EPSDT/CHDP Frequently Asked Questions: School-Based Providers

Child Health and Disability Prevention (CHDP) providers billing for services provided to children and youth enrolled in the Medi-Cal fee-for-service health care delivery system must submit claims directly to the California Medicaid Management Information System (MMIS) Fiscal Intermediary in accordance with HIPAA national standards. School district providers must submit claims using CPT® national codes on the UB-04 claim form, or the respective electronic equivalent.

Codes

  1. What national codes should providers submit?

    CPT codes determined to be most appropriate for current EPSDT/CHDP services. A list of national codes reimbursable to school-based providers is available in the EPSDT/CHDP: School-Based Services provider manual section.

Billing Limitations

  1. Can claims submitted one year from the date of service be reimbursed at the full rate?

    No. Claims processed in the Medi-Cal claims system are subject to the six-month billing limitation. After six-months, reimbursement will be reduced unless a valid late submission reason is entered on the claim, with supporting documentation as appropriate.

Claim Form

  1. Which claim form is used to bill for EPSDT/CHDP school-based services?

    For paper submissions, school-based providers rendering services to eligible children and youth will bill using the Outpatient UB-04 claim form; or for electronic submissions the ANSI X12N 837 institutional (837I) electronic claim format.

    School-based providers bill solely on the UB-04 claim form.

  2. Can billers use the Remarks field (Box 80) on the UB-04 claim form?

    Box 80 on the UB-04 claim form will be available to enter documentation, delay reason remarks and additional information as needed.

  3. Is the county code required on the UB-04 claim form?

    No. The county code is not required on the national claim forms.

  4. Should the date of the next periodic health exam be entered on the UB-04 claim form? If so, where is it entered on the claim?

    National claim forms do not have fields to capture the date for the next required periodic exam. Well-child health assessments should be rendered in accordance with the American Academy of Pediatrics (AAP) Bright Futures periodicity schedule. See both the CHDP Bright Futures Schedule for Health Assessments by Age Group and CHDP/EPSDT Periodicity Schedule for Dental Referral by Age PDFs for guidelines.

Electronic Claim Completion

  1. How is an attachment added to an electronic claim?

    For each electronically submitted claim requiring an attachment, a single and unique Attachment Control Form (ACF) must be submitted via mail or fax. Providers will be required to use the 11-digit Attachment Control Number (ACN) from the ACF to populate the Paperwork (PWK) segment of the 837 HIPAA transaction.

    The electronically submitted 837I ANSI ASC X12N v.5010A1 claim and the paper attachment must contain the ACN to allow the parts of the claim to be synced for processing.

  2. I currently have a submitter who processes my electronic CHDP claims. What would they have to do to submit my CHDP electronic claims?

    The submitter must be approved to submit the UB-04 claims electronically. Instructions are available on the Medi-Cal website or by calling the Telephone Service Center (TSC) at 1-800-541-5555.

Billing

  1. Are there special claim completion instructions when billing for services rendered to CHDP qualified children and youth?

    Yes. Providers who render CHDP services in a school-based setting also bill services for children and youth who qualify for Local Educational Agency (LEA) services. To distinguish between LEA and CHDP services within the Medi-Cal claims processing system, school-based providers must enter condition code “A1” (EPSDT/CHDP) in the Condition Code field (Boxes 18 – 24) on the UB-04 claim form to be reimbursed for CHDP services. Claims submitted for CHDP services without the condition code will be denied.

    Additionally, providers must enter facility type code “891” in the Type of Bill field (Box 4).

    General instructions for completing the UB-04 claim form are located in the UB-04 Completion: Outpatient Services section of the appropriate Part 2, Medi-Cal Provider Manual

  2. Can CHDP and LEA services be submitted on the same claim form?

    No. CHDP and LEA services must be billed on separate claim forms to allow for correct reimbursement.

  3. What code is billed for blood lead draw (venipuncture) by providers certified to perform this service?

    CPT code 99000 (handling and/or conveyance of specimen for transfer from the [physician's] office to a laboratory). Code 99000 includes any of the following: Single or multiple venipuncture, capillary puncture or arterial puncture with one or more tubes, centrifugation and serum separation, freezing, refrigeration, preparation for air transportation or other special handling procedures, supplies, registration of patient or specimen and third party billing.

    Instructions for billing CPT code 99000 are included in the Pathology: Blood Collection and Handling section in the appropriate Part 2, Medi-Cal provider manual.

  4. What code is used to bill for the counseling service(s) associated with blood lead venipuncture?

    Counseling services associated with blood lead venipuncture testing are included as part of a preventive medicine health assessment.

    The codes for billing preventive medicine services are included in the EPSDT/CHDP: School-Based Services section in the Medi-Cal provider manual.

  5. Is a Clinical Laboratory Improvement Amendment (CLIA) certificate required for lab services?

    All Medi-Cal providers billing for laboratory services must have a current Clinical Laboratory Improvement Amendments (CLIA) certificate.

    Guidelines for CLIA certification and information about proficiency testing requirements are included in the Pathology: An Overview of Enrollment and Proficiency Testing Requirements section of the appropriate Part 2, Medi-Cal provider manual.

  6. Will providers currently billing for CHDP services be able to bill Medi-Cal for CHDP-related Early and Periodic Screening, Diagnostic and Treatment (EPSDT) health assessments and immunizations?

    CHDP-approved providers are eligible to bill Medi-Cal for CHDP related well-child health assessments, immunizations and laboratory services rendered under the EPSDT benefit of the Medi-Cal program in accordance with the provider's Medi-Cal enrollment status; for example, Medi-Cal provider type and category of service.

  7. How do CHDP providers bill a partial screening service?

    Providers use the appropriate procedure codes with specified modifiers according to Medi-Cal billing instructions when billing for partial screening services. Refer to the Preventive Services section in the Medi-Cal provider manual. School-Based providers who perform an incomplete/partial screening service must refer the child to their primary care provider or medical home.

Miscellaneous Questions

  1. Why were CHDP local codes changed to national codes?

    The Federal Health Insurance Portability and Accountability Act (HIPAA) requires electronic health care transactions, and their hard copy counterparts, to conform to national standards for electronic health care transactions and use of national standard code sets as specified in federal regulations adopted by the Department of Health and Human Services.

  2. Where can I find help for submitting a claim for EPSDT/CHDP services?

    Providers can receive training on submitting a UB-04 claim form through the computer-based training (CBT) course that is available on the Medi-Cal Learning Portal (MLP). Providers may also contact the Telephone Service Center (TSC) at 1-800-541-5555.

  3. Will payments appear on the Medi-Cal warrant or on a separate checkwrite?

    Claims will be adjudicated in the Medi-Cal system and reimbursements will be reflected on the provider's Medi-Cal warrant.

  4. Where in the Medi-Cal provider manual can I find information related to school-based services?

    The EPSDT/CHDP: School-Based Services section includes information for providers who render CHDP services in a school-based setting, including but not limited to: How to complete a UB-04 claim form, a chart of reimbursable CPT codes and a list of Medi-Cal provider manual sections to reference for help with billing.

Resources

Specific questions concerning billing and reimbursement may be directed to the Telephone Service Center (TSC) at 1-800-541-5555

Providers are also encouraged to subscribe to the Medi-Cal Subscription Service (MCSS) to receive current notifications related to CHDP or other Medi-Cal programs. CHDP providers are specifically encouraged to subscribe to the General Medicine or Clinic and Hospitals bulletin. Providers may sign up for MCSS by completing the MCSS Subscriber Form.