CalOptima Members Asked to Verify Addresses to Prepare for Redetermination of Benefits |
CalOptima is requesting help from providers to inform members of an important step in their verification of Medi-Cal eligibility. The California Department of Health Care Services (DHCS) is returning to regular Medi-Cal eligibility and enrollment operations now that the COVID-19 Public Health Emergency (PHE) is ending in the coming months.
During the PHE, Medi-Cal members retained coverage regardless of any changes in circumstances. After the PHE ends, counties will determine if members are still eligible for Medi-Cal. CalOptima members will receive a mailed letter asking to confirm their contact information as an initial step in this verification effort.
If a member has changed addresses or other contact information during the PHE, they should notify the County of Orange Social Services Agency by calling 855-541-5411 or visiting https://ssa.ocgov.com.
Providers with questions can call CalOptima’s Provider Relations department at
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What You and Your Patients Need to Know About the OneCare 2023 Transition |
CalOptima’s OneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan) will sunset on December 31, 2022. All OneCare Connect (OCC) members will automatically transition to OneCare, CalOptima’s Dual Eligible Special Needs Plan, effective January 1, 2023.
OCC members will receive all their services through December 31, 2022. On January 1, 2023, these members will automatically start receiving services through OneCare. Members do NOT need to do anything to enroll into the matching OneCare plan.
After the transition, members will still receive the same health care benefits they do today. There will be no gap in their coverage.
OneCare will continue to assist members with health care needs and coordinate benefits and care. This includes medical and home- and community-based services, medical supplies and medications. The OneCare network will include the providers who members are seeing today, or CalOptima will help members find a new doctor if requested.
Members will start receiving letters about this change in October 2022. Certain CalOptima Community Network (CCN) providers should have received a contract amendment to add the OneCare program. If you have not already done so, please make sure to sign and return those amendments to CalOptima by April 20, 2022.
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FDA Authorizes Second COVID-19 Vaccine Booster for Older and Immunocompromised Individuals |
On March 29, 2022, the U.S. Food and Drug Administration (FDA) authorized a second booster dose of either the Pfizer-BioNTech or Moderna COVID-19 vaccine for anyone 50 years of age and older, as well as certain immunocompromised individuals. This makes a second booster dose of these vaccines available to populations at higher risk for severe disease, hospitalization and death.
The FDA amended the emergency use authorizations as follows:
- A second booster dose of the Pfizer-BioNTech or Moderna COVID-19 vaccine may be administered to individuals 50 years of age and older at least four months after receipt of a first booster dose of any authorized or approved COVID-19 vaccine.
- A second booster dose of the Pfizer-BioNTech COVID-19 vaccine may be administered to immunocompromised individuals 12 years of age and older at least four months after receipt of a first booster dose of any authorized or approved COVID-19 vaccine.
- A second booster dose of the Moderna COVID-19 vaccine may be administered to immunocompromised individuals 18 years of age and older at least four months after the first booster dose of any authorized or approved COVID-19 vaccine.
CalOptima encourages providers to recommend a second booster dose of the COVID-19 vaccine to patients 50 years of age and older with significant comorbidities, and to all patients 65 years of age and over.
For COVID-19 vaccine information, please see the Orange County Health Care Agency’s website, which includes administration locations.
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Providers Should Bill Physician Administered Drugs as a Medical, not Pharmacy, Benefit |
Earlier this month, DHCS reminded providers and managed care plans (MCPs) that physician administered drugs (PADs) are a medical benefit and should not billed through Medi-Cal Rx as a pharmacy benefit.
In January, DHCS communicated that MCPs are to provide access to PADs, which are prescription drugs administered by a health care professional in a clinic, physician’s office or outpatient setting. PADs remain a medical benefit, even though some may also be available as a pharmacy benefit where medically appropriate.
DHCS continues to receive reports of impeded access to PADs — including chemotherapeutic agents, anti-rejection medications for organ transplants and long-acting contraceptives — by providers who believe PADs are a pharmacy benefit and billable to Medi-Cal Rx.
DHCS reiterated the following:
- Medi-Cal covers all medically necessary PADs administered by a health care professional in a clinic, physician’s office or outpatient setting.
- PADs are always a medical benefit.
- PADs should be billed by the provider on a medical claim to the MCP. MCPs or their subcontractors cannot reassign PAD claims to be processed through Medi-Cal Rx.
- Members should not be directed by their MCP or provider to go to a pharmacy to obtain PADs through Medi-Cal Rx.
The following exceptions apply:
- In certain situations, the pharmacy may fill a prescription and send the PAD to the administering provider. For example, when the administering provider does not maintain stock of the PAD or when a specialty pharmacy is the sole source for the PAD. These situations require a Prior Authorization (PA) issued by Medi-Cal Rx.
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As indicated in the MediCal-Rx-Scope located on the DHCS website, PADs are carved out in the rare situation when they receive PA to be billed as a pharmacy claim.
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Users with access to the Referral module can download a PDF copy of referral records. To do so, click on “Referrals” from the main menu on the left, then click the “Download” link located in the upper right corner of the Referral Details screen.
Contracted primary care providers with access to the Reports module can also now download the December 2021 CCN rate, or Pay for Value (P4V), reports. These reports include the performance measures that are part of the P4V program, as well as the Quality Compass 2020 HEDIS National Medicaid Benchmarks. The reports also highlight a providers’ current percentage rate compared with the National Medicaid Benchmark.
By April 30, contracted providers will be able to download the Quarter 1 Blood Lead Screening Performance report. This report identifies any children ages 6–72 months of age who have not been screened for lead, and will be shared quarterly with providers. To access this report, click on the Reports module, then “Blood Lead Screening” under report type, select the provider name and then click “Download” on the lower right corner of the screen.
Along with these improvements, CalOptima has made other background upgrades to increase the overall operational efficiency of the portal.
Additional functions will be added in coming months. Look for further details in future editions of the Provider Update.
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Continuing Education Workshop on Withdrawal Management Offered in May |
Physicians and other licensed health care professions interested in continuing education regarding withdrawal management (WM) can sign up for a workshop being held next month.
The presentation, “Managing Drug/Alcohol Withdrawals and Tapers,” will be held via Zoom from Noon to 1:30 p.m. on May 4, 2022. The guest speaker will be Mario San Bartolomé, M.D., an addiction medicine specialist who is board certified in both family medicine and addiction medicine.
Topics will include common medications to assist in WM, how WM fits into addiction treatment and tools uses to assess withdrawal. Workshop attendees will receive 1.5 Continuing Medical Education and Continuing Education credits.
Space is limited and interested providers should RSVP by April 29 using the following link: http://bit.ly/3KLtQmI.
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Applied Behavior Analysis P4V Incentive Program to Continue Through 2022 |
CalOptima’s Board of Directors has approved continuing the Applied Behavior Analysis (ABA) P4V incentive program through the end of 2022. ABA providers have the opportunity to earn a maximum incentive of 4% of their 2022 annual total claims paid.
To be eligible, ABA providers must have a base rate. CalOptima will continue to use the 2020 base rate as a starting point. If a provider does not have an established 2020 base rate, CalOptima will use 2021 as the starting point. A performance measure report card will be distributed semiannually, with the first scheduled to be sent in July.
As before, there will be two performance metrics: Applied Behavior Analysis Utilization (ABAU) and Applied Behavior Analysis Hours (ABAH). ABAU will measure the percentage of 1:1 hours utilized versus authorized. ABAH will measure the percentage of supervision hours completed by a Board Certified Behavior Analyst or Behavior Management Consultant.
See the ABAU Annual Percentage P4V and ABAH Annual Percentage P4V tables here.
If you have any questions, please contact Provider Relations at 714-246-8600 or email BHP4V@caloptima.org.
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Use These Criteria When Documenting Patient Alcohol Use Disorders |
OCC providers should use the guidelines below for documenting alcohol use disorder (AUD).
The following criteria is from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Severity is calculated using the number of criteria a person meets based on their symptoms: mild (two-to-three criteria), moderate (four-to-five criteria) or severe (six or more criteria). Screening tools, such as the National Institute on Alcohol Abuse and Alcoholism’s AUDIT and CAGE instruments, can also be used to assess for AUD.
At least two of the following criteria should be observed within a 12-month period:
1) Had times when you ended up drinking more, or longer, than you intended?
2) More than once wanted to cut down or stop drinking, or tried to, but couldn’t?
3) Spent a lot of time drinking? Or being sick or getting over other aftereffects?
4) Wanted a drink so badly you couldn’t think of anything else?
5) Found that drinking — or being sick from drinking — often interfered with taking care of your home or family? Or caused job troubles? Or school problems?
6) Continued to drink even though it was causing trouble with your family or friends?
7) Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink?
8) More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area or having unprotected sex)?
9) Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout?
10) Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before?
11) Found that when the effects of alcohol were wearing off you had withdrawal symptoms, such as trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart or a seizure? Or sensed things that were not there?
Document all coexisting conditions, underlying causes and complications that affect your patient’s care management, quality of life, treatment responses and/or your medical decision-making. Elaborate on your patient’s clinical picture during each episode of care.
For alcohol-related disorders, document the blood alcohol level, if applicable.
For alcohol-related disorders, please use the Dx codes on this table.
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APLs Gives Guidance on Alternate Document Formats, Services for Eating Disorders, Mental Health Services, Older Adult Expansion Reporting Template |
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Policy and Procedures Monthly Update |
Click on the link below to find an outline of changes made to CalOptima policies and procedures during March 2022. The full description of the policies below is available on CalOptima’s website at www.caloptima.org.
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Health Education: Trainings and Meetings |
Click below for a list of training webinars and links happening in April and May 2022:
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Based on the Medi-Cal bulletins and Newsflashes, CalOptima has updated the procedure codes for the subjects listed below:
- Frequency Limits Updated for COVID-19 Related Laboratory Codes
- Providers Holding Submissions of Claims for COVID-19 Vaccine Administration May Now Submit
- Laboratory/Pathology Non-Specific ICD-10-CM Codes Update
- Clinical Laboratory Rate Adjustment Effective July 1, 2021
- Changes to National Correct Coding Initiative Quarterly Update for March 2022
- Postpartum Care Expansion for Medi-Cal and MCAP Beneficiaries
- Updates to the List of Contracted Intermittent Urinary Catheters
- Updates to Rental Policy for Oscillation System
- Aid Code Definitions Expanded for ARPA Postpartum Care Extension
- Drug Medi-Cal Providers Will Now Be Designated Categorical Risk Levels
- Expanded Hearing Aid Coverage for Children Program Benefits Under Aid Code A1
- Bebtelovimab Administration added as New COVID-19 Monoclonal Antibody Benefit
- J0248 Established as Medi-Cal Benefit for Remdesivir to Treat COVID-19
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- CalOptima Board of Directors: May 5 at 2 p.m.
- CalOptima Provider Advisory Committee: May 12 at 8 a.m.
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Follow CalOptima on Social Media |
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CalOptima regularly posts on social media to engage members with heath tips, community resources, event dates, program updates and other pertinent information. Follow the agency on Facebook, Instagram, Twitter and LinkedIn.
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CalOptima, A Public Agency www.caloptima.org
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