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Medical Supplies Billing Requirements: FAQs — Billing Forms and Formats

This category includes questions about Medical Supply Billing Requirements, Billing Forms and Formats.

For additional questions regarding Medical Supply Billing Requirements, contact the Telephone Service Center (TSC) at 1-800-541-5555.

  1. Are providers required to register before they submit claims electronically?
    A: Yes. In order to submit a Computer Media Claims (CMC) transaction in the ASC X12N 5010A1 837P electronic format, providers must review the instructions, complete and sign a Medi-Cal Telecommunication Provider and Biller Application/Agreement (DHCS 6153). After submitting this agreement, providers will be able to implement and test CMC billing. CMC submission is open to all Medi-Cal and Child Health and Disability Prevention (CHDP) providers
  2. Will there be a test period for new electronic claims submissions?
    A: Yes. CMC testing is required for all providers that are new to claims submission in the ASC X12N 5010A1 837P electronic transaction format. Providers can review the instructions for CMC testing in the Testing/Activation Procedures section from the CMC Billing and Technical Manual web page.
  3. Are condoms still covered by Medi-Cal?
    A: Condoms and diaphragms will remain a benefit, however as directed per the December 2008 Provider Bulletin (#694), the billing mechanism has changed. Effective for dates of service on or after March 1, 2009, the Maximum Allowable Product Cost (MAPC) has been established for condoms and diaphragms billed to the Medi-Cal fee-for-service program. In addition, these items will be limited to pharmacy providers only and will be billed using the 11-digit National Drug Code (NDC) or the 11-digit Universal Product Number (UPN). The following medical supply Healthcare Common Procedure Coding System (HCPCS) Level III local codes will be end-dated on the same date, for all manufacturers: 9914A, 9914P, 9925A, 9925B, 9925C, 9925D, 9925E and 9925F.
  4. Pharmaceuticals are currently billed on the National Council for Prescription Drug Programs (NCPDP) 1.2 batch format and D.0 online format. How will the new billing requirements affect pharmacy billing?
    A: Pharmacy Billing requirements and formats, including the 30-1 paper form, will not change for drugs, diabetic supplies (test strips and lancets), peak flow meters, inhaler assist devices, Family PACT (Planning, Access, Care and Treatment) medical supplies and enteral nutritional products. These items must continue to be billed on the 30-1 claim form or the NCPDP Batch Standard Version 1.2 format.

    The changes effective April 1, 2009 are for medical supplies currently billed with the local “99” billing codes. The local billing codes will be discontinued and replaced with the Healthcare Common Procedure Coding System (HCPCS) Level II codes. HCPCS Level II codes for medical supplies must be billed on the ASC X12N 837P 5010A1 electronic format or the CMS-1500 paper claim form. The NCPDP batch and online formats and the Pharmacy Claim Form (30-1) will not be allowed for billing medical supply HCPCS Level II codes on and after April 1, 2009.

    The following table summarizes the products that are impacted by this change:

    Pharmacy/DME Billed Products Changes Effective April 1, 2009*
    Medical supplies currently billed with local “99” billing codes
    1. Local “99” billing codes and the two-digit manufacturer codes will be discontinued
    2. Must use HCPCS Level II codes on claims and TAR/SARs
    3. Universal Product Numbers (UPNs) required on claim for contracted items
    4. Must use one of the following billing formats:
    • ASC X12N 837P 5010A1 electronic
    • CMS-1500 paper
    NCPDP 1.2 Batch and 30-1 paper will not be accepted
    Pharmacy-dispensed drugs and medications No change
    DME products (including Orthotics and Prosthetics) No change
    Pharmacy-only dispensed medical supplies:
    • Diabetic supplies
    • Peak flow meters
    • Inhaler, Assist Devices
    • Family PACT Medical Supplies
    • Enteral nutritional products
    No change

    * A transitiion period for dates of service April 1, 2009 through June 30, 2009 will allow providers the option to continue using existing codes and billing formats for these claims.  For dates of service prior to April 1, 2009, providers must use existing codes and billing formats. Please review Medical Supplies TARs and SARs: Transition to HCPCS Level II Codes article for details.

  5. Do the new billing requirements affect California Children’s Services (CCS) and Genetically Handicapped Persons Program (GHPP) claims, including Los Angeles County CCS ?
    A: Yes. CCS and GHPP claims are included in the new billing requirements. Any program that currently uses the medical supply local “99” billing codes will be required to conform to the new billing requirements effective for dates of service on or after April 1, 2009. Claims for all GHPP clients and CCS clients residing in Los Angeles County must be billed on the CMS-1500 claim form until notified otherwise.
  6. New HCPCS Level II codes can be billed electronically with the UPN. What procedure should be used for California Children’s Services (CCS) claims when the CCS claim is unable to be transmitted electronically?
    A: Providers should use the CMS-1500 claim form for CCS claims. The CMS-1500 claim form allows for UPN information to be entered in the shaded area, left justified, under the Dates of Service field (Box 24A).
  7. Are the new billing requirements applicable to insulin syringes?
    A: Yes. Effective for dates of service on or after October 1, 2009, insulin syringes must be billed by pharmacy providers using either the 11-digit NDC or UPN on the Pharmacy Claim Form (30-1), electronically in the NCPDP 1.2 batch transaction format, electronically in the NCPDP D.0 format or with the Real-Time Internet Pharmacy (RTIP) claim submission system. Insulin syringes can no longer be billed using local “99” codes, the CMS-1500 claim form or the ASC X12N 837P 5010A1 electronic format.
  8. What code should be used for insulin syringes?
    A: Effective for dates of service on or after October 1, 2009, insulin syringes must be billed by pharmacy providers using the 11-digit NDC or UPN. Insulin syringes can no longer be billed using HCPCS Level II code S8490.
  9. Will Medi-Cal require a catalog page or invoice on the billings to determine pricing for insulin syringes?
    A: No. Effective for dates of service on or after October 1, 2009, insulin syringes must be billed by pharmacy providers on the Pharmacy Claim Form (30-1), electronically in the NCPDP 1.2 batch transaction format, electronically in the NCPDP D.0 format or the RTIP claim submission system with an established MAPC of $0.1800. Insulin syringes can no longer be billed using HCPCS Level II code S8490 so catalog page or invoices as attachments to the claims are no longer required..
  10. When submitting a claim on or after April 1, 2009 with date of service prior to April 1, 2009, what billing format should be used?

    A: The correct billing format is the NCPDP 1.2 batch format or the Pharmacy Claim Form (30-1) using the local “99” billing codes. Durable Medical Equipment (DME) providers will continue to bill using the CMS-1500 claim form or the ASC X12N 837P 5010A1 electronic format.
  11. How will claim adjustments and reversals for services rendered prior to April 1, 2009 be handled if the transaction is submitted after the implementation?

    A: Claim adjustments and reversals for services rendered prior to April 1, 2009 must be submitted with the local "99" codes in effect during that time period.
  12. Will the MAPC increase from the established 23 percent markup for medical supplies and 38 percent markup for incontinence supplies?

    A: The 23 percent markup for medical supplies and 38 percent markup for incontinence are set standards and will not change.
  13. Why is the unit of measure required on the CMS-1500 claim form when the product was already identified by the HCPCS Level II code?

    A: At this time, Medi-Cal does not require the unit of measure qualifier and quantity to be entered in the shaded area of the Procedures, Services, or Supplies field (Box 24D) with the specific UPN associated with that HCPCS Level II code. The total units billed for the product associated with the HCPCS Level II code must be entered in the Days or Units field (Box 24G) on the CMS-1500 claim form
  14. If providers bill for medical supplies that do not have a UPN, should providers bill using the Pharmacy Claim Form (30-1) or change to the CMS-1500 claim form?
    A: All claims billed with HCPCS Level II codes must be entered on the CMS-1500 claim form or transmitted in the ASC X12N 837P 5010A1 electronic format. Pharmacies billing with local “99” codes may also continue billing these codes during the April 1 through June 30, 2009 transition period using the Pharmacy Claim Form (30-1) or the NCPDP 1.1 batch transaction. Please review the Medical Supplies TARs and SARs: Transition to HCPCS Level II Codes for details.
  15. Can providers bill more than one HCPCS Level II code for the same date of service without additional documentation if the codes have different UPNs?
    A: Yes.
  16. How should providers bill for different non-contracted items that have the same HCPCS Level II code (such as administration sets/extension sets) without the claim being denied or rejected for duplicate charges?
    A: If the HCPCS Level II code has a price listed in the Medi-Cal provider manual (price on file), providers can submit one HCPCS Level II code with the total number of units that represent the various products that are being billed. A pricing attachment is not required for these claims.

    If the HCPCS Level II code does not have a price on file, an attachment must be included with the claim identifying each product description and price for each item.

    If the medical supply products have different rates, then providers may include separate service lines on the claim with the billed amount for each product (similar to billing for HCPCS codes with different amounts). When this happens, the claim will suspend for review of the invoice attachments and will be priced accordingly. Providers may also place the HCPCS Level II code on one service line with a total quantity and clearly identify each individual product billed under that single HCPCS Level II code and quantity on the attachment.
  17. How will claim adjustments and reversals for services rendered prior to April 1, 2009 be handled if the transaction is submitted after April 1, 2009?

    A: Claim adjustments and reversals for services rendered prior to April 1, 2009 must be submitted with the local codes in effect during that time period.
  18. Where can Pharmacy providers find help completing the CMS-1500 claim form for medical supplies?
    A: The CMS-1500 Claim Form Tutorial is accessible on the Medi-Cal Learning Portal.
  19. Will the requirements for the font and print size change when entering the UPN and HCPCS Level II codes on the CMS-1500 claim form?
    A: No. The Optical Character Recognition (OCR) system can only recognize fonts and size that are currently in use. Providers are encouraged to pay attention to the alignment of the data entered on the claim so the OCR will scan it accurately.
  20. Will the code conversion impact acute care hospitals and the codes on their charge master records?
    A: The code conversion only impacts providers currently billing with local “99” codes. Therefore, providers that are impacted include Durable Medical Equipment (DME) and Pharmacy providers. Hospitals will not be impacted for inpatient services.



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