DHCS requires enrollment for all Medi-Cal managed care providers In January 2018, the California Department of Health Care Services (DHCS) began requiring that all Medi-Cal managed care providers be enrolled through the Medi-Cal program. Medi-Cal managed care plans have the option to develop and implement a managed care physician screening and enrollment process that meets federal requirements, or they may direct their network physicians to enroll through the DHCS fee-for-service (FFS) enrollment portal. (Enrolling through DHCS does not obligate managed care network providers to also see FFS patients.) Some physicians have already reported receiving notices from Medi-Cal managed care plans regarding the change, which is in response to a new federal rule that took effect on January 1, 2018, that requires states to screen and enroll, and periodically revalidate, all network physicians of managed care organizations. These requirements apply to both existing contracting network physicians as well as prospective network physicians. All contracted physicians in a Medi-Cal managed care plan network prior to January 1, 2018, are required to enroll as soon as feasibly possible and no later than December 31, 2018. For plans that choose to develop their own credentialing process, the plan must complete the enrollment process and provide the applicant with an official determination within 120 days of receipt of a physician application. Plans may allow physicians to participate in their networks for up to 120 days, pending the outcome of the screening process. For plans that choose to have their network physicians enroll through DHCS, DHCS will have up to 180 days to complete the enrollment process. If a case is returned to a physician for correction, the 180 days may be extended. Physicians should note that because plans may only allow physicians to participate in their networks for 120 days pending completion of the screening/enrollment process, there could be instances where they would have to stop seeing Medi-Cal managed care patients if DHCS takes more than 120 days to process their application. Medi-Cal managed care physician applicants will not receive expedited processing. Plans are not required to conduct additional screening and enrollment activities for physicians who are enrolled in the Medi-Cal FFS program. Plans and physicians may confirm Medi-Cal FFS enrollment by accessing the Open Data Portal, which is updated monthly. DHCS has confirmed that network physicians who enroll through the DHCS FFS enrollment process do not need to render services to FFS beneficiaries. There is nothing on the Medi-Cal application that would indicate whether a physician is participating in FFS, managed care or both. DHCS has indicated that at some point it intends to modify the application to allow physicians to provide this information. July 11, 2018 Managed Care, Medi-Cal DHCS, Medi-Cal, Medi-Cal Provider Enrollment, Department of Health Care Services 0 0 Comment Read More »
CMA advocacy results in DHCS revaluing two CPT codes The California Medical Association (CMA) received a call from a physician member with concerns that the California Department of Health Care Services (DHCS) had priced a CPT code for destruction of up to 14 benign skin lesions (CPT 17110) at a higher level than it priced a more complex procedure for the destruction of 15 or more lesions (CPT 17111). CMA escalated the issue to DHCS so it could investigate. Upon further inspection and months of discussions, DHCS announced in October that it was increasing reimbursement on both codes, resulting in an increase of 19 percent on CPT 17110 and an increase of 71 percent on CPT 17111. DHCS began reimbursing at the higher rate on October 1, 2017 DHCS further agreed to make the change retroactive to January 1, 2017. It is scheduled to begin automatically reprocessing affected claims dating back to January 1, 2017, sometime this spring. Physicians are encouraged to stay up to date on Medi-Cal changes and updates by signing up to receive Medi-Cal’s Subscription Services bulletin at http://files.medi-cal.ca.gov/pubsdoco/mcss/mcss.asp. April 5, 2018 CMA, General, Medi-Cal Dermatology, DHCS, Economic Advoacy, Billing/Coding, CPT, Department of Health Care Services, Medi-Cal 0 0 Comment Read More »
Child Health and Disability Prevention code and claim form conversion effective July 1 The California Department of Health Care Services (DHCS) is currently transitioning Child Health and Disability Prevention (CHDP) program billing processes to be compliant with HIPAA standards for national health care electronic transactions and code sets. Rather than billing on the CHDP Confidential Screening/Billing Report (PM 160) claim form, claims will be submitted using CPT codes on the CMS 1500 or UB-04 claim forms or equivalent electronic claim transactions. The transition, effective for dates of service on or after July 1, 2017, affects claims for Medi-Cal Early and Periodic Screening, Diagnosis and Treatment, well-child health assessments and immunizations through the CHDP program. After July 1, these services will also be billed as Medi-Cal services in accordance with Medi-Cal policy, will be reimbursed per the Medi-Cal fee-for-service fee schedule and will receive payment on the standard Medi-Cal warrant. DHCS has released an updated CHDP Code Conversion Table, which is accessible on its website. Services provided prior to July 1, 2017, should be billed on the CHDP PM 160 claim form. The California Medical Association (CMA) has received calls from physicians who report that for their practice, the transition to reimbursement based on the Medi-Cal fee-for-service schedule may result in a decrease of up to 20 percent for some services. CMA has also received questions about whether problem-focused evaluation and management visits, when billed with a preventive medicine visit, will continue to both be reimbursed as they were under the CHDP program. CMA has reached out to DHCS for clarification. For more information, view June 2017 DHCS NewsFlash update. June 22, 2017 Managed Care, Medi-Cal Child Health and Disability Prevention Program, Department of Health Care Services, DHCS, HIPAA, Medi-Cal, CHDP 0 0 Comment Read More »
DHCS preps contingencies in case of delayed budget approval The California Department of Health Care Services (DHCS) recently announced it will implement a contingency plan for claim payment if the state budget is not enacted before the beginning of the 2017-2018 fiscal year on July 1. Although the state legislature passed a budget by the June 15 deadline, the Governor has not yet signed it. According to DHCS, providers should continue to submit claims for processing as normal, but payments for some programs may be delayed until the budget is signed. Claims for the following services will be processed and adjudicated regardless of dates of service: Medi-Cal program California Children’s Services (CCS) program/Medi-Cal Child Health and Disability Prevention (CHDP) program/Medi-Cal Family Planning, Access, Care and Treatment (Family PACT) Program Abortion Claims submitted after June 22, 2017, for the following programs will be withheld regardless of dates of service. CCS-only (aid code 9D) CHDP services only (aid code 8Y) Genetically Handicapped Persons Program (GHPP) (aid code 9J) Optional Targeted Low Income Children’s Program (OTLICP) Claims submitted by Every Woman Counts (EWC) will continue to be processed until contingency funding is exhausted. June 22, 2017 General Child Health and Disability Prevention Program, Department of Health Care Services, DHCS, Family PACT, Medi-Cal, California State Budget, CHDP 0 0 Comment Read More »
CMS erroneously warns some physicians of 2017 meaningful use penalties Providers who attested to meaningful use with the Medi-Cal Electronic Health Record (EHR) Incentive Program for program year 2015 are exempt from Medicare payment adjustments in 2017. Because the California Department of Health Services pushed back the deadline to submit meaningful use applications for the 2015 program year to December 13, 2016, the agency was not able to send information to the Centers for Medicare and Medicaid Services (CMS) regarding 2015 Medi-Cal meaningful use attestations until late in December 2016. For this reason, some Medi-Cal providers are now erroneously receiving letters from CMS warning that they are subject to Medicare payment adjustments in 2017. These letters offer providers the option of filling out and sending in a “reconsideration form” to CMS to avoid the payment adjustments. DHCS has received assurance from CMS that all providers who attested to meaningful use with the Medi-Cal EHR Incentive Program for 2015, even as late as December 13, 2016, will not be subject to Medicare payment adjustments in 2017. Submission of the reconsideration form should not be necessary because CMS has now removed the names of all providers who had attested to meaningful use for 2015 with the Medi-Cal EHR Incentive Program from the list of providers subject to payment adjustments in 2017. While a reconsideration form is not required, if you have already filed a reconsideration form, no further action is necessary. Because no Medicare payments for 2017 dates of service were paid before CMS updated its records with California’s 2015 attestation data, no 2017 payments were affected by the error. If you think you received a notice of 2017 payment adjustment in error, you can check the list of providers who attested to meaningful use in 2015 on the DHCS website. Any additional questions can be directed to medi-cal.ehr@dhcs.ca.gov. February 13, 2017 Medi-Cal, Medicare Department of Health Care Services, EHR, Meaningful Use, Medi-Cal, Medicare, CMS 0 0 Comment Read More »
DHCS suspends planned passive enrollment for duals project The Department of Health Care Services (DHCS) announced last week that it would not move forward with its planned annual passive enrollment of dual eligible beneficiaries under the Coordinated Care Initiative (CCI) after it received feedback from the California Medical Association (CMA) and 40 other stakeholders asking the agency to pursue enrollment strategies that support voluntary "opt-in" enrollment. Instead, DHCS said it will implement a voluntary "opt-in" enrollment effort beginning in July 2016. The new streamlined enrollment strategy will include mandatory Managed Medi-Cal Long-Term Supports and Services (MLTSS) plan enrollment. DHCS said it would monitor participation in the program; should voluntary enrollment not prove to be a viable option for program sustainability, passive enrollment remains an option in the future. In April, DHCS released a series of proposals that would have changed the CCI enrollment process to 1) passively enroll beneficiaries into Cal MediConnect; and to 2) streamline enrollment by allowing plans to eliminate or dramatically reduce the role of the enrollment broker. CMA, in partnership with Justice in Aging and other patient advocacy groups, signed a joint letter strongly opposing the proposals. “Experience shows that passive enrollment strategies result in high opt-out rates, confusion, disruption in care, distrust of managed care and high costs to plans,” the letter to DHCS said. “(P)assively enrolling over 100,000 beneficiaries in a two-month period is staggering. The plans, HICAPs, Ombudsman, enrollment broker, and the broader community lack the capacity to meet the needs of the affected beneficiaries, especially on the expedited timeline DHCS has proposed, under which the first set of notices would be mailed to beneficiaries.” The Coordinated Care Initiative was authorized by the state in July 2012 in an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities. The program began with a three-year demonstration project that expected to see a large portion of the state's dual eligible beneficiaries transition to managed care plans. Although the state is not going forward with passive enrollment in 2016, DHCS has stated they are still considering a passive enrollment strategy for 2017. Click here to read CMA's letter to DHCS on this issue. For more about the duals program, visit www.cmanet.org/duals. Contact: Lishaun Francis, (916) 551-2554 or lfrancis@cmanet.org. June 8, 2016 Managed Care, Medi-Cal, Medicare Medi-Cal, Medicare, Cal-MediConnect, Department of Health Care Services, Dual Eligible 0 0 Comment Read More »
Last chance to appeal payments under ACA primary care physician rate increase The California Department of Health Care Services (DHCS) announced that it would provide a 90-day appeal window for physicians who believe they were not paid, or paid incorrectly, under the Affordable Care Act’s (ACA) primary care rate increase. In late February 2016, DHCS announced a streamlined appeal process, which opened on March 1. The appeal window is only available under the following conditions: The provider successfully attested for the ACA incentive by December 31, 2014 For previously paid Medi-Cal claims For Medi-Cal crossover claims paid $0 with Remittance Advance Detail (RAD) code 442: Medicare payment meets or exceeds Medi-Cal maximum reimbursement. Please note: This appeal process is not open to Child Health and Disability Prevention (CHDP) Program claims, as the deadline to appeal payment for those claims has passed. The appeal window will remain open through June 30, 2016. To determine whether your practice qualifies, it is recommended that you review eligible claims closely to determine if additional money is due. Practices should compare the interim payment made to the true up payment received. If the billed charges submitted were less than the Medicare fee schedule amount, the practice is only eligible to receive the lesser amount per federal law (42 CFR 447.405). Another reason for a lower-than-expected payment amount may be because the Medi-Cal reconciliation amount factored in the Medicare geographic pricing. The interim payment did not take that into consideration, which may have caused an overpayment. Qualification for streamlined ACA appeals DHCS is expediting the appeals process by not requiring proof of patients’ eligibility or proof of timely claims submission, as is sometimes required when appealing a Medi-Cal payment. For a streamlined appeals process, the following qualifications must be met: Appeals must be received by Xerox by June 30, 2016. Standard appeal timeframes are waived for ACA payment appeals. Write or type “ACA” at the top of the “Reason for Appeal field” (Box 13) on the standard appeal form (90-1), with the following attachments: Original claim and/or corrected claim if corrections are needed All documentation supporting the original claim, including a copy of the most recent RAD that shows the claim was either paid or was a crossover claim paid at $0 with RAD code 442 Providers can submit up to 14 claims with each appeal form as long as all the claims are for the same patient. Additionally, DHCS published another bulletin on March 16 reminding practices that when submitting appeals on NICU/PICU claims, they must include the appropriate ACA modifier for each claim line. Providers can determine which ACA modifier to use in the ACA Rate Increase for Specified Primary Care Services Implementation Update page of the Medi-Cal website. Questions about the appeal process can be directed to the Medi-Cal telephone service center at (800) 541-5555. April 12, 2016 General Affordable Care Act, Department of Health Care Services, DHCS, ACA 0 0 Comment Read More »
DHCS urges providers to attest for Medi-Cal meaningful use before December 14 The California Department of Health Care Services (DHCS) announced yesterday that after December 14, 2015, it may be required to stop accepting new Medi-Cal meaningful use attestations due to changes in the federal regulations governing the Medi-Cal Electronic Health Records Incentive Program. It is urging all newly attesting Medi-Cal providers to file before December 14, 2015. DHCS said it might be required by the Centers for Medicare and Medicaid Services to stop accepting meaningful use attestations from professionals and hospitals; it is unclear when meaningful use attestations would be reopened. This applies to all professionals and hospitals attesting for the first time in 2015 who are scheduled to report on a 90-day reporting period. According to DHCS, attestations to adopt, implement or upgrade will continue to be accepted after December 14, 2015. For more information, click here. Contact: DHCS at (916) 552-9181 or Medi-Cal.EHR@dhcs.ca.gov. December 21, 2015 Medi-Cal DHCS, Meaningful Use, Medi-Cal, Department of Health Care Services 0 0 Comment Read More »
Medi-Cal to use ICD-10 crosswalk for claims payment The California Department of Health Care Services (DHCS) did not convert from ICD-9 to the ICD-10 coding system by the federally mandated October 1, 2015, conversion date. DHCS has received approval from the Centers for Medicare and Medicaid Services to take incoming claims coded with ICD-10 codes and convert them back to ICD-9 using a crosswalk in order to calculate payments. DHCS reports the crosswalk is a temporary workaround until the department is able to transition to a new claims processing system. The California Medical Association (CMA) has requested that DHCS share more information, including how it plans to remedy any errors that are the result of the crosswalk, as well as the anticipated timeline for full ICD-10 implementation in the new claims processing system. CMA will be monitoring the issue closely and will be in close contact with DHCS staff in the event any problems arise. Practices that experience Medi-Cal related claim issues are encouraged to call Medi-Cal’s telephone service center at (800) 541-5555. For problems relating to global ICD-10 issues, contact the DHCS ICD-10 mailbox at ICD-10Medi-Cal@xerox.com. CMA has a number of ICD-10 resources available to members, including a new FAQ, “Surviving ICD-10: An FAQ for physician practices,” which are all available free to members on our ICD-10 resource page at www.cmanet.org/icd10. October 14, 2015 Medi-Cal DHCS, ICD-10, Medi-Cal, Department of Health Care Services 0 0 Comment Read More »
California State Auditor releases report outlining flaws with Medi-Cal program The California State Auditor’s office released a report on Tuesday expressing a need for better monitoring of the health plans participating in California’s Medicaid program, Medi-Cal, in order to improve beneficiaries’ access to care. Among the key findings of the audit was that the California Department of Health Care Services (DHCS), which administers Medi-Cal, “has not consistently monitored health plans to ensure that they meet beneficiaries’ medical needs—it did not perform any annual medical audits before 2012 and performed medical audits on less than half of the health plans in fiscal year 2013-14,” according to a summary. The audit also found that DHCS “did not verify health plan data,” resulting in an inability to ensure that beneficiary health plans had sufficient networks of physician providers, and that the tool DHCS uses to evaluate the accuracy of doctor directories is “inadequate.” “Furthermore, we noted that thousands of calls from Medi-Cal beneficiaries seeking assistance through Health Care Services’ Medi-Cal Managed Care Office of the Ombudsman have gone unanswered,” California’s independent State Auditor Elaine Howle wrote in the report. “Specifically, each month between February 2014 and January 2015 an average of 12,500 calls went unanswered.” The state legislature ordered the State Auditor to conduct the review last August amid concerns of inaccuracies with provider directories. Currently, about 12.2 million Californians — or about one-third of the state’s residents — receive health care coverage through Medi-Cal. That number has spiked since Medi-Cal eligibility was expanded under the Affordable Care Act last year. For the full report, click here. June 26, 2015 Medi-Cal DHCS, Medi-Cal, Network Adequacy, Provider Networks, Department of Health Care Services 0 0 Comment Read More »
