Medi-Cal Update

Vision Care | November 2017 | Bulletin 478

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1. New Modifier ZB Required for HCPCS Code Q5102

Effective retroactively for dates of service on or after July 1, 2016, modifier ZB (Pfizer/Hospira) is required when billing for Inflectra with HCPCS code Q5102 (injection, infliximab, biosimilar, 10 mg). Modifier ZB was released through the Centers for Medicare & Medicaid Services (CMS) on September 4, 2015. The CMS modifier should not be confused with the local modifier ZB (anesthesia [emergency services, healthy patient]) that was discontinued by HIPAA effective for dates of service on or after March 1, 2011.

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

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Audiology and Hearing Aids
Durable Medical Equipment
Expanded Access to Primary Care Program
Home Health Agencies/Home and Community-Based Services
Local Educational Agency
Medical Transportation
Orthotics and Prosthetics
Therapies
Vision Care
hcpcs (1); modif app (21, 25)
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
hcpcs (1); inject drug i-m (7); modif app (21, 25)
Pharmacy inject drug i-m (7)
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2. New Modifier ZC Required for Billing HCPCS Code Q5102

Effective retroactively for dates of service on or after July 24, 2017, modifier ZC (Merck/Samsung Bioepis) is required when billing for Renflexis with HCPCS code Q5102 (injection, infliximab, biosimilar, 10 mg). Modifier ZC was released through the Centers for Medicare & Medicaid Services (CMS) on September 4, 2015. The CMS modifier should not be confused with the local modifier ZC (anesthesia complicated by extracorporeal circulation) that was discontinued by HIPAA effective for dates of service on or after March 1, 2011.

The new modifier ZC will be available for use January 1, 2018. To avoid claim denials, providers should submit claims for Q5102 with modifier ZC on or after January 1, 2018. Claims submitted for Q5102 without modifier ZC will continue to be accepted.

An Erroneous Payment Correction (EPC) will be generated to accurately adjudicate claims submitted with the CMS modifier ZC with dates of service on or after July 24, 2017. No action is required of providers.

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

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Audiology and Hearing Aids
Durable Medical Equipment
Expanded Access to Primary Care Program
Home Health Agencies/Home and Community-Based Services
Local Educational Agency
Medical Transportation
Orthotics and Prosthetics
Therapies
Vision Care
hcpcs (1); modif app (21, 25)
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
hcpcs (1); inject drug i-m (7); modif app (21, 25)
Pharmacy inject drug i-m (7)
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3. Diagnosis Codes Updated for Professional Services and Ophthalmology

Effective retroactively for dates of service on or after October 1, 2015, incorrectly implemented ICD-10-CM diagnosis code combinations for professional services and ophthalmology have been corrected. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims. No action is required of providers.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
ophthal cd (1–8)
Vision Care pro serv cd (2–7)
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4. Coming Soon: Online PDF RAD and Medi-Cal Financial Summary

Providers will soon be able to securely view and download a PDF version of their paper Remittance Advice Details (RAD) and Medi-Cal Financial Summary. The PDF RADs will be available on the Medi-Cal website under the Transactions Services tab.

Note:  To access the transaction, providers must have a signed Medi-Cal Point of Service (POS) Network/Internet Agreement form on file, an NPI and PIN.

Benefits of PDF RAD
There will be many benefits to accessing RAD and Medi-Cal Financial Summary information online:

No provider payments will be made via PDF RADs. They will be informational only.

Providers should refer to future Medi-Cal Update bulletins for additional information.

Providers also are encouraged to sign up for the ASC X12N 835 transaction using the Electronic Health Care Claim Payment/Advice Receiver Agreement form (DHCS 6246 form). The form, which is expected to be modified in December, is located on the Forms page of the Medi-Cal website (www.medi-cal.ca.gov). The Medi-Cal website contains 835 transactions generated for the last six weeks. For information about 835 transactions, providers may refer to “ASC X12N 835 Transaction” in the Part 1 Medi-Cal provider manual section, Remittance Advice Details (RAD): Electronic.

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5. RTD Generation to be Discontinued in Multiple Phases

The Department of Health Care Services (DHCS) will be phasing out the generation of Resubmission Turnaround Documents (RTDs) (Form 65-1) over the next 12 months. The discontinuation of RTDs will both increase claims processing efficiency and reduce costs.

RTDs will be discontinued in multiple phases. The new process will deny claims submitted with questionable or missing information instead of generating an RTD. As DHCS transitions from the use of RTDs to claim denials, providers can expect to receive fewer RTDs. When the project is completed, the use of RTDs will be completely discontinued.

The implementation of each RTD phase-out period will be announced in a future monthly bulletin. Providers are encouraged to routinely check the Medi-Cal website for more information.

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6. Update to Guidelines for SAR and eSAR Submission

California Children’s Services (CCS) and Genetically Handicapped Persons Program (GHPP) providers can submit Service Authorization Requests (SARs) in an electronic format for fee-for-service claims. This feature aims to eliminate the paper SAR process for providers with internet connectivity.

To submit electronic SARs (eSARs), providers must:

Then select one of the submission options:

  1. Utilize the newly enhanced online fillable form of the PEDI system to submit SARs electronically

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

Registered providers, clearinghouses or Managed Care Plans 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 other practical reasons to do so.

Providers interested in converting from paper SAR to eSAR submission 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
Inpatient Services
Local Educational Agency
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
cal child sar (1, 12); genetic (4, 5)
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8. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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