Medi-Cal Rx Electronic Claims Submission

Update Published December 9, 2020

Given the ongoing challenges and constantly evolving health care landscape associated with the unprecedented COVID-19 public health emergency (PHE), the Department of Health Care Services (DHCS), in partnership and collaboration with Magellan Medicaid Administration, Inc. (Magellan), has decided to lengthen the time for the full implementation of the transition to Medi-Cal Rx by three (3) months. DHCS and Magellan will continue to dedicate their combined efforts and rigorous preparations towards Assumption of Operations (AOO) for Medi-Cal Rx on April 1, 2021. In the interim, all current processes and protocols, both effectuated by DHCS and our Medi-Cal managed care plans (MCPs), respectively, will remain unchanged and in place until Medi-Cal Rx launches. More information on this extension can be found in the article titled “Medi-Cal Lengthens Transition Time to Full Implementation – Go-Live on April 1, 2021” that published on November 16, 2020.

Original Published November 11, 2020

Effective January 1, 2021, Magellan Medicaid Administration, Inc. (Magellan) will provide administrative supports and services for Medi-Cal fee-for-service (FFS) pharmacy benefits, collectively referred to as “Medi-Cal Rx.” Medi-Cal Rx will include all pharmacy benefits billed by pharmacy providers on pharmacy claims, for Medi-Cal beneficiaries in both the Medi-Cal FFS and managed care delivery systems.

Under the existing processes in Medi-Cal, Medi-Cal providers choosing to submit claims electronically to the Medi-Cal FFS Fiscal Intermediary (FI) must complete and submit the DHCS 6153  form, titled Medi-Cal Telecommunications Provider And Biller Application/Agreement. The DHCS 6153 form indicates that Medi-Cal providers will be provided with a unique Medi-Cal Submitter Identification (ID) and password, which is used for claims certification purposes, accuracy and correction of claims or payments and more.

In order to reduce the burden on our existing Medi-Cal pharmacy providers and ease the transition to Medi-Cal Rx, as well as to comply with the Governor’s January 1, 2019 Executive Order N-01-2019, the Department of Health Care Services (DHCS) will use the existing DHCS 6153 forms already on file for Medi-Cal pharmacy providers and billers for Medi-Cal Rx electronic claims submission purposes as of January 1, 2021. For Medi-Cal Rx electronic claims submissions, Medi-Cal pharmacy providers will be provided with unique Medi-Cal Rx credentials, which are different than the Medi-Cal Submitter ID and password used for the existing Medi-Cal FFS FI. Providers should note that use of the unique Medi-Cal Rx credentials constitute acceptance of all of the terms and conditions outlined in the existing DHCS 6153 form.

While DHCS recognizes that the DHCS 6153 form currently only references the current Medi-Cal FFS FI, please also note DHCS is in the process of amending the DHCS 6153 form, or create a new form, to specifically reference Magellan and Medi-Cal Rx, inclusive of all related processes and procedures. DHCS aims to release this revised form via Provider Bulletin no later than May 1, 2021. At that time, the Medi-Cal pharmacy provider/biller will need to return the revised DHCS 6153 (or a new) form, within the specified timeframe, to ensure an up-to-date Medi-Cal Rx inclusive agreement is on file.

Until such time, the provider/biller agrees that using the Medi-Cal Rx credentials when submitting an electronic claim will identify the submitter and shall serve as acceptance to the terms and conditions of DHCS’s form DHCS 6153. The provider/biller further acknowledges the necessity of maintaining the privacy of the Medi-Cal Rx credentials and agrees to bear full responsibility for use or misuse of the Medi-Cal Rx credentials, should privacy not be maintained.

If Medi-Cal pharmacy providers/billers have questions regarding this bulletin, please direct all such communications to MediCalRxEducationOutreach@magellanhealth.com.