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Medi-Cal Update

Clinics and Hospitals | May 2022 | Bulletin 572

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1. Medi-Cal Subscription Service is Coming Back

++An article titled “Medi-Cal Subscription Service (MCSS) is Live” is now posted to the News Flash area of the Part 1 Provider Communications section of the Medi-Cal website. Refer to this article for the most recent status of and instruction regarding MCSS.

Overview

The Department of Health Care Services (DHCS) is pleased to announce that the Medi-Cal Subscription Service (MCSS) is returning.

For providers and Medi-Cal stakeholders unfamiliar with the service, MCSS is a free service that sends subscribers subject-specific emails based on the provider communities they have subscribed to. This keeps subscribers up-to-date when urgent announcements and other updates post to the Medi-Cal Providers website.

DHCS took the service down in October 2021 to address some necessary changes. The returning MCSS retains the functionality and look-and-feel of the service subscribers are familiar with. However, DHCS wishes to highlight one change and one action required of subscribers to ensure they receive MCSS emails once the service is turned back on:

  • Sent From Email Changed: Emails received via MCSS will be sent from the following email address: do-not-reply_MCSSCalifornia@gainwelltechnologies.com.

  • Subscriber Action: The first few messages from MCSS may appear in spam or promotional inboxes. To avoid this, and to ensure they receive the latest messages from Medi-Cal fee-for-service, subscribers are instructed to add do-not-reply_MCSSCalifornia@gainwelltechnologies.com to their list of approved senders. Note that the exact instructions on how to add an email to the list of approved senders, will change depending on the email client in use. Medi-Cal has identified some frequently used email domains and resources on how to manage an approved senders list:

  • Subscribers who have alternative email domains not listed above (for example, @companyname.com), should defer to their company’s IT group or the email provider they use for their business, to ensure MCSSCalifornia@gainwelltechnologies.com is listed as an approved sender.

  • Without taking action to add MCSSCalifornia@gainwelltechnologies.com to the list of approved senders, it is possible that MCSS messages will either be blocked from the subscriber’s account or be filtered into Spam/Promotional folders.

Returning MCSS Subscribers

DHCS recommends existing subscribers add do-not-reply_MCSSCalifornia@gainwelltechnologies.com to their approved sender list to resume receiving MCSS emails. This is the only action needed. You do not need to re-subscribe for MCSS. Subscribers should keep an eye out for a “Welcome Back” email in the near future to see if they have appropriately added do-not-reply_MCSSCalifornia@gainwelltechnologies.com to the approved senders list.

DHCS will not send MCSS emails for publications published between October 2021 and May 2022. Instead, the “Welcome Back” email will highlight major changes and point to additional resources on any missed updates. Medi-Cal apologizes for any inconvenience this may cause.

Existing Subscribers can update their subscription preferences through a link in the footer of MCSS emails they receive. Only the most recent MCSS email will properly update subscription preferences.

New MCSS Subscribers

New subscribers can either sign up now using the current MCSS Subscription Form, or when MCSS returns using the updated online form. New subscribers using the current MCSS Subscription Form will not receive any emails until MCSS returns and the “Welcome Back” email is sent. New subscribers who sign up when MCSS returns will receive a “Welcome to MCSS” email. New subscribers should add do-not-reply_MCSSCalifornia@gainwelltechnologies.com to their approved senders list.

What’s Next

A News article will be published on the Medi-Cal Providers website once MCSS and MLP surveys are officially brought back online, and the “Welcome Back” emails begin to be sent out. DHCS is projecting that this will occur in late May or early June 2022.

Additionally, for all MCSS subscribers, refer to the updated Med-Cal Subscription Service (MCSS) Help page to find more information about this service.

2. FQHC, RHC and Tribal FQHC Providers May Now Submit Claims for COVID-19 Vaccine Administration

Overview

Effective retroactively for dates of service on or after the respective dates for each approved COVID-19 vaccine, Federally Qualified Health Center (FQHC), Rural Health Center (RHC) and Tribal FQHC providers, may receive reimbursement for administration of the Coronavirus Disease 2019 (COVID-19) vaccines during vaccine-only encounters. Vaccine-only encounters are visits where the administration of the COVID-19 vaccine does not otherwise meet the criteria for a qualifying office visit. These vaccine-only encounters are not reimbursable at the Prospective Payment System (PPS) rate for FQHC/RHC providers, nor the Alternative Payment Methodology (APM) for Tribal FQHC providers.

For COVID-19 vaccines that were administered during a qualifying office visit, FQHC, RHC, and Tribal FQHC providers are entitled to reimbursement at their individual PPS/APM rates. Providers are reminded that each administration of the COVID-19 vaccine either falls under either a qualifying office visit or a vaccine-only encounter, not both. DHCS Audit & Investigations will be monitoring for program integrity.

Reimbursement

FQHC, RHC, and Tribal FQHC providers may receive reimbursement up to a maximum allowable rate of $67.00 for COVID-19 vaccines administered during a vaccine-only encounter.

Billing Instructions

Providers Who Held Claims

Providers who held claims, as directed to by Medi-Cal in previous publications (COVID-19 Vaccine Administration: Specific Groups Advised to Hold Claim Submission article originally published on March 18, 2021), must follow the “General” instructions listed below to receive reimbursement for the vaccine-only encounter.

General

Medi-Cal will waive the timeliness requirement for 120 days, effective the date of this publication, for FQHC, RHC and Tribal FQHC providers to submit vaccine-only encounter claims electronically, or via hard copy with the following:

  • Delay Reason Code “10”

  • Documentation indicating that the COVID-19 vaccine was administered is in the Remarks area of the submitted claim (for example, “COVID-19 vaccine-only administration”)

FQHC, RHC and Tribal FQHC providers should refer to the webpages below for billing guidance and effective dates for each vaccine and dose:

Claims submitted for COVID-19 vaccine-only encounters do not currently require revenue codes for reimbursement and utilize the appropriate CPT code for the vaccine manufacturer and dose provided.

Providers Who Submitted Claims

An Erroneous Payment Correction (EPC) will be initiated to reprocess claims that were previously reimbursed at a lower maximum allowable amount, or if the amount billed was greater than or equal to the current Medi-Cal allowed amount ($67.00) at time of initial submission.

Providers who already billed Medi-Cal for the reimbursement of a COVID-19 vaccine-only encounters, and may have erroneously entered a billed amount less than intended , must follow the instructions below to manage their claims appropriately.

Claims within the timeliness guidelines (six months from the date of service):
Claims still within the timeliness standards outlined in the UB-04 Submission and Timeliness Instructions section of the Part 2 provider manual, may be voided and resubmitted either electronically or via hardcopy by providers. Upon resubmission, providers must follow the billing instructions in the “General” subheading in this article. Void and resubmission methods available to providers within this timeframe are given below:
  • Electronic resubmission: Providers who elect to void and resubmit claims electronically, must follow the instructions in the Electronic Methods for Eligibility Transactions and Claim Submissions section of the Part 1 provider manual

  • Hardcopy resubmission: Providers who elect to void and resubmit claims via hard copy, must request a void using the Claims Inquiry Form (CIF), and then resubmit the claim using the Appeal Form (90-1) once the provider has received confirmation of the void on their Remittance Advice Details (RAD). Instructions to complete both the CIF and 90-1 can be found in the:
Note: A void will recoup the original payment. Providers will see this recoupment reflected in the next RAD and Medi-Cal Financial Summary following the recoupment. In order for providers to receive reimbursement, they must follow the process above to completion.

Claims outside of the timeliness guidelines (more than six months from the date of service):
Claims outside of the timeliness standards outlined in the UB-04 Submission and Timeliness Instructions section of the Part 2 provider manual must be processed as follows:

  • Void using the Claims Inquiry Form (CIF), and then resubmit the claim using the Appeal Form (90-1) once the provider has received confirmation of the void on their Remittance Advice Details (RAD). Instructions to complete both the CIF and 90-1 can be found in the:


  • No electronic method is available at this time.

Providers must follow the billing instructions in the “General” subheading in this article for the corrected claim that is included with the Appeal.

Additional Resources

Providers with questions may reach out to the Medi-Cal Telephone Service Center (TSC) at 1-800-541-5555, Monday through Friday, 8 a.m. to 5 p.m., excluding holidays. Additional contact options may be found on the Contact Us page of the Medi-Cal Providers website.

For instructions on how to submit or resubmit a claim with a delay reason code, or a list of all manual sections referenced in this article, providers may reference the following resources:

UB-04:

837:

CIF:

Appeal:

3. Rebilling Period Provided for Telehealth Claims Denied Using TOB 02

The Department of Health Care Services (DHCS) previously published the Medi-Cal Update titled “Medi-Cal Payment for Telehealth and Virtual/Telephonic Communications Relative to the 2019-Novel Coronavirus (COVID-19)” to instruct outpatient providers to bill claims with Place of Service (POS) code “02” in conjunction with the appropriate telehealth modifier.

The DHCS Policy Division has clarified that POS code 02 is only to be billed on a CMS-1500 claim form. Outpatient providers that submitted claims with a Type of Bill (TOB) “02” for telehealth services were erroneously denied with Remittance Advice Details (RAD) code 0062: The Place of Service is not acceptable for this procedure. For additional information regarding POS, please refer to the Medicine: Telehealth section in Part 2 of the Medi-Cal Provider Manual.

For dates of service March 1, 2020, through October 31, 2021, outpatient providers may rebill their claims that denied for RAD code 0062. The TOB should include the appropriate two-digit facility type code that reflects the type of facility that provided the service. For a complete list of the facility type codes, please refer to the UB-04 Completion: Outpatient Services section in Part 2 of the Medi-Cal Provider Manual.

Telehealth claims must also be billed with an appropriate telehealth modifier, as follows:

  • Modifier 95: synchronous, interactive audio and telecommunications systems

  • Modifier GQ: asynchronous store and forward telecommunications systems

Furthermore, the rebilled claims must include the following:

  • Delay Reason code “11”

  • “Rebilling telehealth services for claims denied using TOB 02” under remarks

Medi-Cal will waive the standard billing timelines to allow for rebilling of claims that were erroneously denied because of this issue until July 31, 2022.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals medne tele (5)

4. Billing Multiple NCCI Modifiers Together and Additional NCCI Webpage Resources

As previously announced in the article titled “Multiple NCCI Modifiers Now Billable Together,” multiple National Correct Coding Initiative (NCCI) modifiers may be billed on the same claim line if it is appropriate and medically justified. In particular, claims may have more than one NCCI associated modifier applied to a claim line only when medically necessary, as documented in the medical record, and in accordance with the Medicaid NCCI program and HCPCS and CPT® guidelines for the modifier and procedure code combination. Providers can refer to Correct Coding Initiative: National section in the appropriate Part 2 manual for instructions regarding the appropriate use of NCCI-associated modifiers.

The Correct Coding Initiative: National manual section also includes direction specifically on how providers should complete claims to bypass any potential NCCI edit when they:

  • Perform the same service on the same date for a newborn and the mother or;

  • Perform the same service on the same day for newborns in a multiple birth scenario.

Additionally, the following resource list from the Centers for Medicare & Medicaid Services (CMS) Medicaid NCCI website have been added to the NCCI web page:

  • NCCI Policy Manual for Medicaid Services

  • The Medicare Learning Network (MLN) booklet, “How to Use the Medicaid National Correct Coding Initiative (NCCI) Tools”

  • Complete Medicaid NCCI Edit Files

  • Medicaid Change Reports

  • Proper Use of Modifiers 59 & - X{EPSU}

  • Medicaid NCCI Correspondence Language Manual

  • Medicaid NCCI FAQs
Provider Manual(s) Page(s) Updated
Acupuncture
Chiropractic
appeal form (7); cif co (3); cms comp (15, 21); remit adv (3); remit pay (3)
AIDS Waiver Program
Home Health Agencies/Home and
Community-Based Services
Vision Care
appeal form (7); cif co (3); correct (1–7); correct cod (1); modif app (1); remit adv (3); remit pay (3)
Audiology and Hearing Aids
Therapies
appeal form (7); cif co (3); cms comp (15, 21); correct (1–7); correct cod (1); modif app (1); remit adv (3); remit pay (3)
Chronic Dialysis Clinics
Clinics and Hospitals
Rehabilitation Clinics
appeal form (7); cif co (3); correct (1–7); correct cod (1); modif app (1); modif used (2); remit adv (3); remit pay (3)
Community-Based Adult Services
Heroin Detoxification
Multipurpose Senior Services Program
appeal form (7); cif co (3); correct (1–7); correct cod (1); remit adv (3); remit pay (3)
Durable Medical Equipment appeal form (7); cif co (3); cms comp (15, 21); correct (1–7); correct cod (1); modif app (1); remit adv (3); remit pay (3)
General Medicine
Obstetrics
appeal form (7); cif co (3); cms comp (15, 21); correct (1–7); correct cod (1); modif app (1); modif used (2); preg ex cms (5, 7); remit adv (3); remit pay (3)
Hospice Care Program
Inpatient Services
Long Term Care
appeal form (7); cif co (3); remit adv (3); remit pay (3)
Home Health Agencies/Home and Community-Based Services
Local Educational Agency
appeal form (7); cif co (3); modif app (1); remit adv (3); remit pay (3)
Medical Transportation appeal form (7); cif co (3); cms comp (15, 21); remit adv (3); remit pay (3)
Orthotics and Prosthetics appeal form (7); cif co (3); cms comp (15, 21); correct (1–7); correct cod (1); modif app (1); ortho ex (5); remit adv (3); remit pay (3)
Pharmacy appeal form (7); cif co (3); cms comp (15, 21); ortho ex (5); remit adv (3); remit pay (3)
Psychological Services appeal form (7); cif co (3); cms comp (15, 21); correct (1–7); correct cod (1); remit adv (3); remit pay (3)

5. Claims Processing Error Affecting Select Home Dialysis Codes Resolved

The Department of Health Care Services (DHCS) announced on March 18, 2022, in an article titled “Monthly Block-Billing and By Report Billing Required for Home Dialysis Codes” that claims for the following HCPCS codes may have erroneously denied:

  • S9335 (home therapy, hemodialysis; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment [drugs and nursing services coded separately], per diem) and

  • S9339 (home therapy; peritoneal dialysis, administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment [drugs and nursing visits coded separately], per diem).

The system issue has now been resolved and claims should no longer erroneously deny however Medi-Cal will continue to monitor claim submissions.

As a reminder, HCPCS codes S9335 and S9339 require both monthly block-billing and “By Report” billing. Instructions on how to properly complete a claim for monthly block-billing, or “from-through” billing, as well as how to properly submit “By Report” documentation, may be found in the UB-04 Special Billing Instructions for Outpatients section of the Part 2 provider manual.

6. CHDP Gateway Program 2022 Income Eligibility Guidelines

Effective January 1, 2022, through December 31, 2022, providers are to use the following income guidelines when determining recipient eligibility for pre-enrollment in Medi-Cal through the Child Health and Disability Prevention (CHDP) Gateway program. Providers should disregard all previous CHDP income eligibility guidelines charts.

CHDP Income Eligibility Guidelines
2022 Federal Poverty Level Guidelines
(For determinations of CHDP Gateway aid codes 8W and 8X only)
CHDP FPL Chart – Effective January 1, 2022

Number of
Persons in the
Household
266 Percent
Monthly Income
266 Percent
Annual Income
1 $3,014 $36,150
2 $4,060 $48,705
3 $5,108 $61,260
4 $6,153 $73,815
5 $7,198 $83,671
6 $8,246 $98,926
7 $9,292 $111,481
8 $10,337 $124,036
9 $11,385 $136,591
10 $12,431 $149,147
For households
of more than 10
persons, for
each additional
person, add:
$1,049 $12,556

Note: Annual Federal Poverty Level (FPL) figures updated in the Federal Register by the U.S. Department of Health and Human Services
Provider Manual(s) Page(s) Updated
General Medicine
Obstetrics
Clinics and Hospitals
Audiology and Hearing Aids
Orthotics and Prosthetics
Psychological Services
Vision Care
epsdt chdp gate (11)

7. 2022 Income Eligibility Guidelines for PE4PW

Effective January 1, 2022, through December 31, 2022, Presumptive Eligibility for Pregnant Women (PE4PW) program providers must use the following income guidelines to make PE4PW eligibility determinations. Providers should disregard all previous PE4PW income eligibility guidelines charts.

Presumptive Eligibility for Pregnant Woman Program
2022 Monthly Income Levels

Household Size 213 Percent Monthly 213 Percent Annually
2 $3,251 $39,001
3 $4,090 $49,054
4 $4,927 $59,108
5 $5,764 $69,162
6 $6,603 $79,215
7 $7,441 $89,269
8 $8,278 $99,322
9 $9,117 $109,376
10 $9,954 $119,430
11 $10,791 $129,483
12 $11,630 $139,537
Each Additional Person in Family Household Size $840 $10,054

Note: The 2022 Federal Poverty Levels (FPL) dollar values are rounded up to the next higher dollar amount. The 2022 FPL dollar values are valid through December 31, 2022 and are updated annually in January.
Provider Manual(s) Page(s) Updated
General Medicine
Obstetrics
Clinics and Hospitals
Pharmacy
presum (4); presum proc (4)

8. Hospital Presumptive Eligibility (HPE) Federal Poverty Level (FPL) Updates

The HPE Portal will be updated with the 2022 FPLs on May 24, 2022. In the interim, providers are advised to review denials due to income based upon the 2021 FPLs for potential eligibility based on the 2022 FPLs. The updated 2022 FPLs can be accessed in ACWDL 22-03.

If providers receive an incorrect denial for HPE based upon 2021 FPLs, please send an email including the signed and dated HPE application to DHCSHospitalPE@dhcs.ca.gov. DHCS will manually review for eligibility based on 2022 FPLs. If the individual is determined eligible, DHCS will activate eligibility beginning on the date of application and alert the provider that eligibility has been granted.

This guidance pertains only to denials received due to incorrect FPLs in the HPE Portal.

9. CAR-T Cell Therapies Policy Update

Effective for dates of service on or after June 1, 2022, policies for the following Healthcare Common Procedure Codes (HCPCS) for Chimeric Antigen Receptor (CAR) T cell therapies have been changed:

HCPCS Code Code Description
Q2041 Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR positive T cells, including leukapheresis and dose preparation procedures, per therapeutic dose (Yescarta®)
Q2042 Tisagenlecleucel, up to 600 million CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose (Kymriah®)
Q2053 Brexucabtagene autoleucel, up to 200 million autologous anti-CD19 CAR positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose (Tecartus)
Q2054 Lisocabtagene maraleucel, up to 110 million autologous anti-CD19 CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose (Breyanzi®)
Q2055 Idecabtagene vicleucel, up to 460 million autologous B-cell maturation antigen (BCMA) directed CAR-positive T cells, including leukapheresis and dose preparation procedures, per therapeutic dose (Abecma®)

The policy changes include but are not limited to the following:

  • Outpatient administration is restricted to Hospital Outpatient Services only

  • The provider facility is accredited by the Foundation for the Accreditation of Cellular Therapy (FACT) for Immune Effector Cell Therapy (IECT)

  • Additional billing instructions which will allow providers to bill separately for the administration of CAR-T cell therapies using CPT® code 96413 (Chemotherapy administration, intravenous infusion; up to 1 hour, single or initial substance/drug), etc.
Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
chemo drug a-d (10–14, 27–30); chemo drug e-o (14, 15, 27–29); chemo drug p-z (38–40)

10. Claims Reimbursement Update for Medical and Incontinence Supplies

Effective for dates of service on or after October 1, 2020, the California State Plan Amendment (SPA) 20-0035 updates the Medi-Cal prescriber requirements for medical supplies and incontinence supplies.

Claims for covered medical and incontinence supplies provided upon a prescription are eligible for reimbursement if the prescription is written by a physician, nurse practitioner (NP), clinical nurse specialist (CNS) or a physician assistant (PA) within their scope of practice. Code of Federal Regulations (CFR) Title 42, Section 440.70, requires Medicaid programs to only reimburse providers for medical and incontinence supplies written by a physician, MP, CNS or PA.

In addition to the policy changes, the following spreadsheets are retired from the Medi-Cal website and are available on the Medi-Cal Rx website:

  • List of Contracted Diabetic Test Strips and Lancets

  • List of Contracted Pen Needles

  • List of Contracted Sterile Needles

The Medical Supplies and Incontinence sections of the provider manual have been updated to clarify the prescriber requirements.

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
enteral (1–4); incont (1, 5); incont ex (1); mc sup (1–3, 6–10, 13)
Clinics and Hospitals
General Medicine
incont (1, 5); non ph (1); cal child sar (12)
Obstetrics
Rehabilitation Clinics
cal child sar (12); nonph (1, 4)
Audiology and Hearing Aids
Chronic Dialysis Clinics
Home Health Agencies/Home and Community-Based Services
Inpatient Services
Local Educational Agency
Medical Transportation
Orthotics and Prosthetics
Psychology Services
Therapies
Vision Care
cal child sar (12)
Long Term Care incont (1, 5)

11. Postpartum Care Expansion for Medi-Cal and MCAP Beneficiaries

As part of the American Rescue Act Plan (ARPA), effective April 1, 2022, an individual eligible for pregnancy and postpartum care services under Medi-Cal or the Medi-Cal Access Program (MCAP) is entitled to an additional ten months of postpartum coverage at the end of their 60-day postpartum period for a total 12 months of postpartum coverage. This coverage shall include the full breadth of medically necessary services through the pregnancy and postpartum period.

With this expansion, eligibility for the 12 months of postpartum coverage is granted to any individual in an aid code where postpartum services are a covered benefit.

For more information regarding the ARPA postpartum care expansion (PCE), see the Pregnancy web page on the Medi-Cal Providers website. The web page includes flyers that may be distributed to beneficiaries eligible for the ARPA PCE benefit: This article was originally published on September 16, 2021. It has been republished to continue to bring it to providers’ attention. No additional updates have been made since the original publication with the exception of the paragraph above.

Questions concerning this expansion of postpartum care should be sent to pregnancy@dhcs.ca.gov.

12. Get the Latest Medi-Cal News: Subscribe to MCSS Today

The Medi-Cal Subscription Service (MCSS) is a free service that keeps you up-to-date on the latest Medi-Cal news. Subscribers receive subject-specific emails shortly after urgent announcements and other updates post on the Medi-Cal website.

Subscribing is simple and free!

  1. Go to the MCSS Subscriber Form

  2. Enter your email address and ZIP code and select a subscriber type

  3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

After submitting the form, a welcome email will be sent to the provided email address. If you are unable to locate the welcome email in your inbox, check your junk email folder.

For more information about MCSS, please visit the MCSS Help page.

13. Provider Manual Revisions



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