Family PACT Update

October 2021 | Bulletin 169


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1. Updated Policy for Palivizumab for the 2021–2022 RSV Season

Effective for dates of services on or after August 19, 2021, and continuing for the 2021–2022 respiratory syncytial virus (RSV) season only, county RSV positivity data for the time period reflecting the administered dose of Palivizumab (CPT® code 90378 [respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each]) is no longer required to be accompanied with a Treatment Authorization Request (TAR) for doses submitted outside the time period of a typical RSV season such as 2019–2020. Additional information can be found below.

Resources:

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitations Clinics
immun (62, 64)

2. Signature Requirement for Delivered Medications

Pursuant to Welfare and Institutions Code (W&I Code), Section 14043.341, providers who dispense controlled drugs, dangerous drugs or dangerous devices to a Medi-Cal or Family Planning, Access, Care and Treatment FPACT) beneficiary or client must maintain a record of the signature of the person receiving the drug or device. The Department of Health Care Services (DHCS) is providing further guidance to providers on how they may obtain the required signature prior to sending medications to a beneficiary or client or upon receipt of the medication by the beneficiary or client.

Provider Manual(s) Page(s) Updated
Family PACT prov res (14, 15)
Pharmacy reimbursement (7, 8)

3. Billing Instructions Updated for Contraceptive Patches

Effective for dates of service on or after October 1, 2021, HCPCS code J7304 (contraceptive supply, hormone containing patch, each) must be billed with modifier U1 for norelgestromin and ethinyl estradiol transdermal system (Xulane®) or U2 for levonorgestrel and ethinyl estradiol transdermal system (Twirla®).

HCPCS codes J7304U1 and J7304U2 have a maximum dispensing quantity of 52 patches that can be dispensed twice in a 12-month period. Both codes require a Treatment Authorization Request (TAR) for a third dispensing of the same product requested within a 12-month period.

An Erroneous Payment Correction (EPC) will be implemented to reprocess denied claims with dates of service on or after October 1, 2021, that were appropriately submitted based on the guidance published in this article, but erroneously denied because the system changes to support appropriate adjudication were not yet implemented. Providers may also elect to use this updated billing policy to correct and resubmit previously denied claims as described in the CIF Submission and Timeliness Instructions section of the Provider Manual.

Provider Manual(s) Page(s) Updated
AIDs Waiver Program
Audiology and Hearing Aids
Chronic Dialysis Clinics
Durable Medical Equipment
Home Health Agencies/ Home and Community-Based Services
Local Educational Agency
Medical Transportation
Orthotics and Prosthetics
Therapies
Vision Care
modif app (23, 24)
Clinics and Hospitals
General Medicine
Obstetrics
fam planning (5, 9); modif app (23, 24); non ph (12, 24)
Family PACT ben fam (12); ben grid (3, 46); clinic (11, 12, 22); drug (3, 7)
Rehabilitation Clinics modif app (23, 24); non ph (12, 24)

4. New Contraceptive Vaginal Gel Added as Clinic Benefit for the Family PACT and Medi-Cal Programs

Effective for dates of service on or after July 1,  2021, contraceptive vaginal gel, Phexxi® (lactic acid, citric acid and potassium bitartrate), is a clinic benefit for the Family Planning, Access, Care and Treatment (Family PACT) and Medi-Cal programs. Phexxi is reimbursable under HCPCS code A4269 (contraceptive supply, spermicide [e.g., foam, gel], each) with modifier U5 for contraceptive vaginal gel.

HCPCS code A4269U5 is restricted to one box (12 single-use applicators) per dispensing and is limited to three dispensings per any 75-day period.

An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims with dates of service on or after July 1, 2021, to the implementation date of this policy. Providers may also elect to use this updated billing policy to correct and resubmit previously denied claims as described in the CIF Submission and Timeliness Instructions section of the Provider Manual.

Provider Manual(s) Page(s) Updated
AIDs Waiver Program
Audiology and Hearing Aids
Chronic Dialysis Clinics
Durable Medical Equipment
Home Health Agencies/ Home and Community-Based Services
Local Educational Agency
Medical Transportation
Orthotics and Prosthetics
Therapies
Vision Care
modif app (24)
Clinics and Hospitals
General Medicine
Obstetrics
fam planning (5, 13, 14); modif app (24); non ph (27)
Family PACT ben fam (5, 31); ben grid (2–8, 14, 16, 45); clinic (9); drug (3–5); drug onsite (1); prog stand (6)
Rehabilitation Clinics modif app (24); non ph (27)

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6. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



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