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CHDP Looking Ahead: Phase 2 HIPAA Code Conversion and Claim Form Transition

November 30, 2016

The Department of Health Care Services (DHCS) is initiating Phase 2 of the transition of participating providers of Child Health and Disability Prevention (CHDP) services to comply with Health Insurance Portability and Accountability Act (HIPAA) national standards for health care electronic transactions and code sets to be completed in the third quarter of 2017.

Phase 2
CHDP providers who currently provide Medi-Cal Early and Periodic Screening, Diagnosis and Treatment (EPSDT) well-child health assessments, immunizations and ancillary clinical laboratory services in a single encounter will make the transition during Phase 2. This transition implements claim submission using CPT-4 procedure codes on CMS-1500 or UB-04 claim forms or equivalent electronic claim transactions.

CHDP EPSDT well-child health assessments and immunizations will be billed as Medi-Cal services in accordance with Medi-Cal policy, rates and provider enrollment requirements.

Transition Billing Requirements
Providers will bill CHDP EPSDT well-child health assessments, immunizations and clinical laboratory services using:

  • HIPAA approved methods of transmission for claims for rendering CHDP EPSDT services to recipients.
  • Current Procedural Terminology – 4th Edition (CPT-4) procedure codes.
  • International Classification of Diseases, 10th Revision (ICD-10-CM) diagnosis codes.
  • CMS-1500 and UB-04 claim forms, and the ASC X12N 837 v.5010A1 transaction in lieu of the proprietary CHDP forms or the CHDP computer media claims (CMC) transaction.
Important Facts About the Transition
  • To bill Medi-Cal for CHDP services, a provider must have an active National Provider Identifier (NPI) and be enrolled as an active Medi-Cal provider.
  • Adherence to Medi-Cal provider enrollment requirements and compliance with Medi-Cal billing requirements.
  • Services will be billed in conformance with the HIPAA standard transactions and code sets.
  • The transition of processing claims on the CMS-1500, UB-04 and equivalent electronic claims will be based on a date of service cutover.
  • Providers will bill according to Medi-Cal hard copy and electronic claim submission standards.
  • Reimbursement for services will be at the Medi-Cal rate. The Medi-Cal rate table may be accessed from the Medi-Cal website: Under the References tab click “Medi-Cal Rates.”
  • Payment will be made on providers’ Medi-Cal warrant for claims processed with dates of service on or after the effective date of transition and report of the adjudication of these services on Remittance Advice Details (RAD) forms or the ASCI X12N 835 Health Care Claim Payment/Remittance Advice (RA).
  • Providers may continue to receive 1099s from both the CHDP system and the Medi-Cal CA-MMIS system up to one year from implementation based on the dates of service billed on claims.
  • For services rendered with dates of service prior to the designated effective date, providers will continue to submit claims on the Confidential Screening/Billing Report (PM 160) claim form. If services are billed on the incorrect claim form for the date of service, they will be denied.
  • It is recommended that providers bill electronically for all its many benefits. Providers who may not be able to bill electronically and do not have a supply of national claim forms should order in advance. Delivery of forms does take time. Providers should work with a credible vendor and purchase forms with “drop-out” ink that meet Centers for Medicare & Medicaid (CMS) standards.
  • Information submitted on CMS-1500 and UB-04 claim forms does not need to be forwarded to county CHDP offices, as was required with the CHDP Confidential Screening/Billing Report (PM 160) claim form.

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).

Providers are encouraged to send specific questions or challenges related to the CHDP HIPAA Code Conversion and claim form transition to the transition mailbox at CHDPTransition@xerox.com.

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.