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Medi-Cal Update

Multipurpose Senior Services Program | January 2022 | Bulletin 568

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1. Medi-Cal Rx Transition: Changes to Medi-Cal Providers Website Implemented

Effective January 1, 2022, Medi-Cal Rx is fully implemented. As part of this transition, the pharmacy Medi-Cal provider manual and Medi-Cal Providers website have been updated to remove or alter billing policy and information regarding pharmacy claims, where appropriate.

Non-pharmacy providers are not affected by this change. However, some manual sections that are distributed to non-pharmacy provider communities were updated to reflect these pharmacy-related changes. Non-pharmacy providers are being notified of what sections were updated for their own records, but providers are reminded that only billing policy or submission guidance related to pharmacy claims (hard copy or electronic) were affected by this change.

Provider Manual(s) Page(s) Updated
Part 1 claim pay (2); claim sub (1–3); cmc enroll (2, 5); elect (7); elig rec (2); mcp cohs (2–5, 9); mcp gmc (4, 5, 7, 10); mcp imperial (4, 5, 7); mcp prim (3, 4); mcp spec (5); mcp two plan (5, 7, 8); medicare (6, 8); obra (3, 5); other guide (2, 4); percent (3, 5, 7); point frm1 net (2, 4); prog (6, 11); prov reg (4, 10, 13); prov rel (5, 8); prov rel frm1 ref (1); prov tele (1, 5–8, 20, 25); remit (2); tar (6, 9, 13)
Acupuncture appeal form (2); cif co (1–3, 6, 8, 9); cif sp (3, 4, 6); oth hlth (2); prov bil (1); remit adv (2); remit pay (2, 4)
AIDS Waiver Program
Multipurpose Senior Services Program
appeal form (2); cif co (1–3, 6, 8, 9); oth hlth (2); physician ndc (1); prov bil (1); remit adv (2); remit pay (2, 4)
Audiology and Hearing Aids
Medical Transportation
Orthotics and Prosthetics
Psychological Services
Therapies
appeal form (2); cal child (5, 6); cal child bil guide (1, 2); cif co (1–3, 6, 8, 9); cif sp (3, 4, 6); genetic (3, 9, 11, 12, 14, 16); medi cr cms (1–4, 7–11, 18); oth hlth (2); prov bil (1); remit adv (2); remit pay (2, 4); tar comp (4, 10–14); tar defer (2, 4–14); tar field (5, 6, 15, 16)
Chronic Dialysis Clinics appeal form (2); cal child (5, 6); cal child bil guide (1, 2); cif co (1–3, 6, 8, 9); genetic (3, 9, 11, 12, 14, 16); immun (1); oth hlth (2); prov bil (1); remit adv (2); remit pay (2, 4); tar comp (4, 10–14); tar defer (2, 4–14); tar field (5, 6, 15, 16)
Chiropractic appeal form (2); cif co (1–3, 6, 8, 9); cif sp (3, 4, 6); medi cr cms (1–4, 7–11, 18); oth hlth (2); prov bil (1); remit adv (2); remit pay (2, 4)
Clinics and Hospitals appeal form (2); cal child (5, 6); cal child bil guide (1, 2); chemo an over (1); cif co (1–3, 6, 8, 9); genetic (3, 9, 11, 12, 14, 16); immun (1); oth hlth (2); physician ndc (1); prev (2, 5, 9, 10, 17, 18); prov bil (1); remit adv (2); remit pay (2, 4); subacut lev (2, 3); tar comp (4, 10–14); tar defer (2, 4–14); tar field (5, 6, 15, 16)
Community-Based Adult Services
Heroin Detoxification
Hospice Care Program
appeal form (2); cif co (1–3, 6, 8, 9); oth hlth (2); physician ndc (1); prov bil (1); remit adv (2); remit pay (2, 4); tar comp (4, 10–14); tar defer (2, 4–4); tar field (5, 6, 15, 16)
Durable Medical Equipment appeal form (2); cal child (5, 6); cal child bil guide (1, 2); cif co (1–3, 6, 8, 9); cif sp (3, 4, 6); enteral (1, 2, 15); genetic (3, 9, 11, 12, 14, 16); mc sup (1, 2, 5, 7, 8 , 9, 13); medi cr cms (1–4, 7–11, 18); oth hlth (2); prov bil (1); remit adv (2); remit pay (2, 4); tar comp (4, 10–14); tar defer (2, 4–14); tar field (5, 6, 15, 16)
General Medicine appeal form (2); cal child (5, 6); cal child bil guide (1, 2); chemo an over (1); cif co (1–3, 6, 8, 9); cif sp (3, 4, 6); genetic (3, 9, 11, 12, 14, 16); immun (1); medi cr cms (1–4, 7–11, 18); oth hlth (2); physician ndc (1); prev (2, 5, 9, 10, 17, 18); prov bil (1); remit adv (2); remit pay (2, 4); subacut lev (2, 3); tar comp (4, 10–14); tar defer (2, 4–14); tar field (5, 6, 15, 16)
Home Health Agencies/Home and Community-Based Services appeal form (2); cal child (5, 6); cal child bil guide (1, 2); cif co (1–3, 6, 8, 9); genetic (3, 9, 11, 12, 14, 16); oth hlth (2); physician ndc (1); prov bil (1); remit adv (2); remit pay (2, 4); tar comp (4, 10–14); tar defer (2, 4–14); tar field (5, 6, 15, 16)
Inpatient Services appeal form (2); cal child (5, 6); cal child bil guide (1, 2); cif co (1–3, 6, 8, 9); genetic (3, 9, 11, 12, 14, 16); oth hlth (2); prov bil (1); remit adv (2); remit pay (2, 4); tar comp (4, 10–14); tar defer (2, 4–14); tar field (5, 6, 15, 16)
Local Educational Agency appeal form (2); cal child (5, 6); cal child bil guide (1, 2); cif co (1–3, 6, 8, 9); genetic (3, 9, 11, 12, 14, 16); oth hlth (2); prov bil (1); remit adv (2); remit pay (2, 4)
Long Term Care appeal form (2); cif co (1–3, 6, 8, 9); oth hlth (2); prov bil (1); remit adv (2); remit pay (2, 4); subacut lev (2, 3); tar defer (2, 4–14); tar field (5, 6, 15, 16)
Obstetrics appeal form (2); cal child (5, 6); cal child bil guide (1, 2); cif co (1–3, 6, 8, 9); cif sp (3, 4, 6); genetic (3, 9, 11, 12, 14, 16); immun (1); medi cr cms (1–4, 7–11, 18); oth hlth (2); physician ndc (1); prov bil (1); remit adv (2); remit pay (2, 4); tar comp (4, 10–14); tar defer (2, 4–14); tar field (5, 6, 15, 16)
Rehabilitation Clinics appeal form (2); cal child (5, 6); cal child bil guide (1, 2); cif co (1–3, 6, 8, 9); cif sp (3, 4, 6); genetic (3, 9, 11, 12, 14, 16); immun (1); oth hlth (2); physician ndc (1); prov bil (1); remit adv (2); remit pay (2, 4); tar comp (4, 10–14); tar defer (2, 4–14); tar field (5, 6, 15, 16)
Vision Care appeal form (2); cal child (5, 6); cal child bil guide (1, 2); genetic (3, 9, 11, 12, 14, 16); oth hlth (2); prov bil (1); remit adv (2); remit pay (2, 4); tar defer (2, 4–14)

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) implemented 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 seventy-five percent 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 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. 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.”

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 ‘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.

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
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services Hospice Care Program
Inpatient Services
Local Educational Agency
Multipurpose Senior Services Program
Rehabilitation Clinics
ub sub (2, 6)

4. 2022 ICD-10-CM/PCS Codes Update

Effective for dates of service on or after October 1, 2021, the Centers for Medicare & Medicaid Services (CMS) is modifying the short and long descriptions of ICD-10-CM (Clinical Modifications) and ICD-10-PCS (Procedure Coding System) diagnosis codes as part of the 2022 annual ICD-10-CM and ICD-10 PCS update.

Information and downloads for these codes can be found at the ICD-10 Web page of the CMS website. Specific billing policy related to this update will be published in a future Medi-Cal Update.

5. Medi-Cal Provider “Coffee Break” Event

In April, June and September 2022, we will be holding our “coffee break” event. This event is a 45-minute open discussion to address various Medi-Cal topics. Field Representatives will be available to discuss billing related guidance and address your questions.

There are multiple morning and afternoon sessions available at 10:00 a.m. and 1:30 p.m. for each date. Providers are encouraged to routinely check the Medi-Cal website for information regarding the coffee break topics for the month.

Providers must register through the Medi-Cal Learning Portal Event Calendar. First time users must complete a one-time registration. A short video is available for instructions on how to register for one of these sessions.

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

6. March Virtual Claims Assistance Room (CAR) Event

Receive free one-on-one billing assistance at our Virtual Claims Assistance Room (CAR) Event scheduled for the month of March.

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

Reminder: First time users must complete a one-time registration. There is a link to a short video in the descriptive text under the “Provider Seminars and Webinars” tile on the Medi-Cal Learning Portal homepage, that gives directions on how to register for one of these sessions. Providers can also download the video file.

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.

8. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



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