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Upcoming Pharmacy Fee-For-Service Retroactive Claim Adjustments

May 24, 2019

As has been published in previous Medi-Cal Updates, pursuant to California’s State Plan Amendment 17-002, as approved by the Centers for Medicare & Medicaid Services (CMS) on August 25, 2017, the Department of Health Care Services (DHCS) implemented a new fee-for-service reimbursement methodology for covered outpatient drugs on February 23, 2019.

Starting with the last checkwrite in May 2019, and continuing over a period of 8 to 10 months, DHCS will begin making retroactive adjustments for impacted claims with dates of service from the policy effective date of April 1, 2017, through the implementation date of February 23, 2019. In a previous Medi-Cal NewsFlash, DHCS invited Pharmacy Stakeholders to participate in a teleconference conducted on March 26, 2019, presenting how claim adjustments will be rolled out. A PDF version of the presentation slides are available at the Pharmacy Reimbursement Project page on the DHCS website, under the Latest News heading. Additionally, providers should have received official notice of the upcoming claim adjustments in a mailer sent to their mailing address on fileduring the first week of April.

No action is required of providers. The California Medicaid Management Information System (MMIS) Fiscal Intermediary, Conduent State Healthcare, LLC, will adjust the affected claims. These adjustments will appear on Remittance Advice Details (RAD) forms beginning May 30, 2019, with RAD code 0812: Covered Outpatient Drug Retroactive Payment Adjustment. The PDF of the RAD and Claims Financial Summary (CFS) information are available online earlier than paper RADs and financial summaries. PDF RADs are posted on the Medi-Cal website under the Transaction tab within each provider’s Medi-Cal online account. For additional information about PDF RADs, contact the Telephone Service Center (TSC) at 1-800-541-5555 or visit the Medi-Cal website.