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Medical Supplies Billing Requirements

Overview

As part of the continuing effort to comply with federally-mandated Health Insurance Portability and Accountability Act (HIPAA), the following changes for medical supply billing and supplemental claim attachments will be implemented April 1, 2009.

Effective for dates of service on or after April 1, 2009, medical supplies must be billed with Healthcare Common Procedure Coding System (HCPCS) Level II codes. Providers will no longer bill medical supplies using the local “99” or HCPCS Level I codes. Local “99” codes will be discontinued March 31, 2009.

In addition to the HCPCS Level II codes, the Universal Product Number (UPN) will be required on claims for contracted medical supplies effective for dates of service on or after April 1, 2009. Submission of the UPN will replace supplemental invoice attachments or catalog pages. DHCS regularly publishes UPNs for contracted medical supplies in the monthly Medi-Cal Update. UPNs will not be required on claims for non-contracted items.

Effective for dates of service on or after April 1, 2009, providers will be required to submit electronic medical supply claim transactions in the 837 4010A1 professional format instead of the National Council for Prescription Drug Programs (NCPDP) 1.1 batch transaction standard format. Pharmacy providers will also be required to use the CMS-1500 claim form for medical supplies instead of the Pharmacy Claim Form (30-1).

Effective for dates of service on or after April 1, 2009, the pending changes apply to the following provider communities:

  • Durable Medical Equipment (DME) providers
  • Pharmacy providers

Effective for dates of service on or after April 1, 2009, the pending changes apply to the following types of medical supply items:

  • Disposable medical supplies
  • Incontinence medical supplies

The current billing process for the following “Pharmacy-only” medical supply items using the NCPDP 1.1 batch transaction standard format with UPNs and/or Universal Product Codes (UPCs) will not change. The products will include:

  • Diabetic supplies (test strips and lancets)
  • Inhalers
  • Peak flow meters
  • Family PACT Medical Supplies
  • Enteral nutritional products

Provider Comment Forum
A Medi-Cal Public Comment Forum period beginning January 5, 2009, and ending February 6, 2009, allowed providers to review and comment on the HCPCS Level II and UPN coding requirements for billing, effective for dates of service on or after April 1, 2009. Submitted comments and responses are being added to the billing requirements changes FAQs, and may be viewed on the Medical Supplies Billing Requirements: FAQs page.

Retired Provider Manual Sections – Effective for Dates of Service Prior to April 1, 2009
A number of provider manual sections were either updated or replaced by new sections to reflect the new medical supply billing requirements effective for dates of service on and after April 1, 2009. For the benefit of providers billing for dates of service before April 1, 2009, a copy of the retired provider manual sections remained on the website through June 30, 2010.

Updates to Provider Resources
The following provider resources have been updated with instructions for billing, including instructions for claim form completion, placement of the UPN on Medi-Cal claims and cross referencing local “99” codes to HCPCS Level II codes:

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