Provider Resources Available as Medi-Cal Renewal Begins |
As of April 1, the County of Orange Social Services Agency (SSA) has returned to regular Medi-Cal eligibility and enrollment operations, and has begun a 14-month process of determining if all CalOptima Health members are still eligible.
To aid members in navigating this change, CalOptima Health has created a Medi-Cal renewal toolkit for providers and other community partners that includes a renewal FAQ and sample flyers, posters, social media posts, newsletter articles and text messages. These materials have been customized for Orange County, and we encourage you to use them widely to raise awareness about this critical process so members can keep their Medi-Cal.
Providers should note the basics regarding the renewal process. Members’ eligibility will be assessed according to their renewal month, which is often the month they first enrolled in Medi-Cal. First, SSA will attempt to verify eligibility through available data sources. If members cannot be verified through this “ex parte” process, they will need to provide information on a renewal form, which will be mailed to them in a yellow envelope. SSA encourages providers to continue sharing the following renewal steps with their patients:
- Update your contact information with SSA.
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Create your online account at MyBenefitsCalWIN.org.
- Check your mail for a renewal form in a yellow envelope.
- Complete your renewal form if you get one.
Help your patients keep their Medi-Cal. Direct them to their online Medi-Cal account at MyBenefitsCalWIN.org or to call SSA at 1-800-281-9799.
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End of Public Health Emergency Will Affect Some Medi-Cal Flexibilities |
The federal government has announced that the COVID-19 Public Health Emergency (PHE) will end on May 11. However, the Department of Health Care Services (DHCS) has elected to make permanent several Medi-Cal flexibilities implemented over the course of the PHE. Below is a summary of end dates for key federal Medicaid provisions, with additional details on what flexibilities will continue.
Ending:
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Optional COVID-19 Group for Uninsured Individuals: California has taken advantage of the “optional COVID-19 group” that provides uninsured individuals with Medi-Cal coverage for COVID-19 vaccines, testing and treatment. This coverage expires on the last day of the PHE. In order to prepare individuals in this group for the end of the PHE, DHCS will send member notices on April 24, 2023.
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Section 1135 Waivers: These waivers of certain Medicare, Medicaid and Children’s Health Insurance Program requirements will expire at the end of the PHE. Additionally, DHCS has elected to discontinue emergency Medi-Cal provider enrollment flexibilities, effective March 29, 2023.
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Enhanced Federal Match for COVID-19 Vaccines and Vaccine Administration: States currently receive 100% federal matching funds for coverage of vaccines and vaccine administration. These matching funds end on September 30, 2024.
Continuing:
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No-Cost Coverage for COVID-19 Vaccines, Testing and Treatment to Members: Medicaid is required to cover COVID-19 vaccines, testing and treatment with no cost-sharing for members through the summer of 2024. DHCS is electing to permanently extend coverage for COVID-19 vaccines, testing and treatment at no cost.
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Medicaid Disaster Relief State Plan Amendments (SPAs): DHCS is making permanent many policies authorized under the Disaster Relief SPAs. For details on the specific policies being made permanent, see Part I of the DHCS Unwinding Plan.
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Section 1915(c) Appendix K or Section 1115 Attachment K: DHCS intends to make some 1915(c) and 1115 flexibilities permanent Medi-Cal policies beyond the end of the PHE. For details on these policies, please see Part I of the DHCS Unwinding Plan.
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Retention Payments Coming for Hospital and Skilled Nursing Facility Workers |
In recognition of their efforts to combat COVID-19, providers working in hospitals and skilled nursing facilities will receive a collective $1 billion in one-time retention payments from DHCS.
The agency announced payments to 788,000 physician and non-physician workers at 3,424 qualifying facilities across the state as part of an effort to stabilize and maintain California’s health care workforce. If eligible, full-time non-physician workers may receive up to $1,500, part-time workers may receive up to $1,250 and physicians may receive up to $1,000.
Additionally, 44,000 workers for Covered Services Employers who provide onsite clerical, dietary, environmental, laundry, security, engineering, facility management, administrative and billing services will receive a total of $46 million in payments.
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New Opioid Recovery Handbook Encourages Shared Decision Making |
CalOptima Health has released a new resource to aid our members and providers in practicing shared decision making to overcome opioid addiction.
The Decisions in Recovery: Treatment for Opioid Use Disorder Handbook is a web-based multimedia tool to guide decisions on opioid disorder treatment. The handbook contains written information, videos and self-assessment resources covering how to find help, how and when to use medication, and what to expect during recovery. To download a copy of Decisions in Recovery, visit the Behavioral Health Resources page in the Provider section of our website.
This is one of several evidence-based shared decision making tools that will be released on our website in coming months. Shared decision making is a key component of patient-centered health, where providers and patients work together to make the best health decisions that align with the patient’s goals, preferences and values.
We encourage providers to share their feedback on the Decisions in Recovery handbook and any recommendations on other shared decision making aid topics to include on the website by emailing healtheducationreview@caloptima.org.
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Follow These Guidelines to Submit Clean Claims for Skilled Nursing Facilities |
To avoid delays on claims submitted by skilled nursing facilities, providers need to submit clean claims.
CalOptima Health defines a clean claim as having no defect, impropriety or special circumstance — including incomplete documentation — that delays timely payment. A clean claim includes the required data elements on a standard claim form, along with any attachments and additional elements. Here is an example of a clean claim. Claims for inpatient and facility programs and services need to be submitted on the UB-04 form. State and federal guidelines may supersede these requirements.
Claims can be submitted through Office Ally, CalOptima Health’s contracted clearinghouse. Instructions for submitting through Office Ally can be found on the claims and eligibility page on our website.
The UB-04 form captures essential data elements for providers of services in institutional, inpatient and facility settings. The required elements of a clean claim must be complete, legible and accurate. The claim data elements required on the UB-04, including their form field number, are as follows:
- Field 1: Provider’s name, address and telephone number
- Field 3a: Patient control number
- Field 4: Type of bill code
- Field 5: Valid provider’s federal tax ID number
- Field 6: Statement period (beginning and ending date of claim period)
- Field 8: Patient’s name
- Field 9: Patient’s address
- Field 10: Patient’s date of birth
- Field 11: Patient’s gender
- Field 12: Date of admission (required for inpatient and home health)
- Field 13: Admission hour
- Field 14: Type of admission (e.g., emergency, urgent, elective, newborn) required for inpatient
- Field 15: Source of admission code
- Field 17: Patient-status-at-discharge code
- Field 39–41: Value code and amounts
- Field 42: Valid and eligible revenue code
- Field 43: Revenue/service description
- Field 44: Valid and eligible Healthcare Common Procedural Coding System (HCPCS)/Rates (Current Procedural Terminology [CPT] or HCPCS codes are required)
- Field 45: Service date (required for each date of facility-based non-inpatient services or itemization in a separate attachment is required)
- Field 46: Units of service
- Field 47: Total charge
- Field 50: HMO or preferred provider carrier name
- Field 56: Valid CalOptima Health-enrolled NPI number
- Field 58: Subscriber’s name
- Field 59: Patient’s relationship to subscriber
- Field 60: Insured’s unique ID
- Field 66: Diagnosis qualifier
- Field 67: Principal diagnosis code (ICD-10 codes are required)
- Field 69: Admit diagnosis
- Field 76–79: Provider name and identifiers
- Attachment: Other Health Coverage documentation (Explanation of Medical Benefits [EOMB] if applicable)
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Share Your Input on Opportunities for Community Health Workers and Promotores |
Orange County providers can help guide the development of job opportunities for community health workers (CHWs) and promotores with a phone call.
CalOptima Health participates in the Regional CHW and Promotor Workforce Capacity-Building Collaborative (CHW/P) alongside Latino Health Access (LHA), the Coalition of Orange County Community Health Centers and El Sol Neighborhood Education Center.
LHA is spearheading the development of the CHW/P Capacity-Building Plan for Orange County. Providers can provide input on this plan by signing up for a 30-minute call using this Google form. Involvement is voluntary, and any information will be kept confidential unless providers agree otherwise.
The CHW/P collaborative is also working on:
- Expanding the size and impact of the CHW/P workforce
- Developing and sharing models that enhance the capacity of health and social service systems to provide linguistically and culturally responsive services
- Scaling the CHW/P workforce and connecting CHW/Ps to high-quality jobs
- Developing and sharing financially sustainable, evidence-based models
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Webinar to Cover Substance Use Issues Affecting Infants and Families |
The Orange County Family Treatment Taskforce invites providers to participate in a Zoom webinar from 2:30 to 4 p.m. on April 11 to learn more about a countywide initiative to improve outcomes for infants and families affected by substance use.
OB-GYNs, nurses and social workers in prenatal care offices, substance use disorder treatment – including Medication Assisted Treatment (MAT) — providers, peer mentors, coaches, doulas and others with lived experience are invited to attend and give input on how pregnant people with substance use disorders are screened, identified and engaged in services.
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DHCS Launches New Website for Children and Teen Medi-Cal Members |
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Early Medi-Cal Enrollment Supports Newborn Care |
Ensuring that newborn members can access and maintain their Medi-Cal benefits is important to supporting their health care after birth.
Providers can bill for services provided to the newborn using the mother’s Medi-Cal card (member client index number [CIN]) during the birth month and the following month. New mothers should start the enrollment process for their newborns into Medi-Cal early so there will be no lapse in Medi-Cal coverage or delays in completing important well-child visits.
To prevent a lapse in coverage for the mother or the newborn, remind your Medi-Cal members who are pregnant or recently delivered to complete the following steps:
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*On April 24, www.MyBenefitsCalWIN.org will change to www.benefitscal.com
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Use New CPT Codes for Dyadic Care |
- H1011 – Dyadic Behavioral Health Well-Child Visits
- H2015 – Dyadic Comprehensive Community Support Services, per 15 minutes
- H2027 – Dyadic Psychoeducational Services, per 15 minutes
- T1027 – Dyadic Family Training and Counseling for Child Development, per 15 minutes
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CMS Approves Retroactive Reimbursement for Administering Mpox Vaccine |
The Centers for Medicare & Medicaid Services (CMS) has approved SPA 22-0062, which allows for retroactive reimbursement for administering the mpox, or monkeypox, vaccine.
Providers can submit retroactive claims for mpox vaccine administration to CalOptima Health for dates of service between August 17, 2022, and January 31, 2023. Please be aware that each administration either falls under a qualifying office visit or vaccine-only encounter, not both. Providers will receive a 120-day timeliness override to submit the mpox vaccine-only encounters.
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Merit-Based Incentive Payment Data for 2023 Available |
In February, CMS released its Merit-Based Incentive Payment System (MIPS) Payment Adjustment Data File for payment year 2023.
CalOptima Health uses this information to determine MIPS payment adjustments for Medicare Part B services furnished by out-of-network providers. CalOptima Health is expected to pay the full MIPS amount owed within 30 days of the receipt of clean claim.
Provider can read the full details in this CMS memo, including the file layout in Appendix A on page 3. |
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In-Person Business Requirements Waived for Certain Providers |
On March 1, DHCS distributed a bulletin stating that it will waive certain place-of-business requirements for providers who offer mental health services exclusively through telehealth and non-emergency medical transportation (NEMT) or non-medical transportation (NMT) providers working in California or a border community.
The waived requirements include:
- Regular and permanently posted business hours
- Permanently attaching signage that identifies the name of the provider or business
- Obtaining and maintaining liability insurance coverage for the premises of $100,000 or more per claim, or a minimum aggregate of $300,000
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On March 20, DHCS sent out Revised APL 22-029: Dyadic Care Services Benefit, which explains requirements for providing the dyadic care services. Significant changes in the revised APL include that dyadic care services may be provided by the medical well-child provider and updated billing, claims and payment information.
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Policies and Procedures Monthly Update |
Click on the link below to find an outline of changes made to CalOptima Health policies and procedures during March 2023. The full description of the policies below is available on CalOptima Health’s website at:
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Health Education: Trainings and Meetings |
Click below for a list of training webinars and links happening in April 2023:
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- CalOptima Health Board of Directors: April 6 at 2 p.m.
- CalOptima Health Joint Provider and Member Advisory committees: April 13 at 8 a.m.
At this time, all meetings have an option for virtual attendance due to COVID-19. Visit the CalOptima Health website for more information.
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Follow Us on Social Media |
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CalOptima Health 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 Health, A Public Agency www.caloptima.org
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