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Medi-Cal Update

Pharmacy | June 2021 | Bulletin 993

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1. Temporary Increased COVID-19 Durable Medical Equipment Oxygen and Respiratory Rates

Effective for dates of service on or after March 1, 2020 and updated effective January 1, 2021, Durable Medical Equipment (DME) Oxygen and Respiratory rates are temporarily increased due to the ongoing coronavirus disease 2019 (COVID-19) Public Health Emergency (PHE).

Following the declaration of the PHE and national emergency in the United States, the Centers for Medicare & Medicaid Services approved Disaster Relief State Plan Amendment 21-0016 authorizing the Department of Health Care Services (DHCS) to increase the DME Oxygen and Respiratory rates equivalent to 100 percent of the Medicare rate, retroactively effective from March 1, 2020, to the end of the PHE. In addition, the DME Oxygen and Respiratory codes are exempt from the ten percent payment reduction in Welfare and Institutions (W&I) Code section 14105.192, as described in Attachment 4.19-B, page 3.3, paragraph 13 of the State Plan. DHCS updated the DME Oxygen and Respiratory rates effective for dates of service on or after March 1, 2020 and effective January 1, 2021, based on the corresponding Medicare rural rate as provided in the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies Fee Schedule.

Refer to the Medi-Cal Rates page for more information on rate updates.

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 appropriation and 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.

2. 2021 HCPCS Q3 Update

The 2021 Quarter 3 updates to the Healthcare Common Procedure Coding System (HCPCS) codes are available in the HCPCS Policy Updates PDF. Effective dates for these code additions and deletions vary and are listed in the Policy PDF, however, system implementation for these codes will not be processed until on or after July 1, 2021.

Only those codes representing current and past Medi-Cal benefits are included in the list of updates. Please refer to the HCPCS Level I and II code books for complete descriptions of these codes.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics immun (16–18, 20–22, 28, 29, 34); immun cd (1, 4); inject cd list (4, 5, 9, 10, 16, 17, 19, 22, 23, 26); inject drug a-d (35–38, 42–45, 68); inject drug e-h (39–41); inject drug i-m (22, 23, 26); inject drug n-r (27); modif used (4, 6, 12–14)
Clinics and Hospitals
General Medicine
chemo drug e-o (22–24, 28–30, 37, 38); chemo drug p-z (18, 19, 24, 25, 44–46); immun (16–18, 20–22, 28, 29, 34); immun cd (1, 4); inject cd list (4, 5, 9, 10, 16, 17, 19, 22, 23, 26); inject drug a-d (35–38, 42–45, 68); inject drug e-h (39–41); inject drug i-m (22, 23, 26); inject drug n-r (27); modif used (4, 6, 12–14); non ph (10, 12–16, 27, 28, 30); once (1); presum bill (16); radi dia (27–29); radi nuc (7); tar and non cd0 (33, 34)
Inpatient Services tar and non cd0 (33, 34)
Obstetrics immun (16–18, 20–22, 28, 29, 34); immun cd (1, 4); inject cd list (4, 5, 9, 10, 16, 17, 19, 22, 23, 26); inject drug a-d (35–38, 42–45, 68); inject drug e-h (39–41); inject drug i-m (22, 23, 26); inject drug n-r (27); modif used (4, 6, 12–14); non ph (10, 12–16, 27, 28, 30); once (1); presum bill (16); radi dia (27–29); radi nuc (7); tar and non cd0 (33, 34)
Pharmacy immun (16–18, 20–22, 28, 29, 34); immun cd (1, 4); inject cd list (4, 5, 9, 10, 16, 17, 19, 22, 23, 26); inject drug a-d (35–38, 42–45, 68); inject drug e-h (39–41); inject drug i-m (22, 23, 26); inject drug n-r (27); presum bill (16)
Rehabilitation Clinics immun (16–18, 20–22, 28, 29, 34); immun cd (1, 4); inject cd list (4, 5, 9, 10, 16, 17, 19, 22, 23, 26); inject drug a-d (35–38, 42–45, 68); inject drug e-h (39–41); inject drug i-m (22, 23, 26); inject drug n-r (27); modif used (4, 6, 12–14); non ph (10, 12–16, 27, 28, 30)

3. Policy Update for Specific Chemotherapy and Injection HCPCS Codes

Effective for dates of service on or after June 1, 2021, the Department of Health Care Services (DHCS) has updated the policies for Healthcare Common Procedure Codes (HCPCS) J9023, J9228 J9299 and Q5110 to include:

  • No Treatment Authorization Request (TAR) required for reimbursement

  • FDA approved indications

  • FDA approved dosages

Additional information regarding these HPCPS codes can be found in the updated manual sections located on the Medi-Cal Provider website.

4. Medi-Cal Provider Website: Navigation Improvements to Publications Content

In an effort to improve the Medi-Cal Provider website user experience, the Department of Health Care Services (DHCS) will implement improvements to the organization and navigation to Provider Manuals, news articles, and Provider Bulletins. These changes will be available on July 12, 2021.

When selecting Publications from the header, the new landing page will contain the same content with a new look and feel. Medi-Cal Provider website users will be able to navigate to provider communities to access community-specific content or content merged from all communities. As a result, navigation among provider community-specific content requires fewer clicks and includes intuitive navigation to assist website users to locate the content they seek.

Website users will also be able to select search in the header and search Medi-Cal News and Provider Bulletins content only, similarly to how users can currently search Provider Manuals only.

Provider Bulletins will be more integrated within the Medi-Cal Providers website, as a normal webpage. This will assist in navigating between bulletins and other website content, while still maintaining the ability to print bulletins altogether or a specific article as needed.

5. Start of the Reporting Year (RY) 2023 Payment Error Rate Measurement (PERM) Cycle

The California Department of Health Care Services (DHCS) wishes to notify all California Medi-Cal providers of the start of the Reporting Year (RY) 2023 Payment Error Rate Measurement (PERM) by the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS). The purpose of PERM is to identify erroneous payments made in Medicaid and the Children’s Health Insurance Program (CHIP) in all 50 states and report improper payment estimates to Congress.

During RY 2023 PERM, Medicaid and CHIP Medi-Cal claims will be randomly selected for Medical Reviews for the fiscal year beginning July 1, 2021, and ending June 30, 2022. Your cooperation will help ensure that the payment measurement rate for PERM reviews are accurate and that California retains its much-needed federal match monies for the Medi-Cal program.

What if one of my claims is selected for the PERM?

If one of your Medi-Cal claims is selected for the PERM, you will receive a notification letter from DHCS letting you know you have been selected, and the CMS Review Contractor, (RC) NCI Information Systems, Inc., will be contacting you for medical records. The letter from DHCS will not contain patient specific information.

The RC will contact you via telephone to verify your contact information and, patient name. The RC will also arrange to send you an official request letter on CMS letterhead detailing what information is needed.

DHCS anticipates its notification letters will be sent out for the first quarter of sampled claims in late 2021. The RC may begin contacting quarter one providers in late 2021 or early 2022. A total of four quarters of claims will be selected for review during the PERM cycle so it is possible you may receive multiple requests at different times during the PERM process.

Am I obligated to submit medical records for the PERM?

Yes. One of the most common types of error findings are caused by providers failing to respond to requests for medical records. Another error finding frequently cited is submission of insufficient documentation.

To reduce error findings in PERM reviews and ensure that providers are compliant with State and federal regulations, DHCS would like to remind providers of the following:

  • Title 22 of the California Code of Regulations, Section 51476, states that, “each provider shall keep, maintain, and have readily retrievable, such records as are necessary to fully disclose the type and extent of services provided to a Medi-Cal beneficiary.” This includes medical records, orders, treatment authorization requests, and the time and date of service for each beneficiary.

  • Under Sections 1902(a)(27) and 2107 (b)(1) of the Social Security Act, CMS and their representatives have the authority to collect all documentation to support a Medicaid claim.

  • DHCS requires all enrolled providers to report changes to any information previously submitted as part of the provider enrollment application package, which includes the business address or phone number, within 35 days of the date of change.

  • Failure to respond to requests for medical records may result in suspension from the Medi-Cal program as per Welfare and Institutions Code (W&I), Section 14124.2(b)(1) and Section 14124.2.

Not only do error findings affect California’s PERM rate, but claims cited with error findings at the conclusion of the medical review are also considered improperly paid. Therefore, in accordance with W&I Section 14172.5, DHCS is authorized to recoup these payments. Providers that receive a demand for recovery of claim payments are urged to remit the demand amount as soon as possible.

Where can I find out more about PERM and my responsibility to participate?

You can find more information about PERM on the DHCS website:
https://www.dhcs.ca.gov/individuals/Pages/AI_MRB_PERM.aspx

You can find information about provider specific responsibility on the CMS PERM website:
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicaid-and-CHIP-Compliance/PERM/Providers

You may contact a member of the DHCS PERM Team with your questions at:
PERM@dhcs.ca.gov

6. National Correct Coding Initiative Quarterly Update for July 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 July 1, 2021.

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

7. June 2021 Medi-Cal Provider Training Webinars

Provider Outreach and Education along with the Department of Health Care Services, is offering category-specific webinar sessions in June. Training categories offered will include the following:

  • Resources: June 1, 2021, and June 2, 2021

  • Long Term Care: June 10, 2021

  • Common Denials: June 15, 2021

  • Claims: June 23, 2021

  • Presumptive Eligibility Programs: June 29, 2021

A variety of courses will be offered in each of the training 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 Provider website.

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

8. July 2021 Medi-Cal Provider Training Webinars

Beginning July 6, 2021, continuing throughout the month of July, Medi-Cal providers may participate in the following category-specific webinar sessions.

Categories offered will include the following:

  • Family PACT: July 6, 2021

  • Health Access Programs: July 8, 2021

  • Medical Services: July 13, 2021

  • Home Health Services: July 21, 2021

  • Specialty Programs: July 27, 2021

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 website.

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

9. Updates to the List of Enteral Nutrition Products

Effective for dates of service on or after July 1,  2021, the Department of Health Care Services (DHCS) has updated the List of Enteral Nutrition Products. Providers may refer to the List of Enteral Nutrition Products in the List of Enteral Nutrition Products section of the appropriate Part 2 provider manual.

The manufacturers guarantee that Medi-Cal providers may purchase, upon request, the listed products at or below the maximum acquisition cost (MAC) for dispensing with an approved Treatment Authorization Request (TAR) or a Service Authorization Request (SAR) through the Medi-Cal fee-for-service pharmacy delivery system. Providers can locate MAC price suppliers by calling manufacturer phone numbers listed in the List of Enteral Nutrition Products.

Beneficiaries affected by changes to the list, should seek new prescriptions from their licensed prescriber, and new authorizations from their pharmacy provider for a comparable product on the list. Continuing care does not apply.

Note:
Listing of a product is not a guarantee of its availability. The product number approved on an authorization must be the same product number dispensed to the beneficiary and claimed for reimbursement by the provider.

The amount reimbursed to providers for enteral nutrition products shall not exceed the published estimated acquisition cost (EAC) plus a 23 percent markup.

Medi-Cal beneficiaries denied enteral nutrition products who believe the denial was in error may ask for a state hearing by contacting the California Department of Social Services at 1-800-743-8525 or 1-855-795-0634 or by sending a written request to:

California Department of Social Services
State Hearings Division
P.O. Box 944243, MS 9-17-37
Sacramento, CA   94244-2430

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
enteral (1, 3)

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11. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



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