Medi-Cal Update

Pharmacy | May 2020 | Bulletin 967

Print Medi-Cal Update
 

1. Billing Instructions for PE for COVID-19 Program

The Department of Health Care Services (DHCS) implemented Presumptive Eligibility (PE) for the coronavirus disease (COVID-19) on April 8, 2020. PE COVID-19 is available for individuals with no health insurance or who currently have private insurance that does not cover diagnostic testing, testing-related services, and treatment services, including all medically necessary care as a result of COVID-19, do not qualify for any Medi-Cal programs (with the exception of individuals who have not met their Medi-Cal Share of Cost [SOC] obligation), and are a California resident.

Eligibility for COVID-19 will use Aid Code V2 to determine eligibility for these limited benefits. Aid Code V2 is a limited-scope code that will provide access to COVID-19 diagnostic testing, testing-related services, and treatment services, including all medically necessary care for COVID-19 including laboratory services, and the associated office, clinic or emergency room visits, without regard to immigration status, income or resources. It will have date specific eligibility. A Qualified Provider (QP) will enroll the individual on the date of application and their PE eligibility period will end on the last calendar day of the month in which the 60th day falls from the date of their PE application. This program will utilize existing QP(s) in our current PE programs.

Providers must include ICD-10 diagnosis code U07.1 on all claims for reimbursement of COVID-19 medically necessary care for PE individuals in aid code V2. Claims submitted without this diagnosis code, may not be reimbursed. For more information on ICD-10-CM diagnosis code U07.1, please see the March 26, 2020 NewsFlash article.

For billing related questions, providers may contact the Telephone Service Center (TSC) at 1-800-541-5555. The TSC is available 8 a.m. to 5 p.m., Monday through Friday, except holidays. Border providers and out-of-state billers billing for in-state providers should call (916) 636-1200.

Print Article | Return to Top
 

2. Specimen Collection for COVID-19 Now Medi-Cal Benefit

Effective for dates of service on or after March 1, 2020, HCPCS codes G2023 (specimen collect covid-19) and G2024 (spec coll snf/lab covid-19) are now Medi-Cal benefits.

The Centers for Medicare and Medicaid Services established two Level II HCPCS codes G2023 and G2024 for the specimen collection for COVID-19 testing. These codes are billable by clinical diagnostic laboratories.

Print Article | Return to Top
 

3. Presumptive Eligibility for Pregnant Women (PE4PW) Flexibilities Due to COVID-19

Due to the ongoing response to coronavirus disease 2019 (COVID-19), the Department of Health Care Services (DHCS) is approving immediate enrollment flexibilities for Presumptive Eligibility (PE) Providers to limit potential exposure to COVID-19.

Presumptive Eligibility for Pregnant Women (PE4PW)
Qualified Providers can utilize telephonic signatures for PE4PW applications, noting in the case file “COVID-19 protocol.” If the individual is not at the hospital and is not experiencing an urgent prenatal care health event which requires immediate care, providers should suggest the individual to apply online using the Covered California portal to establish ongoing eligibility for Medi-Cal or Covered California. Providers may also obtain an Authorized Representative Form for the PE4PW applicant, which allows an individual to act on behalf of the applicant and provide the required information to assist with the enrollment of the individual in PE4PW, thereby minimizing direct contact with the individual and promoting physical distancing.

Process
In order to accept a telephonic signature, the following procedure must be followed:

Questions concerning PE4PW Flexibilities should be sent to PE@dhcs.ca.gov.

Print Article | Return to Top
 

4. Hospital Presumptive Eligibility (HPE) Flexibilities Due to COVID-19

Due to the ongoing response to coronavirus disease 2019 (COVID-19), the Department of Healthcare Services (DHCS) is approving immediate enrollment flexibilities for Presumptive Eligibility (PE) providers to limit potential exposure to COVID-19.

Hospital Presumptive Eligibility (HPE)
Enrolling Providers can utilize telephonic signatures for HPE Applications, noting in the case file “COVID-19 protocol.” If the individual is not at the hospital and is not experiencing an urgent health event which requires immediate care, providers should suggest the individual to apply online using the Covered California portal to establish ongoing eligibility for Medi-Cal or Covered California. Providers may also obtain an Authorized Representative Form for the HPE applicant, which allows an individual to act on behalf of the applicant and provide the required information to assist with the enrollment of the patient in HPE, thereby minimizing direct contact with the patient and promoting physical distancing.

Process
In order to accept a telephonic signature, the following procedure must be followed:

Questions concerning HPE Flexibilities should be sent to DHCSHospitalPE@dhcs.ca.gov.

Print Article | Return to Top
 

5. Medi-Cal List of Contract Drugs

The following provider manual section(s) have been updated: Drugs: Contract Drugs List Part 1 – Prescription Drugs and Drugs: Contract Drugs List Part 4 – Therapeutic Classifications.

A summary of drugs that have been added or changed are shown below. For additional information, click on the link to the manual section and scroll to the page indicated or use the find feature to search for the particular drug.

Added Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
January 1, 2020 ZANUBRUTINIB Drug added, administration added, restriction added drugs cdl p1d (34)
drugs cdl p4 (9)
May 1, 2020 CYCLOBENZAPRINE Drug added, administration added drugs cdl p1a (51)
drugs cdl p4 (21)
May 1, 2020 DESVENLAFAXINE SUCCINATE Drug added, administration added drugs cdl p1a (59)
drugs cdl p4 (11)
May 1, 2020 DULAGLUTIDE Drug added, administration added, restriction added drugs cdl p1a (69)
drugs cdl p4 (15)
May 1, 2020 METHOCARBAMOL Drug added, administration added drugs cdl p1b (69)
drugs cdl p4 (21)
May 1, 2020 POTASSIUM BICARBONATE/CITRIC ACID Drug added, administration added, restriction added drugs cdl p1c (35)
drugs cdl p4 (16)
May 1, 2020 POTASSIUM CITRATE Drug added, administration added drugs cdl p1c (36)
drugs cdl p4 (16)
May 1, 2020 SODIUM POLYSTYRENE SULFONATE Drug added, administration added drugs cdl p1d (5)
drugs cdl p4 (20)

May 1, 2020

TIZANIDINE HCL

Drug added, administration added

drugs cdl p1d (20)
drugs cdl p4 (21)

Changed Drug(s)

Effective Date Drug Summary of Changes Page(s) Updated
April 1, 2020 MEDROXYPROGESTERONE ACETATE Strength added drugs cdl p1b (65)
May 1, 2020 CITALOPRAM HBR Strength added, suspension removed drugs cdl p1a (45)
drugs cdl p4 (11)
May 1, 2020 FLUOXETINE HCL Strength added drugs cdl p1b (21)
May 1, 2020 POTASSIUM CHLORIDE product added, restriction added drugs cdl p1c (36)
May 1, 2020 SEVELAMER HCL restriction removed drugs cdl p1d (2)
July 1, 2020 MOXIFLOXACIN HCL restriction added, labeler code removed drugs cdl p1b (78)
Print Article | Return to Top
 

6. April 2020 HCPCS Quarterly Update: Policy Updates

Effective for dates of service on or after April 1, 2020, the following HCPCS codes are new Medi-Cal benefits: C9053 (injection, crizanlizumab-tmca, 1mg); C9056 (injection, givosiran, 0.5 mg); C9057 (injection, cetirizine hydrochloride, 1 mg); and C9058 (injection, pegfilgrastim-bmez, biosimilar, [ziextenzo] 0.5 mg).

An approved Treatment Authorization Request (TAR) is required for reimbursement for HCPCS codes C9053 and C9056.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics inject cd list (4, 7, 13); inject drug a-d (33, 37); inject drug e-h (12, 13); modif used (12)
Clinics and Hospitals
General Medicine
Obstetrics
chemo drug p-z; inject cd list (4, 7, 13); inject drug a-d (33, 37); inject drug e-h (12, 13); modif used (12); non ph (12)
Pharmacy inject cd list (4, 7, 13); inject drug a-d (33, 37); inject drug e-h (12, 13)
Rehabilitation Clinics inject cd list (4, 7, 13); inject drug a-d (33, 37); inject drug e-h (12, 13); modif used (12); non ph (12)
Print Article | Return to Top
 

7. Meningococcal Conjugate Vaccine is a Medi-Cal Benefit

Effective retroactively for dates of service on or after July 1, 2019, CPT code 90619 (Meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, tetanus toxoid carrier [MenACWY-TT] for injection into muscle) is a Medi-Cal benefit.

An Erroneous Payment Correction (EPC) will be initiated to reprocess affected claims for CPT code 90619. No action is required of providers.

Print Article | Return to Top
 

8. Non-Wheelchair Accessories and Supplies Included in Rental Rate

The rental reimbursement rate for non-wheelchair DME equipment includes all associated accessories and supplies. Non-wheelchair DME accessories and supplies are reimbursable only when they are billed for equipment owned by the patient using modifier NU (new equipment). Modifiers RB (replacement as part of a repair) and RR (rental) are not allowed. This has been a long-standing Medi-Cal policy, and this information was erroneously removed from the provider manual. Effective June 1, 2020, this information will be added back to the provider manual.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura bil (2, 12, 13)
Print Article | Return to Top
 

9. Policy Update for Back-up Ventilators

Effective for dates of service on or after June 1, 2020, the Treatment Authorization Request (TAR) criteria for codes E0465 (home ventilator, any type, used with invasive interface) E0466 (home ventilator, any type, used with non-invasive interface) is updated as follows.

The use of a back-up (second) ventilator in the home setting is considered medically necessary for the following additional indication, when applicable. This includes patients who require mechanical ventilation during mobility, as prescribed in their plan of care, and who have justification for why the primary ventilator cannot be used during mobility.

Any claims that were denied due to National Correct Coding Initiative (NCCI) Medically Unlikely Edits (MUE) from October 1, 2016 to June 1, 2020 will be reviewed and reprocessed. Providers need take no action. An Erroneous Payment Correction will be issued for claims that were inappropriately denied due to NCCI MUE.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura oxy (53)
Print Article | Return to Top
 

10. Negotiated Prices and Oxygen Modifier Policy Updates

Effective for dates of services on or after June 1, 2020, reimbursement rate negotiations for Durable Medical Equipment (DME) will be discontinued.

Oxygen Modifier Policy

The following oxygen policy changes also are effective for dates of service on or after June 1, 2020:

General information about TAR price negotiating is available in the Part 2 TAR Completion section, page 3.

Modifier Policy
“Q” modifiers (for example, QA, QB, QE, etc.) are billed only with stationary gaseous (HCPCS code E0424) or liquid (E0439) systems or with a non-portable oxygen concentrator (E1390, E1391). If the prescribed liter flow rate is different for stationary versus portable, the flow rate for stationary must be used. If the prescribed liter flow rate is different at rest versus with exercise, the flow rate at rest must be used. If the prescribed flow rate is different for nighttime versus daytime use, the flow rates are averaged. These modifiers are not reimbursable with any other codes.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura (11); dura oxy (44)
Print Article | Return to Top
 

11. 2020 Income Eligibility Guidelines for PE4PW

Effective January 1, 2020 through December 31, 2020, Presumptive Eligibility for Pregnant Women (PE4PW) program providers must use the following income guidelines to make PE4PW determinations. Providers should disregard all previous PE4PW income eligibility guidelines charts.

Federal Poverty Level Chart for PE4PW
Effective January 1, 2020, through December 31, 2020
Number of Persons in Family 213 Percent
Monthly Income
213 Percent
Annual Income
2 $3,061 $36,722
3 $3,856 $46,264
4 $4,651 $55,806
5 $5,446 $65,349
6 $6,241 $74,891
7 $7,037 $84,434
8 $7,832 $93,976
9 $8,627 $103,518
10 $9,422 $113,061
11 $10,217 $122,603
12 $11,013 $132,146
For family units of more than 12 members, for each additional member, add: $796 $9,543

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
presum (4)
Print Article | Return to Top
 

12. Second Update to NCCI Quarterly Update for January 2020

On February 25, 2020, Centers for Medicare and Medicaid Services (CMS) updated payment policy as part of the National Correct Coding Initiative (NCCI) Quarterly Updates for January. The updated payment policy is effective January 1, 2020.

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

Print Article | Return to Top
 

13. July 2020 Medi-Cal Provider Seminar

The July Medi-Cal provider seminar is scheduled for July 29 – 30, 2020, at the California Center for the Arts in Escondido, 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 July 10, 2020, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After July 10, 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.

Print Article | Return to Top
 

14. Off-label and Investigational Drugs to Treat COVID-19

On March 23, 2020, the Department of Health Care Services (DHCS) received approval of a federal waiver allowing specific flexibilities in response to the COVID-19 public health emergency. Further, on March 28, 2020, the Food and Drug Administration (FDA) issued guidance specific to the use of Chloroquine Phosphate and Hydroxychloroquine Sulfate. As a result, on April 3, 2020, DHCS issued updated guidance relative to temporary flexibilities in dispensing/administration policies governing off-label and investigational use of medications used to treat COVID-19 under the Medi-Cal fee-for-service pharmacy benefit. The policy document is published on the COVID-19 webpage titled: Off-label and/or Investigational Drugs Used to Treat COVID 19 and/or Related Conditions. The policy is temporary and remains in effect until further notice.

Print Article | Return to Top
 

15. Medi-Cal Subscription Service Upgrade Coming Soon

The Medi-Cal Subscription Service (MCSS) portal will soon be upgraded with new features added. The new functionality will support increased collaboration between the Medi-Cal Program and Medi-Cal providers and stakeholders. This will allow DHCS to provide the most relevant information to providers electronically and allow providers to engage with the program through discussion groups and multiple communication channels.

Subscribers will continue to be able access the MCSS portal by selecting the link found on the Medi-Cal website splash page. With these new changes, users can expect to be able to:

In addition, the new MCSS portal will enable Medi-Cal to communicate with providers and stakeholders via additional communication channels in the future, such as SMS text, chat and provider community forums.

Provider community forums are a key functionality change, which will allow Medi-Cal to deploy the other types of communication mechanisms as program and business needs arise.

A current example Medi-Cal plans to roll out is the ability for providers and stakeholders to subscribe to threads and receive alerts in the forums to be notified when new posts are added, which will help keep them up to date on important changes.

In the future as needs evolve, Medi-Cal will announce other forum features and capabilities.

Print Article | Return to Top
 

16. Updates to the List of Enteral Nutrition Products

Effective for dates of service on or after June 1, 2020, Abbott Nutrition is updating several product billing numbers in the List of Enteral Nutrition Products.

The manufacturers guarantee providers can purchase the listed products at or below the maximum acquisition cost (MAC), upon request, for dispensing to Medi-Cal fee-for-service outpatient beneficiaries. Refer to the Enteral Nutrition Products section of the appropriate Part 2 manual for the MAC price suppliers' telephone numbers.

Note:

Listing of a product is not a guarantee of its availability. The product number approved on an authorization must be the same product number dispensed to the beneficiary and claimed for reimbursement by the provider.

The amount reimbursed to providers for enteral nutrition products shall not exceed the published estimated acquisition cost (EAC) plus a 23 percent markup.

Medi-Cal beneficiaries denied enteral nutrition products who believe the denial was in error may ask for a state hearing by contacting the California Department of Social Services at 1-800-743-8525 or 1-855-795-0634 or by sending a written request to:

California Department of Social Services
State Hearings Division
P.O. Box 944243, MS 9-17-37
Sacramento, CA  94244-2430

Print Article | Return to Top
 

17. Recommencement of Pharmacy Retroactive Claim Adjustments Remains Paused

As has been published in a previous Medi-Cal Update, the Department of Health Care are Services (DHCS) did not resume retroactive pharmacy claim adjustments adjustments beginning with the February 10, 2020, checkwrite date. Recommencement of retroactive pharmacy claim adjustments due to a change in the reimbursement methodology for covered outpatient drugs will continue to be paused until further notice.

Print Article | Return to Top
 

18. Get the Latest Medi-Cal News: Subscribe to MCSS Today

MCSS Logo

The Medi-Cal Subscription Service (MCSS) is a free service that keeps you up-to-date on the latest Medi-Cal news. Subscribers receive subject-specific emails shortly after urgent announcements and other updates post on the Medi-Cal website.

Subscribing is simple and free!

  1. Go to the MCSS Subscriber Form

  2. Enter your email address and ZIP code and select a subscriber type

  3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

After submitting the form, a welcome email will be sent to the provided email address. If you are unable to locate the welcome email in your inbox, check your junk email folder.

For more information about MCSS, please visit the MCSS Help page.

Print Article | Return to Top
 

19. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

Print Article | Return to Top


Note:

If you cannot view the MS Word or PDF (Portable Document Format) documents correctly, please visit the Web Tool Box to link to a download site for the appropriate reader.