Welcome to the Department of Health Care Services Welcome to Medi-Cal Welcome to the Department of Health Care Services

Part 2 – Pharmacy

106,894 Bytes206,336 Bytes

Medi-Cal Program (00medi-cal)

3,922 Bytes22,016 Bytes

Medi-Cal Provider Manual Contents

9,015 Bytes30,208 Bytes

Manual Organization (0Amanorg)

23,816 Bytes86,016 Bytes

How to Use This Manual (0Bhwtouse)

21,648 Bytes82,944 Bytes

Getting Started: Where to Find the Answers (0C get start)

20,579 Bytes76,800 Bytes

Contents (Part 2 – Medi-Cal Billing and Policy): Pharmacy (2toc pharm)

112,485 Bytes166,400 Bytes

Appeal Form Completion (appeal form)

23,812 Bytes87,552 Bytes

Blood and Blood Derivatives (blood)

18,480 Bytes60,928 Bytes

California Children's Services (CCS) Program (cal child)

5,600 Bytes32,768 Bytes

California Children’s Services (CCS) Program Approved Hospitals (cal child appr)

9,823 Bytes32,256 Bytes

California Children's Services (CCS) Program Billing (cal child bil)

459,780 Bytes526,336 Bytes

California Children's Services (CCS) Program Billing Example: CMS-1500 (cal child bil cms)

9,952 Bytes40,448 Bytes

CCS Program Billing Guidelines (cal child bil guide)

814,019 Bytes898,048 Bytes

California Children's Services (CCS) Program Billing Example: Pharmacy Claim Forms (cal child bil ph)

20,850 Bytes112,128 Bytes

California Children’s Services (CCS) Program County Office Directory (cal child county)

16,877 Bytes55,808 Bytes

California Children's Services (CCS) Program Eligibility (cal child elig)

9,495 Bytes34,304 Bytes

California Children's Services (CCS) Program Medical Therapy Program (cal child med)

21,122 Bytes77,824 Bytes

California Children's Services (CCS) Program Provider Paneling (cal child panel)

16,759 Bytes90,624 Bytes

Form: California Children’s Services (CCS) Program Individual Provider Paneling Application for Physicians and Podiatrists (DHS 4514)

20,274 Bytes102,912 Bytes

Form: California Children’s Services (CCS) Program Individual Provider Paneling Application for Allied Health Care Professionals (DHS 4515 )

12,914 Bytes72,704 Bytes

California Children's Services (CCS) Program Referrals (cal child ref)

28,613 Bytes103,936 Bytes

California Children's Services (CCS) Program Service Authorization Request (SAR) (cal child sar)

70,809 Bytes311,808 Bytes

California Children’s Services (CCS) Program Service Code Groupings (cal child ser)

4,199 Bytes26,624 Bytes

California Children’s Services (CCS) Program Special Care Centers (cal child spec)

10,361 Bytes37,376 Bytes

Child Health and Disability Prevention (CHDP) Program (child)

126,123 Bytes209,920 Bytes

CIF Completion (cif co)

103,149 Bytes162,304 Bytes

CIF Special Billing Instructions (cif sp)

64,864 Bytes100,864 Bytes

CIF Submission and Timeliness Instructions (cif sub)

563,624 Bytes714,752 Bytes

CMS-1500 Completion (cms comp)

194,122 Bytes256,000 Bytes

CMS-1500 Special Billing Instructions (cms spec)

17,983 Bytes77,824 Bytes

CMS-1500 Submission and Timeliness Instructions (cms sub)

13,571 Bytes51,712 Bytes

CMS-1500 Tips for Billing (cms tips)

605,849 Bytes316,416 Bytes

Compound Drug Pharmacy Claim Form (30-4) Completion (compound comp)

1,541,126 Bytes1,728,512 Bytes

Compound Pharmacy Claim Form (30-4) Examples (compound ex)

22,022 Bytes80,384 Bytes

Drug Use Review (DUR) Program (drug)

9,807 Bytes34,816 Bytes

Drugs: Contract Drugs List Introduction (drugs cdl intr)

89,539 Bytes515,072 Bytes

Drugs: Contract Drugs List Part 1 – Prescription Drugs (A through D) (drugs cdl p1a)

100,383 Bytes564,224 Bytes

Drugs: Contract Drugs List Part 1 – Prescription Drugs (E through M) (drugs cdl p1b)

75,366 Bytes402,432 Bytes

Drugs: Contract Drugs List Part 1 – Prescription Drugs (N through R) (drugs cdl p1c)

54,302 Bytes276,992 Bytes

Drugs: Contract Drugs List Part 1 – Prescription Drugs (S through Z) (drugs cdl p1d)

32,215 Bytes155,136 Bytes

Drugs: Contract Drugs List Part 2 – Over-the-Counter Drugs (drugs cdl p2)

14,569 Bytes58,880 Bytes

Drugs: Contract Drugs List Part 3 – Over-the-Counter Cold/Cough Preparations (drugs cdl p3)

40,461 Bytes152,064 Bytes

Drugs: Contract Drugs List Part 4 – Therapeutic Classifications (drugs cdl p4)

59,111 Bytes635,392 Bytes

Drugs: Contract Drugs List Part 5 – Authorized Manufacturer Labeler Codes (drugs cdl p5)

18,628 Bytes78,848 Bytes

Drugs: Contract Drugs List Part 6 – Deleted Drugs (drugs cdl p6)

5,934 Bytes41,472 Bytes

Drugs: Contract Drugs List Part 7 - Preferred TAR-Approved Drug List (drugs cdl p7)

11,375 Bytes44,032 Bytes

Drugs: Contract Drugs List Part 8 – Step Therapy (drugs cdl p8)

9,932 Bytes33,792 Bytes

Drugs: Contract Drugs List Part 10 – MAIC List (drugs cdl pa10)

6,641 Bytes31,232 Bytes

Drugs: MAIC Rate Review (drugs maic rate)

16,012 Bytes77,824 Bytes

Form: California MAIC Rate Review Application (CAMRRA) (MC 3150)

31,280 Bytes108,032 Bytes

Durable Medical Equipment (DME): An Overview (dura)

99,820 Bytes122,368 Bytes

Form: Certificate of Medical Necessity for All Durable Medical Equipment (DME) (Except Wheelchairs and Scooters) (DHS 6181)

7,333 Bytes40,448 Bytes

Form: Certificate of Medical Necessity for Apnea Monitors (MC 4600)

7,182 Bytes41,472 Bytes

Form: Certificate of Medical Necessity for Nebulizers (MC 4601)

12,058 Bytes52,736 Bytes

Form: Certificate of Medical Necessity for Oxygen (MC 4602)

59,048 Bytes242,688 Bytes

Durable Medical Equipment (DME): Bill for DME (dura bil dme)

16,613 Bytes58,368 Bytes

Durable Medical Equipment (DME): Bill for Infusion Equipment (dura bil inf)

53,046 Bytes241,664 Bytes

Durable Medical Equipment (DME): Bill for Oxygen and Respiratory Equipment (dura bil oxy)

53,807 Bytes269,824 Bytes

Durable Medical Equipment (DME): Bill for Therapeutic Anti-Decubitus Mattresses and Bed Products (dura bil thp)

30,040 Bytes119,296 Bytes

Durable Medical Equipment (DME): Bill for Wheelchairs and Wheelchair Accessories (dura bil wheel)

274,925 Bytes352,256 Bytes

Form: Certificate of Medical Necessity for a Manual Wheelchair, Standard or Custom (DHS 6181-A)

282,134 Bytes359,424 Bytes

Form: Certificate of Medical Necessity for a Motorized Wheelchair, Custom or Standard (DHS 6181-B)

249,872 Bytes330,240 Bytes

Form: Certificate of Medical Necessity for a Power Operated Vehicle (POV) aka Scooter, Standard or Bariatric (DHS 6181-C)

91,589 Bytes750,080 Bytes

Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates (dura cd)

10,071 Bytes40,448 Bytes

Durable Medical Equipment (DME): Billing Codes for California Children's Services (CCS) (dura cd ccs)

20,126 Bytes99,840 Bytes

Durable Medical Equipment (DME) Billing Codes: Frequency Limits (dura cd fre)

4,034,713 Bytes4,481,024 Bytes

Durable Medical Equipment (DME): Billing Examples (dura ex)

45,299 Bytes176,640 Bytes

Durable Medical Equipment (DME): Wheelchair and Wheelchair Accessories Guidelines (dura wheel guide)

30,950 Bytes133,632 Bytes

End of Life Option Act Services (eloa)

981,740 Bytes1,128,448 Bytes

End of Life Option Act Services Billing Examples: CMS-1500 (eloa cms)

36,793 Bytes168,448 Bytes

Enteral Nutrition Products (enteral)

13,843 Bytes43,520 Bytes

Forms: Legibility and Completion Standards (forms leg)

9,676 Bytes32,256 Bytes

Forms Reorder Request: Guidelines (forms reo)

162,697 Bytes289,792 Bytes

Forms Reorder Request: Pharmacy (forms reo ph)

31,588 Bytes115,200 Bytes

Genetically Handicapped Persons Program (GHPP) (genetic)

37,724 Bytes143,360 Bytes

Immunizations (immun)

11,754 Bytes37,888 Bytes

Immunizations Code List (immun cd)

30,924 Bytes121,856 Bytes

Incontinence Medical Supplies (incont)

449,806 Bytes521,216 Bytes

Incontinence Medical Supplies Example: CMS-1500 (incont ex)

17,363 Bytes68,608 Bytes

Injections: An Overview (inject an over)

33,843 Bytes114,688 Bytes

Injections: Code List (inject cd list)

65,406 Bytes253,952 Bytes

Injections: Drugs A-D Policy (inject drug a-d)

57,167 Bytes247,808 Bytes

Injections: Drugs E-H Policy (inject drug e-h)

42,473 Bytes162,304 Bytes

Injections: Drugs I-M Policy (inject drug i-m)

39,087 Bytes143,872 Bytes

Injections: Drugs N-R Policy (inject drug n-r)

43,007 Bytes163,328 Bytes

Injections: Drugs S-Z Policy (inject drug s-z)

10,069 Bytes37,888 Bytes

Injections: Hydration (inject hydra)

11,442 Bytes44,544 Bytes

Intravenous or Intra-arterial Solutions: Administration Sets (iv sol admin)

14,321 Bytes49,664 Bytes

Intravenous or Intra-arterial Solutions: Special Billing (iv sol spec)

28,088 Bytes110,080 Bytes

Medical Supplies (mc sup)

474,242 Bytes579,072 Bytes

Medical Supplies: Billing Examples (mc sup ex)

8,444 Bytes47,616 Bytes

Medicare Covered Drugs (medicare drugs)

34,385 Bytes142,336 Bytes

Medicare/Medi-Cal Crossover Claims: Pharmacy Services (medi cr ph)

5,229,481 Bytes5,747,200 Bytes

Medicare/Medi-Cal Crossover Claims: Pharmacy Services Billing Examples (medi cr ph ex)

44,868 Bytes280,064 Bytes

Medicare/Medi-Cal Crossover Claims: Pharmacy Services Medi-Cal Pricing Examples (medi cr ph pr)

15,653 Bytes65,536 Bytes

Medicare Non-Covered Services: HCPCS Codes (medi non hcp)

33,168 Bytes132,608 Bytes

Optional Benefits Exclusion (opt ben exc)

32,805 Bytes128,512 Bytes

Orthotic and Prosthtic Appliances and Services (ortho)

8,743 Bytes32,256 Bytes

Form: Physician Certification of Medical Necessity for Therapeutic Diabetic Shoes and Inserts (ortho 1 form)

55,591 Bytes308,736 Bytes

Orthotic and Prosthetic Appliances and Services: Criteria for Authorization and Reimbursement – Orthotics (ortho auth ortho)

41,252 Bytes254,976 Bytes

Orthotic and Prosthetic Appliances and Services: Criteria for Authorization and Reimbursement - Prosthetics (ortho auth pros)

61,410 Bytes509,440 Bytes

Orthotic and Prosthetic Appliances: Billing Codes and Reimbursement Rates – Orthotics (ortho cd1)

45,989 Bytes371,200 Bytes

Orthotic and Prosthetic Appliances: Billing Codes and Reimbursement Rates – Prosthetics (ortho cd2)

15,734 Bytes60,416 Bytes

Orthotics and Prosthetics: Frequency Limits for Orthotics (ortho cd fre1)

13,443 Bytes52,736 Bytes

Orthotics and Prosthetics: Frequency Limits for Prosthetics (ortho cd fre2)

1,285,446 Bytes1,440,768 Bytes

Orthotic and Prosthetic Appliances: Billing Examples (ortho ex)

16,266 Bytes54,784 Bytes

Other Health Coverage (OHC) (oth hlth)

449,784 Bytes530,944 Bytes

Pharmacy Claim Form (30-1) Completion (pcf30-1 comp)

2,582,044 Bytes2,803,200 Bytes

Pharmacy Claim Form (30-1) Examples (pcf30-1 ex)

15,762 Bytes50,176 Bytes

Pharmacy Claim Form (30-1): Special Billing Instructions (pcf30-1 spec)

16,894 Bytes67,072 Bytes

Pharmacy Claim Form (30-1): Submission and Timeliness Instructions (pcf30-1 sub)

14,864 Bytes57,856 Bytes

Pharmacy Claim Form (30-1) Tips (pcf30-1 tips)

94,969 Bytes190,464 Bytes

Pharmacist Services (pharm serv)

13,075 Bytes46,592 Bytes

Physician-Administered Drugs (physician)

21,610 Bytes74,752 Bytes

Presumptive Eligibility for Pregnant Women (presum)

26,986 Bytes99,328 Bytes

Presumptive Eligibility for Pregnant Women: Billing Codes (presum bill)

26,986 Bytes30,720 Bytes

Form: Presumptive Eligibility for Pregnant Women Provider Fact Sheet (presumb prv fact)

10,177 Bytes33,280 Bytes

Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (presumfpatfact)

17,006 Bytes77,824 Bytes

Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (MC 264) (Spanish)

17,006 Bytes27,648 Bytes

Form: Explanation of Ineligibility For The Presumptive Eligibility For Pregnant Women Program (presumjnobene)

21,167 Bytes82,432 Bytes

Presumptive Eligibility for Pregnant Women Program Process (presum proc)

17,978 Bytes63,488 Bytes

Presumptive Eligibility for Pregnant Women Provider Enrollment Instructions (presum prov)

10,006 Bytes36,352 Bytes

Presumptive Eligibility for Pregnant Women Provider Enrollment Checklist (presum prov enroll frm)

12,367 Bytes44,032 Bytes

Provider Billing after Beneficiary Reimbursement (Conlan v. Shewry) (prov bil)

29,880 Bytes109,056 Bytes

Reimbursement (reimbursement)

19,041 Bytes105,472 Bytes

Reject Codes for Real-Time Internet Pharmacy (RTIP) (reject cd)

12,139 Bytes40,448 Bytes

Remittance Advice Details (RAD) (remit adv)

26,688 Bytes169,984 Bytes

Remittance Advice Details (RAD) Examples: Pharmacy (remit ex ph)

10,686 Bytes35,328 Bytes

Remittance Advice Details (RAD): Payments and Claim Status (remit pay)

713,103 Bytes748,032 Bytes

Share of Cost (SOC): 30-1 for Pharmacy (share ph)

12,148 Bytes44,544 Bytes

Sign Language Interpretation (sign)

12,121 Bytes41,472 Bytes

Subacute Care Programs: Adult (subacut adu)

13,278 Bytes46,592 Bytes

Subacute Care Programs: Level of Care for Adults and Children (subacut lev)

14,250 Bytes59,392 Bytes

Form: Information for Authorization/Reauthorization of Subacute Care Services – Adult Subacute Program (DHS 6200 A)

17,235 Bytes64,000 Bytes

Subacute Care Programs: Pediatric (subacut ped)

77,141 Bytes138,240 Bytes

TAR Completion (tar comp)

294,934 Bytes543,232 Bytes

TAR Deferral/Denial Policy (Frank v. Kizer) (tar defer)

29,977 Bytes124,416 Bytes

TAR Field Office Addresses (tar field)

48,903 Bytes97,280 Bytes

TAR Submission: Drug TARs (tar sub drug)

104,194 Bytes151,552 Bytes

TAR Submission: Transmittal Form (tar submis)

10,532 Bytes33,792 Bytes

TAR: Submitting Appeals (tar submit)

32,289 Bytes186,880 Bytes

Taxable and Non-Taxable Items (tax)



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