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November 1 Go Live: CHDP Phase 3 HIPAA Code Conversion for School-Based Services

October 16, 2018

The Department of Health Care Services (DHCS) has initiated Phase 3 of the Child Health and Disability Prevention (CHDP) claim form transition and code conversion. To comply with HIPAA national standards for health care electronic transactions and code sets, school-based services will transition to national standards on November 1, 2018.

School-based providers will bill services directly to Medi-Cal in accordance with HIPAA national standards. Services will be billed with CPT-4 national codes on the UB-04 claim form or electronic equivalent. Services billed on the incorrect claim form for the date of service will be denied.

As a reminder, well-child health assessments and lab services conducted by school-based providers will continue to be performed in accordance with the American Academy of Pediatrics (AAP) Bright Futures periodicity schedule.

Frequently Asked Questions for School-Based Providers
A set of Frequently Asked Questions (FAQs) is available for Phase 3, school-based providers transitioning to new billing codes and submitting claims on the UB-04 claim form.

Condition Code and Facility Type: Required on UB-04
School-based providers also bill services for children and youth who qualify for Local Educational Agency (LEA) services. To distinguish between LEA and CHDP/Early and Periodic Screening Diagnostic and Treatment (EPSDT) services within the Medi-Cal claims processing system, school-based providers must enter condition code “A1” (EPSDT/CHDP) in the Condition Code field (Boxes 18 – 24) on the UB-04 claim to be reimbursed for preventive health services rendered in a school-based setting. Claims submitted for CHDP/EPSDT services without the condition code will be denied.

Additionally, providers must enter facility type code “891” in the Type of Bill field (Box 4)

Instructions for entering facility type and condition codes on the claim are located in the UB-04 Completion: Outpatient Services section of the appropriate Part 2 Medi-Cal Provider Manual.

CLIA Certification
Providers transitioning from billing laboratory services according to CHDP standards are reminded to review their Medi-Cal credentials to ensure they meet the standards for billing to Medi-Cal. All Medi-Cal providers billing for laboratory services must have a current Clinical Laboratory Improvement Amendments (CLIA) certificate.

Guidelines for CLIA certification and information about proficiency testing requirements are included in the Pathology: An Overview of Enrollment and Proficiency Testing Requirements section of the appropriate Part 2 Medi-Cal Provider Manual.

CHDP Manual Updates
The CHDP Transition to National Standards: School-Based Services section is added to the CHDP Provider Manual with a list of CPT-4 codes that school-based providers will use to bill qualified CHDP/EPSDT services to Medi-Cal.

The other sections in the CHDP Provider Manualare retained to help providers still billing on the PM 160 for claims with a date of service prior to November 1, 2018. Boxed text has been added on page 1 of each section to remind providers that when billing CPT-4 codes on the national claim forms, they should refer to the new CHDP Transition to National Standards: School Based Services sections. Sections with boxed text will be retained for some time as reference.

Billing CHDP and LEA Services, Same Day, Same Recipient
CHDP and LEA services must be billed on separate claim forms to allow for reimbursement.

Providers may continue to submit claims on the Confidential Screening/Billing Report (PM 160) up to six months after the transition date, as long as the date of service is before November 1, 2018. For dates of service on or after November 1, 2018, providers must submit claims for school-based preventive health services to qualified children and youth on the UB-04 claim.

After implementation, providers will have six months from the Remittance Advice Details (RAD) date to submit follow-up documentation, including:

  • Notice of Claim Denial From Critical Edit Appeal

  • Fee Adjustment Appeal

  • Denied Claim Appeals

  • Fee Cut Appeal

  • Balance Due Request

  • Tracer

Correction: Code Conversion Table
The full code conversion is available in the CHDP Code Conversion Table. Information in the table changed subsequent to its releases in July and September 2018. Providers should not use crosswalk charts dated earlier than November 1, 2018.

Additional Information
For additional important information concerning this code conversion, providers may refer to the already published article, CHDP Phase 3: School-Based Services Transition Coming Soon.

Providers are encouraged to subscribe to the Medi-Cal Subscription Service (MCSS) to receive notifications related to the upcoming changes. These notifications will inform and prepare providers to minimize unnecessary service disruptions. Providers may sign up for MCSS by completing the MCSS Subscriber Form.

Email Address for Questions/Concerns
Providers may submit questions or concerns regarding the CHDP Phase 3 school-based services code conversion and claim form transition to CHDPTransition@conduent.com. Including the provider NPI in the subject line will expedite a response.