Medi-Cal Logo

Medi-Cal Update

Local Educational Agency | November 2021 | Bulletin 566

Print Medi-Cal Update Print Icon

1. MCSS Emails and MLP Surveys Temporarily Suspended

Due to technical difficulties, the following Medi-Cal services are temporarily suspended until further notice:

  • Medi-Cal Subscription Service (MCSS): emails sent to MCSS subscribers are temporarily suspended. Existing subscribers can still access their profile and edit their subscription preferences during this period, and potential new subscribers can also sign up with MCSS, although they may not receive a traditional welcome email after successful subscription.

  • Medi-Cal Learning Portal (MLP): survey links available in the MLP for users who have completed a course, are temporarily suspended. Users can still access the MLP and complete MLP courses, but they will not be able to submit a survey after completion of the course.

Note: During this period survey completion will not be required to obtain a certificate for completion of the Audits & Investigations courseware.

Medi-Cal is monitoring the issue and working on resuming both services as soon as possible. We apologize for the inconvenience.

2. Safety Net Clinic Billing Instructions for CalAIM Dental Initiatives

Effective for dates of service on or after January 1, 2022, the Department of Health Care Services (DHCS) will implement the California Advancing and Innovating Medi-Cal (CalAIM) dental initiatives statewide. CalAIM dental initiatives are based on the successful outcomes of the Dental Transformation Initiative (DTI), which was implemented in certain counties from 2016 to 2021 under the 2020 Medi-Cal 1115 Waiver.

CalAIM dental initiatives include pay-for-performance payments for preventive services and continuity of care/ establishing a dental home, and two new program benefits: caries-risk assessment (CRA) bundle for children ages zero to six and application of caries arresting medicament silver diamine fluoride (SDF).

For the pay-for-performance payments, Indian Health Services, Memorandum of Agreement (IHS-MOA), Federally Qualified Health Centers (FQHCs), Tribal FQHCs, and Rural Health Clinics (RHCs) also referred to as Safety Net Clinics (SNCs), must submit detailed claims data to the Dental Fiscal Intermediary (FI) following the guidelines below for the new CRA and SDF benefits. In addition to the pay-for-performance payments, dental services will be reimbursable at the clinic’s established per-visit rate via the Medi-Cal FI using the billing instructions in the Rural and Indian Health Provider, Tribal FQHC Manuals.

Pay-for-Performance Payments

  • Preventive services, paid at 75% of the standard Schedule of Maximum Allowances (SMA) fee for each paid preventive service

    • The Current Dental Terminology (CDT) procedures eligible for this pay-for-performance payment are as follows:

    • Ages 0 to 20:

      • D1120, prophylaxis, child

      • D1206, topical application of fluoride varnish

      • D1208, topical application of fluoride - excluding varnish

      • D1351, sealant - per tooth

      • D1352, preventive resin restoration in a modern to high caries risk patient, permanent tooth

      • D1510, space maintainer – fixed, unilateral, per quadrant

      • D1516, space maintainer – fixed, bilateral, maxillary

      • D1517, space maintainer – fixed, bilateral, mandibular

      • D1526, space maintainer – removable, maxillary

      • D1527, space maintainer – removable, mandibular

      • D1551, re-cement or re-bond bilateral space maintainer – maxillary

      • D1552, re-cement or re-bond bilateral space maintainer – mandibular

      • D1553, re-cement or re-bond unilateral space maintainer – per quadrant

      • D1556, removal of fixed unilateral space maintainer – per quadrant

      • D1557, removal of fixed bilateral space maintainer – maxillary

      • D1558, removal of fixed bilateral space maintainer – mandibular

      • D1575, distal shoe space maintainer, fixed, unilateral – per quadrant

    • Ages 21 or older:

      • D1320, tobacco counseling for the control and prevention of oral disease

      • D1999, unspecified preventive procedure, by report

  • Continuity of care, paid at $55 annually for each beneficiary who receives at least one annual dental exam for two or more years in a row at the same dental service office location (dental home).

    • The CDT procedures eligible for this pay-for-performance payment are as follows:

      • D0120, periodic oral evaluation – established patient

      • D0145, oral evaluation for a patient under three years of age and counseling with primary caregiver

      • D0150, comprehensive oral evaluation – new or established patient

  • Pay-for-performance payments are issued to providers once per month and inclusive of both preventive services and continuity of care.

  • To earn pay-for-performance payments, SNCs must send qualifying paid claims data (including CDT codes for services rendered) to the Dental FI for processing and payment. Claims must be submitted within 12 months of the date of service to qualify for payment. Claims may be submitted electronically through the Electronic Data Interchange (EDI) process, or the proprietary paper form submission process described on the CalAIM Dental web page. The proprietary mailing address is:

Medi-Cal Dental Operations
SNC Paper Encounter Submissions
PO Box 13189
Sacramento, CA 95813-3189

New Benefits

The new benefits described below are reimbursable at the clinic’s established per-visit rate.

  • CRA and nutritional counseling bundle for children ages zero to six.

    • All providers are required to take and complete the Treating Young Kids Everyday (TYKE) training hosted by the California Dental Association to provide CRA treatment to patients. If a provider has previously successfully completed the TYKE training for DTI, they do not have to retake the training.

    • Certification of completion must remain on file for audit purposes.

    • Providers must use the CRA forms, which are posted on the DHCS CalAIM Dental These forms must remain on file for audit purposes.

  • SDF application for children ages zero to six and for individuals of all ages for whom non-restorative caries treatment is optimal (including the Department of Developmental Services (DDS) population, those living in Skilled Nursing Facilities/Intermediate Care Facilities [SNFs/ICFs], or those with another demonstrated medical necessity).

Providers are reminded that treatment plans should be patient-centered and equitable. Per Medi-Cal Dental policy, providers shall minimize the number of dental visits for the patient when applicable, feasible, and consistent with the standard of care. Documentation should follow requirements established in the Medi-Cal Dental Provider Handbook and Manual of Criteria and should indicate the medical necessity of any additional visits required for treatment. In most cases, SDF/caries arresting medicaments should be applied during the regular dental exam, prophylaxis appointments, or during CRA appointments.

3. Introduction of Therapeutic Substance into Mouth and Pharynx Not Restricted to Females

Effective retroactively for dates of service on or after October 1, 2015, ICD-10-CM code 3E0DXGC (introduction of Other Therapeutic Substance into Mouth and Pharynx, External Approach) is not restricted to female patients. The system was incorrectly updated and is causing erroneous denials.

An Erroneous Payment Correction (EPC) will be implemented to reprocess claims denied on the basis of the patient’s sex, with dates of service on or after the effective date of this billing policy that were appropriately submitted.

4. New Electronic Claim Resubmission Helps Providers Avoid Paper CIFs/Appeals

Providers can electronically resolve a claim denial or incorrect payment for 837I (Institutional) and 837P (Professional) electronic claims. By resubmitting the claim with either frequency type code “7” (replacement of prior claim) or “8” (void/cancel of prior claim), there is no longer a need to adjust claims using paper Claims Inquiry Forms (CIFs) or Appeal Forms with accompanying Remittance Advice Details (RADs) to show proof of previous claim payment or denial. Electronic claim resubmission is not available for pharmacy claims.

The ANSI X12 v.5010 837 electronic transactions claim format allows a provider to initiate changes to already-adjudicated claims. The 837 Implementation Guides refer to the National Uniform Billing Data Element Specifications Loop 2300 CLM05-3 for explanation and usage. In the 837 formats, the codes are called “claim frequency codes.”

Replacement and void claims can be sent in the same batch as new claims.

Electronic replacement claims must be submitted within six months of the previous claim payment or denial. Providers may submit an electronic follow-up claim even if the original was a paper claim. Claims for which a CIF or appeal are already in progress must not be electronically resubmitted. Claims for which a CIF or appeal is in progress will be denied.

The following chart outlines the use of codes “7” and “8.”

Frequency Type Code ‘7’

Electronic allied health, long term care, medical services, obstetric, outpatient and vision care claims resubmitted with Frequency Type code “7” (replacement claim):

  • Are used to modify only one claim line. They cannot be used to replace multiple original claim lines.

  • A separate replacement claim transaction must be performed for each claim line being replaced. For example, to replace all five lines of an outpatient claim, the submitter must submit five separate transactions.

  • Must contain corrected information for the original claim.

  • Must include the 13-digit Claim Control Number (CCN) from the original paid claim. For the claim to be considered for full reimbursement, the RAD date for the previous claim payment or denial must be within six months of the date the replacement claim was submitted.

Electronic inpatient claims resubmitted with Frequency Type code “7” (replacement claim):

  • Replace the entire inpatient care claim.
Claim Frequency Code/Definition Use Filing Guidelines Result
7
Replacement of Prior Claim
Use to replace a claim line or entire claim in an already adjudicated paid or denied claim (see following instructions per claim type) File the claim line or entire electronic claim including all services for which reconsideration is requested Medi-Cal will adjust the original claim. The corrections submitted will be reflected on the 835 Transaction and/or paper Remittance Advice Details (RAD) and other standard claim response vehicles
8
Void/Cancel of Prior Claim
Use to eliminate an already adjudicated claim for a specific provider, recipient and date of service (see following instructions per claim type) File the claim electronically and include all claims data and charges that were on the original claim Medi-Cal will void the original claim from history based on request, which will be reflected on the 835 Transaction and/or paper RAD and other standard claim response vehicles

Frequency Type Code ‘8’

Electronic long term care, medical services, outpatient and vision care claims resubmitted with Frequency Type code “8,” (void/cancel of prior claim):

  • Must include the 13-digit CCN from the original paid claim.

  • Serve as a full void for one claim line only. Multiple original claim lines cannot be voided with one void claim transaction.

  • A separate void claim transaction must be performed for each claim line being voided. For example, to void all five lines of an outpatient claim, the submitter must submit five separate transactions.

Electronic inpatient claims resubmitted with Frequency Type code “8” (void/cancel of prior claim):

  • Void the entire inpatient care claim.

Errors to Avoid

Providers should pay attention to the instructions above that certain claim types can replace or void one claim line only. Additionally, the CCN of the original claim is the proper information to insert in the REF segment.

Correct CCN for Crossover Claims

Providers resubmitting a Medicare to Medi-Cal crossover claim should take care to enter the CCN from the Medi-Cal claim they are resubmitting and not the CCN from the Medicare claim.

Claim Attachments

Attachments required with the initial claim submission are required for replacement claim submissions. Copies of claims initially submitted on paper are not needed. Information from the paper claim will already have been keyed into the claims processing system.

No attachments are required when voiding a claim.

Information about submitting attachments for electronic claims is available in the Billing Instructions: Acceptable Claims, Attachments and ASC X12N 835 v.5010 Transactions section of the Medi-Cal Computer Media Claims (CMC) Billing and Technical Manual, specifically under the following headings:

  • “Supporting Documentation – Attachments”

  • “Attachment Control Form: Required and Optional Fields”

  • “Attachment Control Form (ACF) Guidelines”

Associated RAD Code and Correlation Table Update

The following Remittance Advice Details (RAD) message has been added in the Part 1, RAD Repository, provider manual section to help providers reconcile claims submitted using claim frequency code “7.” (The claim frequency code is the third digit of the “Type of Bill” Code.)

Code Message
9174 Computer Media Claims (CMC) replacement submitted after six months of referred claim Remittance Advice Details (RAD) is not payable

Reimbursement

If the initial adjudicated claim was subject to a reimbursement reduction due to late claim submission, then reimbursement for the resubmitted claim also will be reduced.

Reference

Providers may wish to save a copy of this article for future reference.

Provider Manual(s) Page(s) Updated
Part 1 appeal (1); cif (1); elect (3–5); RAD Repository
AIDS Waiver Program
Chronic Dialysis Clinics
Clinics and Hospitals
Community-Based Adult Services
ub sub (2, 6)

5. National Correct Coding Initiative Quarterly Update for October 2021

The Centers for Medicare & Medicaid Services (CMS) issued replacement files with revised procedure-to-procedure (PTP) files for the 4th quarter of 2021. The mandatory national edits were incorporated into the Medi-Cal claims processing system and were effective for claims received on or after October 1, 2021.

For additional information, refer to The National Correct Coding Initiative in Medicaid page of the Medicaid website.

6. 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.

7. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



Note:
Download PDF (Portable Document Format) reader from the Web Tool Box.