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Frequently Asked Questions: School-Based Providers

Effective November 1, 2018, school-based CHDP/EPSDT (Child Health and Disability Prevention/Early and Periodic Screening, Diagnostic and Treatment) providers who billed services to the CHDP program will bill services directly to Medi-Cal in accordance with HIPAA national standards. School-based providers will no longer bill two-character CHDP codes on the Confidential Screening/Billing Report (PM 160) but will submit CPT-4 national codes on the UB-04 claim form, or electronic equivalent.

Codes

  1. What national codes should providers submit?

    CPT-4 codes determined to be most appropriate for current CHDP/EPSDT services. A list of national codes reimbursable to school-based providers is available in the CHDP provider manual section, CHDP Transition to National Standards: School-Based Services.

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 be phased out. After November 1, 2018, providers will have six months from the Remittance Advice Details (RAD) date to submit follow-up documentation:

    • 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 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 school-based services provided on or after November 1, 2018?

    For paper submissions, school-based providers rendering services to eligible children and youth will bill using the Outpatient UB-04 claim form, or for electronic submissions, the ANSI X12N 837 institutional (837I) electronic claim format.

    School-based providers bill solely on the UB-04 claim form.

  2. What is happening to the PM 160?

    The PM 160 will not be used to bill for services provided for dates of service or after November 1, 2018.

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

    Services provided for dates of service prior to November 1, 2018, are submitted using a PM 160 claim form.

    Services provided for dates of service on or after November 1, 2018, are submitted on a UB-04 claim form.

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

    No. The RTD has been phased out of use by Medi-Cal.

  5. Can billers use the Remarks field (Box 80) on the UB-04 claim form?

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

  6. Is the county code required on the UB-04 claim form?

    No. The county code is not required.

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

    National claim forms do not have fields to capture the date for the next required periodic exam. Well-child health assessments 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.

    The electronically submitted 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. If a provider has a submitter who processes their electronic CHDP claims, what changes does the submitter need to make?

    The submitter must be approved to submit the 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. What is the deadline for submitting my claim on a PM 160 claim form?

    Providers may continue to submit claims on the 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 CHDP services to qualified children and youth on the UB-04 claim form.

  2. Are there special claim completion instructions when billing for services rendered to CHDP qualified children and youth?

    Yes. Providers who render CHDP services in a school-based setting also bill services for children and youth who qualify for Local Educational Agency (LEA) services. To distinguish between LEA and CHDP 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 form to be reimbursed for CHDP services. Claims submitted for CHDP services without the condition code will be denied.

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

    General instructions for completing the UB-04 claim form are located in the UB-04 Completion: Outpatient Services section of the appropriate Part 2, Medi-Cal Provider Manual.

  3. Can CHDP and LEA services be submitted on the same claim form?

    No. CHDP and LEA services must be billed on separate claim forms to allow for correct reimbursement.

  4. What code is billed for blood lead draw (venipuncture) by providers certified to perform this service?

    CPT-4 code 99000 (handling and/or conveyance of specimen for transfer from the [physician's] office to a laboratory). Code 99000 includes any of the following: Single or multiple venipuncture, capillary puncture or arterial puncture with one or more tubes, centrifugation and serum separation, freezing, refrigeration, preparation for air transportation or other special handling procedures, supplies, registration of patient or specimen and third party billing.

    Instructions for billing CPT-4 code 99000 are included in the Pathology: Blood Collection and Handling section in the appropriate Part 2, Medi-Cal provider manual.

  5. What code is used to bill for the counseling service(s) associated with blood lead venipuncture?

    Counseling services associated with blood lead venipuncture testing are included as part of a preventive medicine health assessment.

    The codes for billing preventive medicine services are included in the CHDP Transition to National Standards: School-Based Services section in the CHDP Provider Manual.

  6. Is a Clinical Laboratory Improvement Amendment (CLIA) certificate required for lab services?

    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.

  7. 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.

  8. Will providers currently billing for CHDP services be able to bill equivalent services for EPSDT health assessments and laboratory services?

    CHDP-approved providers are eligible to bill Medi-Cal for equivalent well-child health assessments and laboratory 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.

  9. How do CHDP providers bill a partial screening service for services provided on or after November 1, 2018?

    Providers use the appropriate procedure codes with specific 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 and use of standard code sets as specified in federal regulations adopted by the Department of Health and Human Services.

  2. Will there be a grace period?

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

  3. Will transition training be provided?

    For providers who are not actively billing on the 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.

  4. Will payments appear 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 services provided on or after November 1, 2018, claims will be adjudicated in the Medi-Cal system and reimbursements will be reflected on the provider's Medi-Cal warrant.

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

    The ANSI 837I electronic claim and the corresponding claim form 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 child's or youth's records.

  6. With the CHDP conversion to the UB-04 claim form for school-based providers, 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.

  7. Is the CHDP Provider Manual being updated?

    A CHDP Transition to National Standards: School-Based Services section has been added to the CHDP Provider Manual. The section includes tips for providers who render CHDP services in a school-based setting to complete the UB-04 claim form, a chart of reimbursable CPT-4 codes and a list of Medi-Cal provider manual sections to reference for help with billing.

    Billing and policy instructions related to the PM 160 claim form will be retained in the CHDP Provider Manual for a period of time to allow processing of CHDP claims with dates of services prior to November 1, 2018.

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.