As has been published in previous Medi-Cal Updates, the Department of Health Care Services (DHCS) implemented a new fee-for-service reimbursement methodology for covered outpatient drugs. Part of this methodology is a two-tiered professional dispensing fee based on a pharmacy provider’s total (Medi-Cal and non-Medi-Cal) annual pharmacy claim volume ($13.20 if fewer than 90,000 claims per year; $10.05 if 90,000 or more). Reporting the claim volume is a self-attestation process. The claim volume report will be submitted electronically and must be repeated annually.

Note:

DHCS policy is that a claim is equivalent to a dispensed prescription; therefore, the attestation is for the total dispensed prescription volume.

Only fee-for-service Medi-Cal providers dispensing fewer than 90,000 total prescriptions per calendar year are eligible to receive the higher of the two professional dispensing fees and must complete this attestation in order to receive it.

The attestation period for the 2019 calendar year was open from January 15, 2020, through February 29, 2020. No additional attestations will be accepted. The attestation for the 2019 calendar year reporting period will determine the professional dispensing fee component of the pharmacy claim reimbursement for claims with dates of service within the state’s following fiscal year (dates of service from July 1, 2020, through June 30, 2021).

For additional information, providers can refer to the Pharmacy Provider Self-Attestation FAQs on the Medi-Cal website or the Pharmacy Reimbursement Project page on the DHCS website. For inquiries not covered in either, providers may call the Telephone Service Center at 1-800-541-5555, or (916) 636-1960 if calling outside of California, and select the following options:

  1. Option 1 for English or option 2 for Spanish

  2. Option 1 for Provider

  3. Option 4 for Technical Help Desk

  4. Option 2 for Pharmacy

  5. Option 1 for Provider

  6. Option 1 for NPI – enter NPI followed by the pound (#) sign

  7. Option 2 for Pharmacy

After following the steps above, the caller will be directed to an agent.

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3. Recommencement of Pharmacy Retroactive Claim Adjustments on Pause

The Department of Health Care Services (DHCS) will not resume retroactive adjustments beginning with the February 10, 2020, checkwrite date. Recommencement of pharmacy retroactive claim adjustments will continue to be paused until further notice.

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4. Updates to the List of Contracted Incontinence Absorbent Products

Effective for dates of service on or after April 1, 2020, certain products from Cardinal Health 200, LLC are added to the List of Contracted Incontinence Absorbent Products.

Effective for dates of service on or after August 1, 2020, certain products from Cardinal Health 200, LLC are deleted from the list. The manufacturer no longer guarantees the maximum acquisition cost (MAC) for deleted products.

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5. Electronic SAR Now Supports Attachments

The California Children’s Services (CCS) and Genetically Handicapped Persons Program (GHPP) providers can now submit Service Authorization Requests (SARs) in an electronic format (eSARs) with attachments. Attachments must be in format of PDF, JPG or TIF. Attachments must be less than 15 megabytes (MB) in size, with the sum of all attachments being less than 150 MB. This feature aims to eliminate the paper SAR process for providers with internet connectivity.

To submit eSARs, providers must:

Then, select one of the available options to submit:

  1. Utilize the enhanced online fillable form of the PEDI system to submit eSARs with the attachment

  2. Generate and submit one of the supported file-based transmission formats:
    • Web-based file upload utility in the eSAR system to submit ASC X12 275/278 transactions

    • Simple Object Access Protocol (SOAP)/Hypertext Transfer Protocol Secure (HTTPS) secure web services method to transmit and receive ASC X12 275/278 transactions

Registered providers and clearinghouses can complete and submit the eSAR requests on behalf of the providers and facilities in their network.

Paper SAR submissions remain an option for low-volume SAR providers or submitters who may have technical limitations or practical reasons to do so.

Providers interested in learning more about eSAR submissions should contact the CMS Net Help Desk at cmshelp@dhcs.ca.gov or 1-866-685-8449 for helpful guidance and additional information.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids
Chronic Dialysis Clinics
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Inpatient Service
Local Educational Agency
Obstetrics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
cal child sar (12)
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6. Erroneously Denied Claims for Contraceptive Ring and Patch

The Department of Health Care Services identified claims for HCPCS codes J7303 (contraceptive supply, hormone containing vaginal ring, each) and J7304 (contraceptive supply, hormone containing patch, each) that were erroneously denied with Remittance Advice Details (RAD) code 9942: NCCI (National Correct Coding Initiative) quantity billed greater than allowed MUE (Medically Unlikely Edit) quantity.

An Erroneous Payment Correction (EPC) will be implemented to reprocess claims that were erroneously denied for dates of service on or after January 1, 2019. No action is required of providers.

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7. Retroactive Frequency Limitation Updates for Vestronidase, HCPCS Code J3397

Effective retroactively for dates of service on or after January 15, 2019, HCPCS code J3397, (injection, vestronidase alfa-vjbk, 1 mg) has been updated.

No action is required of providers. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

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8. New Provider Web Page Coming Soon to the New Medi-Cal Provider Website

The Department of Health Care Services (DHCS) will launch a New Provider web page with the upcoming release of its new Medi-Cal Provider website.

This new web page will offer an organized location for critical information, helpful documents and charts, as well as key links that a “new provider” will need to ensure a successful setup and future as a provider within the Medi-Cal program.

The “New Provider” web page will include information on the following critical Medi-Cal subjects:

DHCS projects a spring 2020 launch. It is recommended that providers continually check the current Medi-Cal website for updates. Providers are also encouraged to subscribe to the convenient and free Medi-Cal Subscription Service (MCSS) to ensure they receive the latest policy news and program updates immediately and regularly.

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9. May 2020 Medi-Cal Provider Seminar

The May Medi-Cal provider seminar is scheduled for May 12, 2020, at the Red Lion Hotel in Redding, California. Providers can access a class schedule for the seminar by visiting the Provider Training web page of the Medi-Cal Learning Portal (MLP) and clicking the seminar date(s) they would like to attend. Providers may RSVP by logging in to the MLP.

Throughout the year, the Department of Health Care Services (DHCS) and the California MMIS Fiscal Intermediary conduct Medi-Cal training seminars. These seminars, which target both novice and experienced providers and billing staff, cover the following topics:

Providers must register by April 24, 2020, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After April 24, 2020, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks page of the Medi-Cal website.

Note:

  Wi-Fi will not be provided at the seminar. Please plan accordingly.

Providers that require more in-depth claim and billing information have the option to receive one-on-one claims assistance, which is available at all seminars, in the Claims Assistance Room.

Providers may also schedule a custom billing workshop. To contact the regional representative for your area, providers must first contact the Telephone Service Center (TSC) at 1-800-541-5555 and request to be contacted by a regional representative.

Providers are encouraged to bookmark the Provider Training web page and refer to it often for current seminar information.

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10. Final Reminder: Wound Care Advanced Dressings No Longer Contracted

Effective for dates of service on or after April 1, 2020, the wound care advanced dressings HCPCS billing codes have the following updates:

Providers may refer to the Medical Supplies Billing Codes, Units and Quantity Limits spreadsheet for the specific HCPCS billing code policy.

Reminders:   

A signed and dated prescription written by a physician is required, ordering only those medical supplies necessary for the care of the recipient and as documented in the recipient’s medical record. The number of wounds being treated must also be documented. The prescription must be dated within 12 months of the date of service on the claim. The HCPCS billing code on the claim must be appropriate for the medical supply dispensed.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
mc sup (1)
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11. Medical Supply Billing Codes Are Not Yet Updated to DME Supply Billing Codes

A previously published Medi-Cal Update article titled “Policy for Medical Supply Billing Codes Updated to DME Supply Billing Codes” notified providers that, effective for dates of service on or after February 1, 2020, certain medical supply billing codes are updated to Durable Medical Equipment (DME) supply billing codes, certain DME codes are added and certain medical supply codes policy is changed. The policy from that article will not be implemented at this time, including policy regarding benefit status and billing requirements. All updates that were made to reflect this policy are removed from the Medi-Cal provider manuals. Until further notice, providers should continue to bill the codes in this policy as medical supply codes and should not bill these items as DME supply codes.

HCPCS Code Description
A4230 Infusion set for external insulin pump, non needle cannula type
A4231 Infusion set for external insulin pump, needle type
A4232 Syringe with needle for external insulin pump, sterile, 3 cc
A4483 Moisture exchanger, disposable, for use with invasive mechanical ventilation
A7002 Tubing, used with suction pump, each
A7003 Administration set, with small volume nonfiltered pneumatic nebulizer, disposable
A7004 Small volume nonfiltered pneumatic nebulizer, disposable
A7006 Administration set, with small volume filtered pneumatic nebulizer
A7007 Large volume nebulizer, disposable, unfilled, used with aerosol compressor
A7008 Large volume nebulizer, disposable, prefilled, used with aerosol compressor
A7010 Corrugated tubing, disposable, used with large volume nebulizer, 100 ft
A7012 Water collection device, used with large volume nebulizer
A7013 Filter, disposable, used with aerosol compressor or ultrasonic generator
A7016 Dome and mouthpiece, used with small volume ultrasonic nebulizer
B4035 Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape
S8186 Swivel adaptor

Until further notice, medical supplies HCPCS code A4223 (infusion supplies not used with external infusion pump, per cassette or bag) continues to be reimbursable for infusion supplies with or without an infusion pump. HCPCS code A4222 (infusion supplies for external drug infusion pump, per cassette or bag) is not yet reimbursable as a DME supply.

Until further notice, the following HCPCS codes are not yet reimbursable:

HCPCS Code Description
A4224 Supplies for maintenance of insulin infusion catheter, per week
A4225 Supplies for external insulin infusion pump, syringe type cartridge, sterile, each
E0574 Ultrasonic/electronic aerosol generator with small volume nebulizer

Until further notice, the following medical supplies codes are no longer end-dated and continue to be reimbursable:

HCPCS Code Description
B9998 Extension set for enteral feeding
B9999 Infusion supplies not otherwise classified
S1015 IV tubing extension set

Providers are encouraged to check the Medi-Cal website regularly for updates.

Updated manual pages and the updated Medical Supplies Billing Codes, Units and Quantity Limits spreadsheet reflecting this change will be released in a future Medi-Cal Update.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Chronic Dialysis Clinics
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Medical Transportation
Psychological Services
Rehabilitation Clinics
Vision Care
medi non hcp (1)
Audiology and Hearing Aids medi non hcp (1); tax (6–8, 10, 12, 14)
Durable Medical Equipment dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); dura inf (4, 6); dura oxy (25, 29, 30, 50, 52); mc sup (2, 8); medi non hcp (1); tax (6–8, 10, 12, 14)
General Medicine
Obstetrics
Clinics and Hospitals
medi non hcp (1); presum bill (12)
Orthotics and Prosthetics dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); medi non hcp (1); tax (6–8, 10, 12, 14)
Pharmacy dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); dura inf (4, 6); dura oxy (25, 29, 30, 50, 52); mc sup (2, 8); medi non hcp (1); presum bill (12); tax (6–8, 10, 12, 14)
Therapies dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); medi non hcp (1)
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12. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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