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CHDP Frequently Asked Questions

Child Health and Disability Prevention (CHDP) providers who bill CHDP will start billing services directly to Medi-Cal in accordance with HIPAA national standards. Transitioning from billing two-character CHDP codes on the Confidential Screening/Billing Report (PM 160) to billing with CPT-4 national codes on the CMS-1500 or UB-04 claim form, or electronic equivalent, will occur in two phases:

Phase 1: Transitions clinical laboratory-only services effective for dates of service on or after February 1, 2017.
Phase 2: Transitions the remaining CHDP services with effective dates of service on or after July 1, 2017.

Codes

  1. What national codes should providers submit?

    CPT-4 codes determined to be most appropriate for current CHDP services. A list of national codes “crosswalked” to the two-character CHDP local codes are available in the article “CHDP Phase 2: HIPAA Code Conversion and Claim Form Transition.”

Billing Limitations

  1. Can claims still be submitted one year from the date of service?

    No. Claims processed in the Medi-Cal claims system are subject to the six month billing limitation. After six months, reimbursement will be cut-back unless a valid late submission reason is entered on the claim, with supporting documentation as appropriate.

Forms/Notices

  1. What forms or notices will be discontinued?

    The following forms will no longer be used when billing Medi-Cal for CHDP EPSDT health assessments and immunizations for services provided on or after February 1, 2017 for CHDP clinical laboratory providers and on or after July 1, 2017 for all other CHDP Medi-Cal providers.

    • Confidential Screening/Billing Report (PM 160) claim form (fee-for-service)
    • Notice of Provider Correction Request
    • Notice of Claim Denial from Critical Edit
    • Notice of Claim Denial from Fee Adjustment Edit
    • Notice of Tracer/Duplicate Claim Denial from History Edit
    • Notice of Claim Denial from History Edit
    • Notice of Partial Claim Denial from History Edit
  2. Can copies of the Confidential Screening/Billing Report (PM 160) still be ordered?

    Yes, a limited number of PM 160 forms will be available to allow for late billing and appeals. Providers who need additional hard copy forms will need to follow existing guidelines and contact their local county office for a supply.

Claim Form

  1. Which claim form is used for services provided on or after the transition?

    For paper submissions, providers will bill using the CMS-1500 or Outpatient UB-04 claim form, or for electronic submissions the ANSI X12N 837 professional (837P) or 837 institutional (837I) electronic claim format.

  2. What is happening to the PM 160?

    This form will no longer be used for services provided on or after the effective date of the transition.

  3. How do providers know whether to submit a PM 160 claim form or a CMS-1500 or UB-04 claim form?

    For Phase 1: Any services provided on or after February 1, 2017, need to be submitted using CMS-1500 or UB-04 claims forms.

    For Phase 2: Any services provided on or after July 1, 2017, need to be submitted using the CMS-1500 or UB-04 claim form.

  4. If providers submit incorrect information on a hard copy CMS-1500 or UB-04 claim form can they use a Resubmission Turnaround Document (RTD) to fix the inaccurate, questionable or missing information?

    Yes. A Resubmission Turnaround Document (RTD) can be used to correct the claim.

  5. Can CHDP providers use the Additional Claim Information field (Box 19) on the CMS-1500 claim form or the Remarks field (Box 80) on the UB-04 claim form?

    Box 19 on the CMS 1500 and Box 80 on the UB-04 will be available to enter documentation, delay reason remarks and additional information as needed.

  6. Is the county code required on the CMS-1500 or UB-04?

    No. The county code is not required on the national claim forms.

  7. Should the date of the next periodic health exam be entered on the CMS-1500 or UB-04? If so, where is it entered on the claim?

    The national claim forms do not have fields to capture the date for the next required periodic exam. CHDP well-child health assessments and immunizations should be rendered in accordance with the American Academy of Pediatrics (AAP) Bright Futures periodicity schedule. See both the CHDP Bright Futures Schedule for Health Assessments by Age Group and CHDP/EPSDT Periodicity Schedule for Dental Referral by Age PDFs for guidelines.

Electronic Claim Completion

  1. How is an attachment added to an electronic claim?

    For each electronically submitted claim requiring an attachment, a single and unique Attachment Control Form (ACF) must be submitted via mail or fax. Providers will be required to use the 11-digit Attachment Control Number (ACN) from the ACF to populate the Paperwork (PWK) segment of the 837 HIPAA transaction.

    Both the electronically submitted 837P and 837I ANSI ASC X12N v.5010A1 claim and the paper attachment must contain the ACN to allow the parts of the claim to be synced for processing.

  2. I currently have a submitter who processes my electronic CHDP claims. What changes do they need to make?

    The submitter must be approved to submit the CMS-1500 or UB-04 claims electronically. Instructions are available on the Medi-Cal website or by calling the Telephone Service Center (TSC) at 1-800-541-5555.

Billing

  1. Physicians bill lab codes for services performed during the CHDP exam. Should physicians continue billing for those services the same way?

    Medi-Cal, physicians need to bill for these services in accordance with their Medi-Cal enrollment status. If the physician is not authorized to bill for the specific lab codes under their Medi-Cal enrollment, the claim will be denied. For dates of service on or after July 1, 2017, all CHDP claims billed in Medi-Cal will follow the current Medi-Cal policies and procedures for claims processing.

  2. How do CHDP providers bill a partial screening service for services provided on or after the transition?

    Providers use the appropriate procedure codes with specified modifiers according to Medi-Cal billing instructions when billing for partial screening services.

Rates

  1. Are reimbursement rates changing?

    Some rates may change. Reimbursement rates are being aligned with Medi-Cal rates.

  2. Is rate information available online?

    The Medi-Cal rate table may be accessed from the Medi-Cal website: Under the References tab providers should click “Medi-Cal Rates.”

Miscellaneous Questions

  1. Why are CHDP changes occurring?

    The Federal Health Insurance Portability and Accountability Act (HIPAA) requires electronic health care transactions, and their hard copy counterparts, to conform to national standards for electronic health care transactions and use of national standard code sets as specified in federal regulations adopted by the Department of Health and Human Services.

  2. Are ICD-10-CM diagnosis codes required on my claim?

    Yes, if the policy instructions in the Medi-Cal provider manual say an ICD-10-CM diagnosis is required for the service being billed.

  3. Will there be a grace period?

    No, there will be no grace period. The transition is based on a date of service cutover.

  4. Is the CHDP Provider Manual being updated?

    Yes. New information has been incorporated for Phase 1 and will be for Phase 2 to reflect use of the CMS-1500, UB-04 and national billing codes, including CPT-4 codes, ICD-10-CM diagnosis codes and modifiers. Billing and policy instructions related to the PM 160 claim form will be retained in the CHDP Provider Manual for a period time to allow processing of CHDP claims with dates of service prior to February 1, 2017 (clinical laboratory services) and July 1, 2017 (all other CHDP services).

  5. Will transition training be provided?

    For providers who are not actively billing on the CMS-1500 or UB-04 claim form, a claim completion, computer-based training (CBT) course is available through the Medi-Cal Learning Portal (MLP). On completion of the CBT training, if staff needs further training, providers should contact TSC to request training.

  6. Will providers currently billing for CHDP services be able to bill equivalent services for CHDP-related Early and Periodic Screening, Diagnosis and Treatment (EPSDT) health assessments and immunizations?

    CHDP-approved providers are eligible to bill Medi-Cal for equivalent services for CHDP related well-child health assessments, immunizations and ancillary services rendered under the EPSDT benefit of the Medi-Cal program in accordance with the provider's Medi-Cal enrollment status, for example, Medi-Cal provider type and category of service.

  7. Will my payments come on the Medi-Cal Warrant or on a separate checkwrite?

    For services provided prior to the transition processed in the CHDP subsystem, the provider will not notice a change. For any services provided on or after the transition date of July 1, 2017, claims will be adjudicated in the Medi-Cal system and reimbursements will be reflected on the provider's Medi-Cal warrant.

  8. When billing with the CMS-1500 form, will providers be required to provide the parent and county office a copy of the health assessment as is done with the CHDP Confidential Screening/Billing Report (PM 160) forms?

    It will no longer be necessary to provide the county office a copy of the claim form. The health assessment provider should provide the child, parent or guardian with the results of the health screening and evaluation and an explanation of the meaning of the results.

  9. The current PM 160 form has fields for clinical results as well as other information that is not currently captured on the CMS-1500, UB-04 or ANSI 837P/837I form. Will there be specific information about where to put that information on those forms or formats?

    The ANSI 837P/837I electronic claims and the corresponding claim forms and completion instructions will not be modified to accommodate the fields on the PM-160 form that do not appear in the national standard electronic transactions and claim forms. Providers will document the clinical data in the recipient's records.

  10. With the CHDP conversion to the CMS-1500 form, what is the status of the Body Mass Index, Hemoglobin, Hematocrit, Tobacco and other additional fields?

    Providers will be expected to perform these tests as indicated on the “CHDP Bright Futures Schedule for Health Assessments by Age Group” PDF. However, it is no longer required to include these metrics on the claim form.

  11. Which signatures and National Provider Identifiers (NPI) are required when billing on the CMS-1500 form?

    The claim must be signed and dated by the provider or representative assigned by the provider.

  12. Do providers need to fill out the service facility location information?

    Yes. Providers enter the provider name and address of the facility where the services were rendered, including the nine-digit ZIP code.

  13. Does the billing provider's information need to be included?

    Yes. The provider name and address must be entered without a comma between the city and state, including the nine-digit ZIP code, without a hyphen, and the telephone number and the provider's NPI.

  14. Which signatures and NPIs are required when billing on the UB-04 form?

    Provider name, address and ZIP code are required including the city and state with nine-digit ZIP code.

  15. Will new Medi-Cal providers interested in providing CHDP-related services have to apply to be a CHDP provider to use the CHDP Gateway or render services in accordance with the Bright Futures Periodicity Schedule?

    Under the transition of CHDP claims adjudication, CHDP providers are required to be enrolled as Medi-Cal providers and approved as CHDP providers. This enables providers to submit claims for CHDP EPSDT well-child health assessments, immunizations and ancillary services to Medi-Cal, and to enroll youths in presumptive eligibility Medi-Cal through the CHDP Gateway. CHDP services under the transition are Medi-Cal state plan benefits and conform to the AAP Bright Futures periodicity schedule and benefit guidelines. Claims for reimbursement for these services will be billed in accordance with Medi-Cal billing requirements, procedures and policies, and will be reimbursed at Medi-Cal rates. Providers will receive reimbursement for CHDP services on the Medi-Cal checkwrite.

Resources

Specific questions concerning the transition can be sent to the CHDPTransition@conduent.com mailbox.

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