Medi-Cal Logo

Medi-Cal Update

Multipurpose Senior Services Program | September 2021 | Bulletin 564

Print Medi-Cal Update Print Icon

1. Manual Adjudication of Presumptive Eligibility Aid Codes Within the Same Month of Eligibility

Background

Qualified Providers (QPs) who have attempted to enroll individuals in another Presumptive Eligibility (PE) program when the individual is currently active on the COVID-19 Uninsured Group Program (aid code V2) are receiving a response that the individual currently has Medi-Cal eligibility. QPs are unable to enroll individuals in a more beneficial Presumptive Eligibility (PE) program aid code where benefits are not limited to COVID-19 related services. This limitation has created issues in accessing care for individuals who should be receiving services beyond COVID-19 related services.

In addition, federal guidance allows retroactive eligibility for V2 back to April 8, 2020. Currently, the COVID-19 Uninsured Group Program portal does not allow for retroactive eligibility requests.

Interim Process

Effective immediately and continuing until further guidance, QPs are instructed to send the appropriate application information to the Department of Health Care Services (DHCS) when the QP is unable to enroll an individual in another PE aid code within the same month of eligibility as outlined in the following scenarios.

For the Child Health and Disability Prevention (CHDP) Gateway Program

Scenario 1: The individual is currently enrolled in V2 and the QP attempts to process a CHDP Program application through the portal. However, the QP receives a denial eligibility response for the CHDP Program because the individual is currently enrolled in V2.

Action: The QP should complete a manual determination based on CHDP Gateway Program requirements. If the QP determines that the individual is eligible for the CHDP Gateway Program, the QP should send a secure email to PE@dhcs.ca.gov with “Request to Overlay V2” in the email subject line and include the following information/documentation in the body of the email, or as attachments:

  • Completed CHDP Gateway Program Application (DHCS 4073)

  • Copy of the denial eligibility response showing the CHDP Gateway Program could not be approved due to other PE coverage

  • Client Index Number (CIN)

  • The new CHDP aid code in which the individual should be enrolled

For the Hospital Presumptive Eligibility (HPE) Program

Scenario 2: The individual is currently enrolled in V2 and the QP attempts to process a HPE Program application through the portal. However, the QP receives a denial eligibility response for the HPE Program because the individual is currently enrolled in V2.

Action: The QP should complete a manual determination based on HPE Program requirements. If the QP determines that the individual is eligible for the HPE Program, the QP should send a secure email to PE@dhcs.ca.gov with “Request to Overlay V2” in the email subject line and include the following information/documentation in the body of the email, or as attachments:

  • Completed HPE Program Application (DHCS 7022)

  • Copy of the denial eligibility response showing the HPE Program could not be approved due to other PE coverage

  • CIN

  • The new HPE aid code in which the individual should be enrolled

For the Presumptive Eligibility for Pregnant Women (PE4PW) Program

Scenario 3: The individual is currently enrolled in V2 and the QP attempts to process a PE4PW Program application through the portal. However, the QP receives a denial eligibility response for the PE4PW Program because the individual is currently enrolled in V2.

Action: The QP should complete a manual determination based on PE4PW Program requirements. If the QP determines that the individual is eligible for the PE4PW Program, the QP should send a secure email to PE@dhcs.ca.gov with “Request to Overlay V2” in the email subject line and include the following information/documentation in the email body or as attachments:

  • Copy of PE4PW Program Application (MC 263)

  • Copy of the denial eligibility response showing the PE4PW Program could not be approved due to other PE coverage

  • CIN

  • The new PE4PW aid code in which the individual should be enrolled

For the Breast and Cervical Cancer Treatment Program (BCCTP)

Scenario 4: The individual is currently enrolled in V2 and the QP attempts to process a BCCTP PE application through the portal. However, the QP receives a denial eligibility response for the BCCTP PE because the individual is currently enrolled in V2.

Action: The QP should complete a manual determination based on BCCTP PE requirements. If the QP determines the individual is eligible for the BCCTP PE, the QP should send a secure email to BCCTP@dhcs.ca.gov with “Request to Overlay V2” in the email subject line and include the following information/documentation in the body of the email, or as attachments:

  • Completed BCCTP Application (MC 210BC)

  • Copy of the denial eligibility response showing BCCTP could not be approved due to other PE coverage

  • CIN

  • The new BCCTP PE aid code in which the individual should be enrolled

For the COVID-19 Uninsured Group Program

Scenario 5: The individual was previously enrolled in another PE aid code for the month and the QP attempts to process a COVID-19 Uninsured Group Program application through the portal in the same month. However, the QP receives a denial eligibility response for V2 because the individual was previously enrolled in another PE aid code within the same month.

Action: The QP should complete a manual determination based on COVID-19 Uninsured Group Program requirements. If the QP determines the individual is eligible for V2, the QP should send a secure email to COVID19Apps@dhcs.ca.gov with “Request to Overlay PE Aid Code” in the email subject line and include the following documentation:

  • Completed COVID-19 Uninsured Group Program Application (MC 374)

  • Copy of the denial eligibility response showing V2 could not be approved due to other PE coverage

  • CIN

  • Name of QP’s organization

  • QP’s National Provider Number (NPI)

During the interim process, DHCS will manually process the application referrals from QPs and provide a response to the provider via secure email. QPs should note DHCS will not process incomplete application referrals. If further information is needed, DHCS will reach out to the QP.

Once the QP receives confirmation from DHCS that the PE program application has been processed and approved, QPs should contact the individual regarding their approval into the new PE program and obtain an eligibility response for the individual.

Additionally, providers are to submit their claims for processing using the appropriate billing exception code. Refer to CMS-1500 Submission Timeliness Instructions in Part 2 of the Medi-Cal Provider Manual for further instructions. If your claim is denied for timeliness or eligibility, an Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims. Claims re-processed by EPC are still subject to all edits and audits as governed by the Medi-Cal program and could be denied for a reason other than timeliness or eligibility. Providers may submit a Claims Inquiry Form (CIF) within six months of the new Remittance Advice Details (RAD) date or you may submit an Appeal Form (90-1) within 90 days of the new RAD date. For CIF completion instructions, please refer to the CIF Completion and CIF Special Billing Instructions sections in the appropriate Part 2 manual or on the Medi-Cal Providers website. For Appeal Form (90-1) completion instructions, please refer to the Appeal Form Completion section in Part 2 of the Medi-Cal Provider Manual.

Questions

  • Questions concerning the CHDP Gateway, HPE, or PE4PW Programs should be sent to PE@dhcs.c.agov.

  • Questions concerning BCCTP PE should be sent to Nancy Ojeda at BCCTP@dhcs.ca.gov.

  • Questions concerning the COVID-19 Uninsured Group Program should be sent to COVID19Apps@dhcs.ca.gov.

  • For billing or payment questions, providers may call the Telephone Service Center (TSC) at 1-800-541-5555, from 8 a.m. to 5 p.m., Monday through Friday.

2. 2021 HCPCS/CPT® Q4 Update

The 2021 Quarter 4 updates to Healthcare Common Procedure Coding System (HCPCS) codes and Current Procedural Terminology – 4th Edition (CPT) codes are available in the 2021 HCPCS Q4 Policy PDF. These additions, changes and deletions are effective October 1, 2021.

Only those codes representing current and past Medi-Cal and Family Planning, Access, Care and Treatment (Family PACT) benefits are included in the list of updates. Please refer to the appropriate code books for complete descriptions of these codes.

Further manual page updates will be released in a future Medi-Cal Update.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
AIDS Waiver Program modif app (23, 24)
Audiology and Hearing Aids
Durable Medical Equipment
Orthotics and Prosthetics
cal child ser (27); modif app (23, 24); tax (12)
Chronic Dialysis Clinics blood (5, 7, 12–15); cal child ser (27); immun (16–24); inject cd list (2, 4, 5, 7, 9, 13, 16–18, 20, 23, 26); inject drug a-d (35, 45, 47); inject drug e-h (39); inject drug n-r (17–20); inject drug s-z (18, 19); modif app (23, 24)
Clinics and Hospitals
General Medicine
cal child ser (27); chemo drug a-d (3, 31); chemo drug e-o (13–16, 27-30, 36); chemo drug p-z (23, 25, 45); fam planning (5, 9); immun (16–24); inject cd list (2, 4, 5, 7, 9, 13, 16–18, 20, 23, 26); inject drug a-d (35, 45, 47); inject drug e-h (39); inject drug n-r (17–20); inject drug s-z (18, 19); modif app (23, 24); non ph (10, 12–15, 29); once (1); presum bill (16); prop lab (30, 59–61); surg integ (4); tar and non cd0 (3, 34–39)
Family PACT (Policies, Procedures and Billing Instructions) ben fam (12); ben grid (3, 45); clinic (8, 20, 22); drug (3, 6, 7)
Heroin Detoxification tax (12)
Home Health Agencies/Home and Community-Based Services
Local Educational Agency
Medical Transportation
Therapies
Vision Care
cal child ser (27); modif app (23, 24)
Inpatient Services cal child ser (27); tar and non cd0 (3, 34–39)
Long Term Care tar and non cd0 (3, 34–39)
Obstetrics cal child ser (27); fam planning (5, 9); immun (16–24); inject cd list (2, 4, 5, 7, 9, 13, 16–18, 20, 23, 26); inject drug a-d (35, 45, 47); inject drug e-h (39); inject drug n-r (17–20); inject drug s-z (18, 19); modif app (23, 24); non ph (10, 12–15, 29); once (1); presum bill (16); prop lab (30, 59–61); tar and non cd0 (3, 34–39)
Pharmacy blood (5, 7, 12–15); cal child ser (27); immun (16–24); inject cd list (2, 4, 5, 7, 9, 13, 16–18, 20, 23, 26); inject drug a-d (35, 45, 47); inject drug e-h (39); inject drug n-r (17–20); inject drug s-z (18, 19); presum bill (16); tax (12)
Psychological Services cal child ser (27)
Rehabilitation Clinics cal child ser (27); immun (16–24); inject cd list (2, 4, 5, 7, 9, 13, 16–18, 20, 23, 26); inject drug a-d (35, 45, 47); inject drug e-h (41); inject drug n-r (17–20); inject drug s-z (18, 19); modif app (23, 24); non ph (10, 12–15, 29)

3. Upcoming Changes to Outpatient Claims Processing and Provider Identifiers

To implement provisions of the Patient Protection and Affordable Care Act (ACA)(Public Law 111-148, Section 1104), information will be accepted in the Other fields (Boxes 78 and 79) on the UB-04 claim and the equivalent loops used electronically. The appropriate provider type qualifier will be entered in the first small field for rendering (82), ordering/referring/prescribing (DN) and other operating (ZZ) providers. The National Provider Identifier (NPI) will be entered in the second, larger field labeled NPI. The ACA also requires an attending individual provider (Type 1 NPI) on all outpatient UB-04 and electronic claims. The Attending field (Box 76) and loop 2310A will be mandatory. The Operating field (Box 77) will be used for claims with surgery codes. When entering rendering, referring and operating providers, the individual (Type 1 NPI) must be used.

For detailed information, refer to the National Uniform Billing Committee (NUBC) UB-04 Data Specifications Manual for paper claim instructions and the ANSI ASC X12 TR3 for electronic claim instructions as these are the national standards. The supplemental provider boxes and equivalent electronic loops of boxes 76-79 will be used for the few atypical providers that do not have an NPI. More specific instructions related to this update, including the effective date, will be published in future News articles, Provider Manuals, and Medi-Cal Updates.

4. Improvements to Transaction Services

Beginning September 20, 2021, in an effort to continue to modernize and improve the user experience for Medi-Cal Provider website users, the look and feel of several webpages will be updated.

Note: Functionality is not changing. These updates refresh the look and feel only.

This release includes user interface updates to applications within Transaction Services and several webpages outside of Transaction Services.

A complete list of enhancements, updates and additional website changes can be viewed within the Medi-Cal Provider Website Release Change Log (PDF file size 69 KB).

The next release will include all of the remaining Transaction Services updates, as well as updating and reorganizing the Transaction Services Menu page for a better user experience.

Providers are also encouraged to subscribe to the free Medi-Cal Subscription Service (MCSS). The MCSS allows each subscriber to choose and tailor both the subject matters and types of communications they wish to receive from the Medi-Cal Program.

5. National Correct Coding Initiative Quarterly Update for October 2021

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 dates of service on or after October 1, 2021.

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

6. November 2021 Virtual Claim Assistance Room (CAR) Event

Receive free one-on-one billing assistance at our virtual Claims Assistance Room (CAR) event scheduled for the month of November.

There are multiple morning and afternoon sessions available. Providers must register through the Medi-Cal Learning Portal Event Calendar.

Reminder: First time users must complete a one-time registration. For instructions on how to enroll in one of these sessions, use the link to the short video in the descriptive text on the “Provider Seminars and Webinars” tile on the Medi-Cal Learning Portal home page.

Providers are encouraged to bring their more complex billing issues and receive individual assistance from a provider field representative.

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

7. 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.



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