Medi-Cal Logo

Medi-Cal Update

Local Educational Agency | June 2022 | Bulletin 573

Print Medi-Cal Update Print Icon

1. Update: Second Booster Dose for Select COVID-19 Boosters Now a Benefit

Effective for dates of service (DOS) on or after March 29, 2022, the U.S. Food and Drug Administration (FDA) amended the Emergency Use Authorization (EUA) for the Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine, to allow for use of a second booster dose, to be administered at least four months after initial booster dose, to the following groups for each respective vaccine:

Pfizer-BioNTech:

  • Individuals 12 years of age or older with certain kinds of immunocompromise. This includes individuals who have undergone solid organ transplantation, or who are living with conditions that are considered to have an equivalent level of immunocompromise.

  • Individuals 50 years of age and older.

Moderna:

  • Individuals 18 years of age or older with certain kinds of immunocompromise. This includes individuals who have undergone solid organ transplantation, or who are living with conditions that are considered to have an equivalent level of immunocompromise.

  • Individuals 50 years of age and older.

Providers may now submit claims for second booster dose administration using the following codes:

  • Pfizer:

    • Administration Code 0004A for the originally authorized formulation (phosphate buffered saline)

    • Administration Code 0054A is for the Tris buffered formulation

  • Moderna:

    • Administration Code 0064A

    • Administration Code 0094A for new booster formulation (50 mcg/0.5 ml)

Billing:

Providers can now bill for administration code 0094A. A booster dose of any manufacturer cannot be billed for the same recipient more than once on the same DOS.

For the most current information regarding Medi-Cal’s COVID-19 response, see the COVID-19 Medi-Cal Response page on the Medi-Cal Provider website.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
immun (41, 42, 44, 45); immun cd (5)

2. Unsatisfactory Immigration Status Population in the Local Educational Agency Medi-Cal Billing Option Program

Effective for dates of service on or after July 16, 2021, Medi-Cal covers emergency and pregnancy related services provided to Unsatisfactory Immigration Status (UIS) beneficiaries are eligible for Federal Financial Participation (FFP). However, the Local Educational Agency (LEA) Billing Option Program (BOP) does not reimburse for these types of services. Furthermore, the LEAs are responsible to fund LEA BOP services provided to UIS beneficiaries through local funds and state general fund will not be expended for this population.

FFP is not allowed for the LEA BOP for non-emergency and non-pregnancy related services for beneficiaries with UIS, per the Social Security Act section 1903(v) (2).

The Department of Health Care Services (DHCS) has updated the Fiscal Intermediary and data match process to ensure that LEA claims for beneficiaries with UIS are appropriately denied for FFP and excluded from the Medi-Cal Eligibility Ratio process. The LEA BOP provides the federal share of reimbursements for services provided to Medi-Cal enrolled students who have an Individualized Education Plan (IEP)/Individualized Family Services Plan (IFSP)/Individualized Health and Support Plan (IHSP).

No action is required by providers. An Erroneous Payment Correction (EPC) will be implemented to reprocess the affected claims.

Beneficiaries (with an UIS) are individuals who fall into at least one of the following groups:

  • Any individual that falls within a restricted scope Medi-Cal aid code. Restricted scope Medi-Cal aid codes are those aid codes that cover only emergency and pregnancy related services, and when needed, long-term care. FFP for these aid codes is limited to emergency and pregnancy related services.

  • Any individual that falls within a full scope aid code who is receiving state funded full scope Medi-Cal because they have an UIS. FFP for individuals receiving state funded full scope Medi-Cal is also limited to emergency and pregnancy related services. Individuals with an UIS, who are receiving state funded full scope Medi-Cal, will fall into one of the following categories:

    • “Qualified” Non-Citizen (QNC) beneficiaries who are subject to and have not met the five-year bar.

    • QNC beneficiaries who are not federally eligible for full scope Medi-Cal.

    • Individuals who are Permanently Residing Under Color Of Law (PRUCOL).

    • Senate Bill 75 (Chapter 18, Statutes of 2015).

    • Young Adult Expansion (YAE) beneficiaries (ages 21 to 25).

    • Trafficking and Crime Victim Assistance Program (TCVAP) beneficiaries. The TCVAP program is a cash and medical assistance program for eligible non-citizen victims of trafficking and other crimes. TCVAP beneficiaries are in the following aid codes: 2V, 4V, 5V and 7V. TCVAP beneficiaries in aid code 2V and 4V are 100 percent State Funded. For individuals in aid code 5V or 7V, FFP is available only for emergency and pregnancy related services.

    • Effective May 1, 2022, Older Adult Expansion (OAE) beneficiaries (50 years of age or older)
Provider Manual(s) Page(s) Updated
Local Educational Agency loc ed elig (1, 2)

3. Frequency Update for Select LEA BOP Assessments Billed with CPT Code 96156

As previously announced in the article titled “Modifiers HL and HM Billable with CPT Codes 96156 and 99401 for Select LEA BOP Services,” associate marriage and family therapists and associate clinical social workers may be billed for select Local Educational Agency Medi-Cal Billing Option Program (LEA BOP) services using CPT® codes 96156 and 99401. Among those services were non-Individual Education Plan (IEP) and non-Individual Family Service Plan (IFSP) psychosocial status assessments.

Effective for dates of service on or after July 1, 2021, non-IEP/IFSP psychosocial status assessments billed with CPT code 96156 are reduced from four units of 15-minute increments per day per student to one unit per day per student in compliance with Centers for Medicare and Medicaid Service (CMS) initiatives.

As a reminder, LEA providers are to submit historical claims with dates of service on or after July 1, 2021, to Medi-Cal by June 30, 2022, to receive a denial. An Erroneous Payment Correction (EPC) will be implemented to reprocess denied claims with dates of service on or after the effective date of this billing policy, that were appropriately submitted based on the guidance published in this article, but erroneously denied because Medi-Cal had not yet implemented the system changes to support appropriate adjudication. 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
Local Educational Agency loc ed serv psych (2, 5, 10)

4. LEA Reimbursement Rates Updated for Fiscal Year 2022 Through 2023

Effective for dates of service on or after July 1, 2022, the maximum allowable rates for Local Educational Agency (LEA) services have been updated for state fiscal year 2022 through 2023. Providers can find these updates rates in the “LEA Services Billing Codes Chart” in the Part 2, Local Educational Agency (LEA) Billing Codes manual.

Provider Manual(s) Page(s) Updated
Local Educational Agency loc ed bil cd (2–25, 28–43, 45, 46)

5. National Correct Coding Initiative Quarterly Update for July 2022

The Centers for Medicare & Medicaid Services (CMS) has released the quarterly National Correct Coding Initiative (NCCI) payment policy updates. These mandatory national edits have been incorporated into the Medi-Cal claims processing system and are effective for claims received on or after July 1, 2022.

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

6. July 2022 Medi-Cal Provider “Coffee Break” Event

Medi-Cal's Outreach and Education department, along with the Department of Health Care Services is offering a “Coffee Break” event in July for category specific topics.

Topics discussed will include the following:

Topic Date
Remittance Advice Details July 5 and July 19
Medi-Cal Resources July 5 and July 19
Claims Follow-up July 6 and July 20
Eligibility/Share of Cost (SOC) July 6 and July 20
Lab Services July 7 and July 21
Home Health/Early and Periodic Screening Diagnostic and Treatment (EPSDT) July 7 and July 21
Medical Transportation July 12 and July 26
Durable Medical Equipment and Medical Supplies (DME) July 12 and July 26
Inpatient Obstetrics (OB) July 13 and July 27
Family Planning, Access, Care and Treatment (Family PACT) July 13 and July 27
California Children's Services (CCS)/Genetically Handicapped Person's Program (GHPP) July 14 and July 28
Obstetrics (OB)/Comprehensive Perinatal Services Program (CPSP) July 14 and July 28

Providers may visit the Medi-Cal Learning Portal (MLP) to view available coffee break times and to register in the Event Calendar.

Providers are encouraged to bring questions relating to the “Coffee Break” session topic. This is an open forum, therefore, claim examples are not needed for this event.

For additional assistance, contact the Telephone Service Center (TSC) at 1-800-541-5555.

7. August 2022 Medi-Cal Provider Training Webinars

Outreach and Education (O&E) along with the Department of Health Care Services (DHCS) are offering category specific webinar sessions in August.

Session Date
Medi-Cal Resources 101 August 2
Navigating the Medi-Cal Website and Online Billing August 2 and 9
Long Term Care August 4
Inpatient and Outpatient Services August 9
Claims Follow-Up August 11
Health Access Programs August 16, 18 and 23
Hospital Presumptive Eligibility August 16
Every Woman Counts August 23
Durable Medical Equipment & Medical Supplies August 25
Medical Transportation Service August 25
Home Health Services August 30

A variety of courses will be offered in each of the categories listed. Providers must register through the Medi-Cal Learning Portal (MLP) Event Calendar.

Providers will be able to print class materials and ask questions during the training sessions.

To view the webinars, providers must have internet access and a user profile in the MLP. Detailed instructions about the registration process and how to access webinar classes are available on the Outreach & Education page of the Medi-Cal Providers website.

For additional assistance, contact the Telephone Service Center (TSC) at 1-800-541-5555.

8. 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.

9. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



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