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Medi-Cal Update

Pharmacy | July 2021 | Bulletin 995

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1. Sotrovimab (A Monoclonal Antibody) for COVID-19 Treatment Now a Benefit

Effective for dates of service on or after May 26, 2021, Sotrovimab has been authorized by the U.S. Food and Drug Administration (FDA) for use under an Emergency Use Authorization for the treatment of mild-to-moderate coronavirus 2019 (COVID-19) in adults and pediatric patients (12 years of age and older weighing at least 40 kg) with positive results of direct SARS-CoV-2 viral testing, and who are at high risk for progression to severe COVID-19, including hospitalization or death.

Unlike other monoclonal antibody therapies used for the treatment of COVID-19 whereby initial supplies were purchased and distributed free of charge by the Federal Government, Sotrovimab will be purchased by providers who must bill and be reimbursed for the cost of the product.

Providers may bill for the cost of administration (infusion) using Healthcare Common Procedure Coding System (HCPCS) codes M0247 (intravenous infusion, sotrovimab, includes infusion and post administration monitoring), M0248 (intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the covid-19 public health emergency) and for the cost of the product using Q0247 (injection, sotrovimab, 500 mg).

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
immun (29–36); immun cd (1, 3); modif used (6); non ph (15, 30)
Chronic Dialysis Clinics immun (29–36); immun cd (1, 3); modif used (6)
Pharmacy immun (29–36); immun cd (1, 3)
 

2. In-Person Signature Requirement for Delivered Medications

In an April 28, 2020 article titled, “Temporary Suspension of In-Person Signature Requirement for Delivered Medications,” the Welfare and Institutions Code, Section 14043.341 requirement that “providers who dispense controlled drugs, dangerous drugs or dangerous devices to a Medi-Cal beneficiary to maintain a record of the signature of the person receiving the drug or device” was waived pursuant to Executive Order (EO) N-55-20 in response to the coronavirus disease 2019 (COVID-19) public health emergency.

EO N-55-20 will expire on June 30, 2021 per Governor Newsom’s most recent EO N-08-21 (issued June 11, 2021) to lift specific COVID-19-related executive orders that were put in place since March 2020. The Department of Health Care Services will end this policy change effective July 1, 2021 for all programs. Beneficiaries and clients, or their representatives, will need to sign for medications in person from their home or sign onsite at their provider location.

 

3. Correction to 2021 HCPCS Quarter 3 Update

The previously published Medi-Cal Update for the 2021 Quarter 3 Healthcare Common Procedural Coding System (HCPCS) codes, effective July 1, 2021, has been updated from the correction file recently released by the Centers for Medicare & Medicaid Services (CMS). HCPCS code C9065 was terminated and replaced by HCPCS code J9314, which was added as a new Medi-Cal benefit. CMS has sent an update reversing these changes. Code C9065 is no longer terminated and remains a Medi-Cal benefit, and code J9314 will not be implemented as a benefit in its place. Providers should continue to bill for services using code C9065 and not with code J9314.

Please refer to either the HCPCS Policy Updates PDF or the designated manual sections for more information.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics inject cd list (23); modif used (14)
General Medicine inject cd list (23); modif used (14); non ph (13,15); chemo drug p-z (25)
Clinics and Hospitals
Obstetrics
Rehabilitation Clinics
inject cd list (23); modif used (14); non ph (13,15)
 

4. Medi-Cal Provider Website: Future Enhancements and Changes

The Department of Health Care Services (DHCS) is committed to improving and enhancing the Medi-Cal Provider website. As such, DHCS launched its series of ongoing releases of enhancements, updates and changes to improve website navigation and user experience.

DHCS will incorporate Provider and Stakeholder feedback, industry best practices and California State web publishing guidelines when evaluating potential website changes. This new update includes:

  • Standardized website color scheme, font and formatting

  • Improved navigation and organization for Publications News, Provider Bulletins and Provider Manuals

  • Updated filters and sorting capabilities on the Medi-Cal News Articles page

  • Added ability for search to yield only News and Provider Bulletins content

A complete list of the enhancements, updates and additional website changes can be viewed within the Medi-Cal Provider Website Release Change Log (PDF file size 158 KB).

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. Updated Rates for Hormone Containing Vaginal Rings

Effective for dates of service on or after April 1, 2021, rates are updated for claims billed with HCPCS code J7303 (contraceptive supply, hormone containing vaginal ring, each) and modifier U1 (etonogestrel and ethinyl estradiol) or U2 (segesterone acetate and ethinyl estradiol vaginal system), as follows:

Procedure Code with Modifier Description Rate
J7303 U1 Contraceptive vaginal ring, each (etonogestrel and ethinyl estradiol)  $121.62  
J7303 U2 Contraceptive vaginal ring (segesterone acetate and ethinyl estradiol vaginal system)  $2,090.00  
 

6. Update to Allowable Specialized Services

Effective for dates of service on or after July 1, 2021, the list of specialized services that can be billed on an outpatient claim, even when provided on an inpatient basis, is updated. Existing policy currently in place for other allowable specialized services shall remain in place.

Blood Factors HCPCS Code Effective Dates Notes
Blood Factor X J7175 July 1, 2021 N/A
Blood Factor Von Willebrand J7179 July 1, 2021 N/A
Blood factor XIII Antihemophilic factor J7181 July 1, 2021 Replaces C9134
Blood Factor VIII/Noveoeight J7182 July 1, 2021 N/A
Blood Factor VIII J7204, J7205, J7211, J7207, J7208, J7209, J7210 July 1, 2021 N/A
Blood Factor VIII/Obizur J7188 July 1, 2021 N/A
Blood Factor VIIa/SevenFact J7212 July 1, 2021 Previously J7199
Blood Factor IX/Rixubis/Alprolix/Idelvion/Rebinyn J7200, J7201, J7202, J7203 July 1, 2021 N/A
Aprolix J7201 July 1, 2021 Previously J7199
Onasemnogen abeparvovec xioi (Zolgensma® J3399 July 1, 2021 Separate CCS authorization is required for outpatient administration

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Chronic Dialysis Clinics
Pharmacy
Rehabilitation Clinics
inject drug n-r (13)
Inpatient Services diagnosis ip (8)
 

7. Updated Rates for Select Physician-Administered Drugs

Effective for dates of service on or after April 1, 2021, reimbursement rates are updated for claims billed with HCPCS code J3490 (unclassified drugs) with the following modifiers:

Procedure Code with Modifier Description Rate
J3490 U5 Ulipristal acetate, 30 mg $34.28
J3490 U6 Levonorgestrel, 1.5 mg $9.28
J3490 U8 Medroxyprogesterone acetate, 150 mg/ml $41.42

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 Part 2 Medi-Cal Provider Manual.

 

8. September Virtual Claims Assistance Room Events

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

Multiple morning and afternoon sessions are available.

Providers must register through the Mediā€‘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 to receive individual assistance from a Provider Field Representative.

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

 

9. Updates to the List of Enteral Nutrition Products

Recently, the Department of Health Care Services (DHCS) updated the List of Enteral Nutrition Products with changes effective July 1, 2021.

Please note that the Maximum Acquisition Cost (MAC) and Estimated Acquisition Cost (EAC) pricing for Abbott Nutrition’s Ensure Harvest product and Nestlé HealthCare Nutrition’s four Compleat Organic Blends products were listed incorrectly. The correct MAC and EAC pricing, effective July 1, 2021, is as follows:


Manufacturer Product Label Name Medi-Cal Billing Code (NDC like number) MAC per gm or ml EAC per gm or ml
Abbott Nutrition  Ensure Harvest 8oz Recloseable Carton 70074067965 0.0145 0.0161
Nestlé HealthCare Nutrition Compleat Pediatric Organic Blends – Chicken-Garden Blend, 24 x 10.1oz (300mL) pouch 43900084642 0.0131 0.0147
Nestlé HealthCare Nutrition Compleat Pediatric Organic Blends – Plant Based, 24 x 10.1oz (300mL) pouch 43900011721 0.0131 0.0147
Nestlé HealthCare Nutrition Compleat Organic Blends – Chicken-Garden Blend, 24 x 10.1oz (300mL) pouch 43900047993 0.0153 0.0169
Nestlé HealthCare Nutrition Compleat Organic Blends – Plant Based, 24 x 10.1oz (300mL) pouch 43900019270 0.0153 0.0169

For dispensing to eligible Medi-Cal fee-for-service outpatient beneficiaries, the contractors have guaranteed that Medi-Cal providers may purchase, upon request, the products at or below the MAC with an approved Treatment Authorization Request (TAR) or a Service Authorization Request (SAR). Providers can locate MAC price suppliers by calling manufacturer phone numbers referenced in the List of Enteral Nutrition Products.

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

 

10. 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.

 

11. Provider Manual Revisions



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