Medi-Cal Renewal Continuing – Remind Your Patients to Complete the Process
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During the Public Health Emergency, federal continuous coverage requirements meant Medi-Cal members kept their coverage regardless of any change in their circumstances. On April 1, the Department of Health Care Services (DHCS) returned to regular Medi-Cal eligibility and enrollment operations. Locally, the County of Orange Social Services Agency (SSA) began redetermining the eligibility for CalOptima Health members. The process began with those who have a renewal month in June.
If your patient’s renewal date was in June, and they didn’t respond by June 30, they have 90 days, until September 30, to return their Medi-Cal renewal packet to get their coverage reinstated. The same 90-day “cure” period is available to all members in any renewal month going forward. Please remind your patients to look for their Medi-Cal renewal packets in the mail in a yellow envelope and to act quickly to keep their coverage by returning those renewal documents.
Providers should continue to encourage members to take the following renewal steps:
- Update their contact information with SSA.
- Create an online account at BenefitsCal.com. They can check what their renewal month is so they are aware of when to act.
- Check their mail for a renewal form in a yellow envelope.
- Complete the renewal form if they get one.
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Providers Can Access Member Health Information Forms Through Provider Portal |
As part of the CalAIM Population Health Management program, CalOptima Health is working to streamline initial screenings for members. The Health Information Form/Member Evaluation Tool (HIF/MET) is a federally required screening form sent to newly enrolled members to identify those needing expedited care. CalOptima Health sends the HIF/MET in the New Member Welcome Packet for members to fill out and mail back.
Beginning this past month, primary care providers (PCPs) can view HIF/MET information in the CalOptima Health Provider Portal. PCPs can download HIF lists, view and acquire member HIFs, and receive alerts when HIF lists are available.
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Medi-Cal Wrap Services Require Prior Authorizations |
Reminder: Providers participating in OneCare (HMO D-SNP), a Medicare Medi-Cal Plan, must submit prior authorizations for Medi-Cal wrap services to CalOptima Health.
Under the previous OneCare Connect program, which ended December 31, 2022, these non-Medicare-covered services were overseen by members’ health networks. These services include but are not limited to:
- Hearing aids
- Durable Medical Equipment (various types), if not covered by Medicare
- Ear mold/insert not disposable (any type)
- Incontinence supplies over what Medi-Cal allows
- Non-Emergency Medical Transportation (NEMT) — wheelchair vans
For a complete list of authorization codes for Medi-Cal wrap services, please see this table.
Providers must submit prior authorizations through the Provider Portal. Medi-Cal wrap authorizations need to be submitted under the Medi-Cal line of business for the member. Authorizations submitted under the OneCare line of business will produce an error message.
Please see this PDF for detailed instructions on how to submit wrap services authorizations.
If you have not registered for the Provider Portal yet, please see our website, which contains helpful information such as a step-by-step Provider Portal training video and Provider Portal Reference Guide.
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Virtual Learn Meeting to Cover Important Provider Topics |
CalOptima Health’s Provider Relations department invites contracted providers and their staff to a virtual learn meeting on Tuesday, August 22 at 1 p.m.
The one-hour Zoom meeting will cover:
- The Pay for Value (P4V) Program
- Blood lead screenings
- CalOptima Health Provider Portal submissions
- Medi-Cal renewal
- Provider directory validation
Contracted providers, office managers, back-office billing staff, authorization staff and any other staff who would benefit from this virtual learn meeting are welcome to attend. Register by clicking on this Zoom link.
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New Guide Assists Providers in Optimizing Performance on W30 HEDIS Measure |
CalOptima Health has created a guide to assist providers with optimizing their performance on the Well-Child Visits in the First 30 Months of Life (W30) Healthcare Effectiveness Data and Information Set (HEDIS) measure. The guide covers:
- How W30 well-child visits are measured
- Newborn medical coverage under mother’s CIN and early registration for Medi-Cal benefits
- Getting credit for providing care to the newborn under the mother’s CIN
- When to schedule well-child visits
- Optimizing office processes for well-child visits
For additional resources on the W30 HEDIS measure, see the following:
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DHCS Reminds That Physician Administered Drugs Are a Medical Benefit |
DHCS is reminding providers and managed care plans (MCPs) that physician administered drugs, or PADs, are a medical benefit and should not be billed through Medi-Cal Rx.
PADs are prescription drugs administered by a health care professional in a clinic, physician’s office or outpatient setting, such as chemotherapeutic agents, anti-rejection medications for organ transplants and long-acting contraceptives. Since the implementation of Medi-Cal Rx last year, PADs must be submitted to MCPs like CalOptima Health and never billed as a pharmacy benefit.
DHCS has recently been made aware that some medical claims for PADs may have been inappropriately denied by MCPs and shifted to Medi-Cal Rx. This may have resulted in prescribers rescheduling or canceling medical procedures and negatively impacting members.
When billing for PADS, please remember:
- 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.
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Reduce Unnecessary Imaging to Improve Low Back Pain HEDIS Measure Score |
To improve HEDIS scores, CalOptima Health encourages providers to reduce imaging studies when evaluating members for low back pain (LBP).
The HEDIS LBP measure evaluates members ages 18–75 with a principal diagnosis of LBP in an outpatient or emergency department visit who did not have an imaging study (X-ray, CT scan or MRI) within 28 days of the primary diagnosis. A higher measure rate indicates appropriate treatment, as evidence shows that unnecessary or routine imagining for LBP is not associated with improved outcomes, according to the National Committee for Quality Assurance (NCQA).
How to improve your HEDIS scores for LBP:
- Avoid ordering diagnostic studies within 30 days of a diagnosis of new onset back pain in the absence of red flags (e.g., cancer, recent trauma, intravenous drug abuse, neurologic impairment, HIV, spinal infection, major organ transplant, prolonged use of corticosteroids, hospice, osteoporosis, fragility fracture, lumbar surgery, spondylopathy or palliative care).
- Provide patient education on comfort measures, e.g., pain relief, stretching exercises and activity level.
- Use correct exclusion codes if applicable (e.g., cancer).
- Look for other reasons for visits for LBP (e.g., depression, anxiety, narcotic dependency, psychosocial stressors, etc.).
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Avoiding Unnecessary Prostate Cancer Screening for Older Men |
Due to a high number of false positives and other negative impacts, CalOptima Health-contracted providers should avoid conducting unnecessary prostate cancer screenings on men over age 70.
The United States Preventive Services Task Force (USPSTF) recommends against prostate-specific antigen (PSA)-based screening for men ages 70 years or older. While USPSTF found evidence that PSA screenings may slightly lower the chance of death from prostate cancer, it also found that many men are at risk of negative effects from these screenings. Such effects include a high rate of false positives due to other conditions and potential complications from a prostate biopsy, both of which are more prevalent in older men.
Additionally, PSA screenings can lead to overdiagnosis, or the diagnosis of prostate cancer in some men whose cancer will never become symptomatic in their lifetime. Treating cancer in these cases can result in harm to the individual with no benefit. According to USPSTF, randomized trials suggest 20% to 50% of men diagnosed with prostate cancer through PSA screening were over diagnosed, a rate that is expected to be at its highest in men over age 70.
For the Non-Recommended PSA-based Screening in Older Men HEDIS measure, a lower rate indicates better performance. You can improve this HEDIS score by:
- Educating patients on the adverse effects and benefits of the testing
- Avoiding testing for low-risk men if the patient has no prior family history of prostate cancer or has no prior history of elevated PSA test value (>4.0 nanogram/milliliter [ng/mL])
To read the full USPSTF rationale for their recommendation, visit their website.
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Use Spirometry Testing to Assess and Diagnose COPD |
Providers should utilize spirometry testing when evaluating members suspected of a new or worsening diagnosis of chronic obstructive pulmonary disease (COPD). Spirometry results can verify a COPD diagnosis and be valuable when deciding a course of treatment.
The HEDIS Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR) measure evaluates the percentage of members ages 40 and older with a new diagnosis of COPD or newly active COPD who received appropriate spirometry to confirm the diagnosis.
This measure consists of:
- Diagnosis — A 12-month lookback period that begins July 1 of the year prior to the measurement year and ends June 30 of the measurement year. This lookback period captures the first COPD diagnosis.
- Spirometry testing — At least one claim/encounter for spirometry testing to confirm the diagnosis in the two years prior to the diagnosis through six months after the diagnosis.
CalOptima Health offers the following best practice tips:
- Emphasize the importance of spirometry testing to members newly diagnosed with COPD or newly active COPD.
- Incorporate the use of spirometry testing for all members with a new diagnosis of COPD to verify.
- Perform in-office spirometry if equipment is available. Ensure you and your staff are trained on the proper administration of spirometry testing. Maintain and calibrate the spirometry equipment according to manufacturer guidelines.
- If equipment is not available, arrange for the member to complete spirometry testing at a location/provider where spirometry equipment is available. Submit timely claims for spirometry testing performed in-office.
- Check problem lists and encounter forms. Confirm that the diagnosis coding is accurate (i.e., acute vs. chronic bronchitis) to prevent the member from inadvertently being pulled into the SPR measure.
- Educate members about the importance of adhering to their medication regimen (proper dose, frequency route and time).
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Virtual Workshop to Focus on Childhood Lead Poisoning Treatment and Prevention |
A virtual workshop on August 23 at Noon will cover sources and risk factors for childhood lead exposure, California’s childhood lead screening operations and appropriate interventions. The workshop will feature Jean Woo, M.D., MPH, MBA, Public Health Medical Officer at the Childhood Lead Poisoning Prevention Branch of the California Department of Public Health.
Participants can earn 1.5 CME and CE credits. Space is limited, so please register by August 18. More information can be found on this flyer. Contact Bao Anh Le at 714-246-8515 or email continuingeducation@caloptima.org for questions. |
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CalOptima Health Updates Notices of Nondiscrimination |
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APL Lays Out Authorization Requirements for Post-Stabilization Care Services |
Authorizations for post-stabilization care services have the following requirements:
- When a member is stabilized, but the provider (either out-of-network or in-network) believes they require additional medically necessary covered services and may not be discharged safely, CalOptima Health must approve or disapprove a provider’s authorization request within 30 minutes of the request. If CalOptima Health fails to do so within that time, the care services are deemed as authorized.
- Title 28 CCR section 1300.71.4, and specifically the 30-minute requirement, must apply to all network provider, subcontractor and downstream subcontractor agreements.
- All requests for authorization of medically necessary post-stabilization care services, and all responses, must be fully documented. Documentation must include the date and time of the request, the name of the requesting provider and the name of the CalOptima Health or health network representative responding to the request.
Training
- If any of the above action items require revisions to processes, policies or procedures, please provide proper training to impacted staff.
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APL Explains Requirements for Medical Pregnancy Termination Services Directed Payments |
MCPs must pay individual qualified contracted and non-contracted providers for medical pregnancy termination services for dates of service after July 1, 2017. DHCS requires MCPs to pay at least the rate for Current Procedural Terminology – 4th Edition (CPT-4) code 59840 in the amount of $400 and CPT-4 code 59841 in the amount of $700.
MCPs must ensure that qualifying medical pregnancy termination services are reported to DHCS in encounter data that is complete, accurate, reasonable, timely and using the correct CPT-4 codes. In instances where a member is found to have other health coverage sources, MCPs must cost avoid or make a post-payment recovery.
Upon request by a provider, CalOptima Health and its delegated health networks must make available an itemization that includes sufficient information to identify the qualifying service for which payment was made. CalOptima Health is prohibited from paying any amount for any covered service or item, other than emergency services, to an excluded provider.
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APL Explains Requirements for Medical Pregnancy Termination Services Directed Payments |
On June 13, DHCS distributed APL 23-017: Directed Payments for Adverse Childhood Experience Screening Services to provide MCPs with guidance on directed payments for the provision of standardized adverse childhood experiences (ACEs) screening services for children and adults 64 years old and younger. This APL supersedes APL 19-018.
To meet the requirements in this APL, CalOptima Health and its contracted health networks:
- Should promote the availability of ACE screening and payment to eligible providers; educate members about ACE screening and toxic stress; establish policies and procedures to incorporate ACE screening results into member risk stratification; establish consistent protocols for ACE screening, referrals and follow-up processes and a pathway to incorporate ACE screening results; establish quality metrics to measure and monitor ACE screenings and member outcomes; and standardize approaches to facilitate claims payment, data aggregation and population health level analysis for reporting and evaluation purposes.
- Must ensure that all criteria on Pages 6–7 of the APL are met for providers submitting claims as an institution.
- Must require providers to document the requirements listed on Page 7 of the APL in the member’s medical record and be available upon request by the member and their parent or guardian in compliance with all state and federal privacy laws.
- Are prohibited from paying any amount for any covered service or item, other than emergency services, to an excluded provider.
- Must make available an itemization of payments made to individual providers, which includes sufficient information to uniquely identify the qualifying services for which payment was made, upon the provider’s request unless the health networks have an established periodic dissemination schedule. This must be made available in an electronic format when feasible.
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APL Charges MCPs With Communicating Claims and Encounter Submission Processes |
The revised version states that MCPs have an obligation to communicate and provide clear policies and procedures to their network providers with respect to the MCP’s claims or encounter submission processes, including what constitutes a clean claim or accepted encounter. If the network provider does not adhere to these articulated policies and procedures, the MCP is not required to make payments for claims or submitted encounters submitted one year following the date of service.
Under this APL, CalOptima Health and its delegated health networks:
- Must not pay any amount for any services or items, other than emergency services, to an excluded provider
- Must make available to a provider upon request an itemization of payments made
- Must ensure to communicate the description of the requirements of the revised APL to their providers
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Policy Guide and APL Prepare MCPs for 2024 Managed Care Transition |
On June 23, DHCS distributed APL 23-018: Managed Care Health Plan Transition Policy Guide, which provides guidance to MCPs regarding the 2024 MCP Transition on January 1, 2024.
This APL establishes the 2024 Managed Care Plan Transition Policy Guide as the authority — along with contracts and additional APLs and guidance documents — regarding the transition. It has been updated to include the transition policies for Enhanced Care Management (ECM) and Community Supports in Sections VI and VII, respectively, to ensure eligible members do not experience disruptions to their authorizations, provider relationships or services. The guide will continue to be updated throughout 2023.
The guide also outlines policies, DHCS operational requirements and guidelines specific to MCP-to-MCP member transitions resulting from the following three changes:
- County-driven MCP model changes
- Changes to commercial MCP contracting
- A new direct contract with Kaiser Permanente
Member Enrollment and Noticing
Members delegated to Kaiser in Orange County as of September 2023 will automatically enroll with Kaiser as their MCP on January 1. To facilitate these automatic transitions:
- By November 3, Kaiser and CalOptima Health must submit to DHCS a list of members enrolled with Kaiser as of September 2023.
- Kaiser must draft and transmit a 90-, 60- and 30-day notice no later than October 1, November 1 and December 1 to members indicating this transition and stating there is no change to their provider network or member services.
- CalOptima Health may not place any new members with Kaiser after September 2023.
Continuity of Care (CoC)
- CalOptima Health and its delegated health networks must ensure all transitioning members have CoC protections. Additionally, some transitioning members will need enhanced protection (see the list of special populations on Pages 25–26 of the policy guide).
- CalOptima Health and its delegated health networks must provide enhanced CoC protections for special populations as outlined in Section V of the policy guide.
Data Transfer
- Kaiser must receive ingestible, accurate and timely data from CalOptima Health, its delegated health networks and DHCS.
- CalOptima Health and its delegated health networks must complete all data transfer as described in Section V.G of the Policy Guide. DHCS reserves the right to perform audits to confirm successful data transfer, and CalOptima Health will be subject to sanctions if it does not meet data requirements.
- CalOptima Health and its delegated health networks must prepare to exchange utilization data beginning November 1.
- DHCS requires CalOptima Health to transmit authorization data, member information —including preferred form of communication — supplemental data for special populations and any additional data elements identified by DHCS for data transfer directly to Kaiser.
- CalOptima Health and its delegated health networks must follow the data transfer and sharing requirements in Figure 9 (Pages 45–50) of the policy guide.
CalOptima Health encourages providers and health networks to review this APL and take steps to ensure that all policies and procedures are updated to be in accordance with its requirements.
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DHCS Guidance Covers Standards for Contracting With Cancer Centers |
On January 24, DHCS distributed a courtesy notice to MCPs that Senate Bill (SB) 987 went into effect January 1 under Section 14197.45 of the Welfare and Institutions Code (WIC). SB 987 codified requirements for MCPs to make good faith efforts to contract with at least one National Cancer Institute (NCI)-designated comprehensive cancer center, site affiliated with the NCI Community Oncology Research Program (NCORP) or qualifying academic center within each county in which they operate. DHCS provided initial guidance to MCPs regarding SB 987 requirements in APL 23-001: Network Certification Requirements.
Significant updates in this DHCS guidance include:
- The cancer centers must be Medi-Cal enrolled or meet the standards of participation required to contract with the MCP.
- The MCP must allow any eligible member with a complex cancer diagnosis to request a referral to receive medically necessary services through any in-network cancer centers unless the member chooses a different cancer treatment provider.
- MCPs that are unsuccessful in good faith contracting efforts must allow members to request a referral to receive medically necessary services through an out-of-network cancer center unless the member chooses a different cancer treatment provider.
- MCPs must ensure that a denial of a member’s referral request is based upon a determination by the treating provider that the request is not medically necessary; the requested services not being available or applicable to the member’s cancer diagnosis; or the cancer center being out-of-network and the MCP and cancer center are unable to come to payment agreement.
- SB 987 is limited to covered benefits and services that are medically necessary and does not include coverage of experimental services.
DHCS will monitor MCPs’ progress in making good faith contracting efforts to include the designated cancer centers within its networks and may issue Corrective Action Plans if MCPs fail to demonstrate that good faith contracting efforts have been made.
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DHCS Distributes Updates to ECM and Community Supports Policy Guides |
On July 12, DHCS distributed updated CalAIM ECM and Community Supports policy guides. The updated policy guides support greater uptake and delivery of ECM and Community Supports to eligible members while reducing administrative burden and duplication.
Significant updates to the ECM Policy Guide include:
- Updated Population of Focus eligibility criteria that MCPs must use to evaluate members. Also, MCPs cannot impose additional eligibility requirements for ECM authorization
- Updated ECM provider contracting requirements
- Addition of Birth Equity Population of Focus, effective January 1
- Updates to the Comprehensive Assessment and Management Plan section, which indicates that DHCS does not require an annual reassessment for members
- Summary of approaches to ECM overlaps/non-duplication
- Requirement that members who meet ECM Population of Focus criteria should be enrolled in ECM and may no longer be enrolled in both ECM and targeted case management programs at the same time
- Updates to specialty mental health services intensive care coordination for children
- Updates on development of a diverse ECM provider network
- Requirement to have a care management documentation system
- Updates on ECM provider payments
- Updates on identifying members for ECM
- Updates to the ECM referrals for members section that indicates that the primary mechanism for member identification should be referrals from the community
- Updates on authorizing ECM for MCP members
- Updates on assignment to an ECM provider
- Requirements for quarterly implementation reporting
Significant updates to the Community Supports Policy Guide include:
- MCPs do not need to actively assess or report on cost effectiveness for Community Supports for the purposes of rate setting or compliance with federal requirements.
- MCPs that deliver similar services, but do not consider them to be Community Supports, must determine the feasibility of transitioning them into the Community Supports program.
- DHCS expectations of MCPs to source the majority of referrals for Community Supports from the community
- MCPs must adhere to the full DHCS-established Community Supports service definitions without modifications or restrictions.
- MCPs should work with Community Supports providers to define a process and appropriate circumstances for presumptive/retroactive authorization of all Community Supports offered, especially for members in need of Recuperative Care and Short-Term Post-Hospitalization Housing.
- Updates to prime and subcontracted MCP authorization alignment
- Updates on contracting with Local Community Supports Providers with Specialized Skills or Expertise Guidance
- Requirements for providers who contract with more than one MCP, including those that may not require Community Supports providers to utilize their MCP portal for documentation of all services and day-to-day work, such as notes and care plans. MCPs may rely on portals for sharing the information contained in the Member Information Sharing guidance document
- Community Supports are subject to the same standard reimbursement timelines as other Medi-Cal services.
Providers and health networks should distribute the ECM and Community Supports policy guides within their organization to ensure regulatory requirements are met and that all desktops, policies and procedures are updated.
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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 July 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 August 2023:
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Based on Medi-Cal Bulletins and NewsFlashes, CalOptima Health has updated the procedure codes and other relevant information for the subjects listed below:
- Message for Providers Regarding HMS Provider Portal
- Updated Age Availability for Some EWC Breast Covered Services
- CCS Service Code Groupings Policy Update
- CHDP Gateway Program 2023 Income Eligibility Guidelines
- Presumptive Eligibility for Pregnant Women Program 2023 Monthly Income Levels
- Updated Billing Policy for Doula Services
- Policy Update for Hydroxyprogesterone Caproate
- Durable Medical Equipment Codes that Require KF Modifier
- Billing Resources for Medi-Cal Providers
- Correspondence Specialist Unit Inquiry Guidelines
- Reminder: Postpartum Care Expansion for Medi-Cal and MCAP Beneficiaries
- National Correct Coding Initiative Quarterly Update for July 2023
- Enteral Provider Manual Section to be Retired
- Heated Humidifiers and Breathing Circuits Not Reimbursable with Ventilator Rentals
- June 2023 Update: Discontinuation of the COVID-19 Uninsured Group Program
- Mpox Vaccine No Longer a Benefit for FQHC, RHC, HIS-MOA and Tribal FQHC Providers
- PE4PW and HPE Programs Resume Wet Signature Requirement
- Elimination of COVID-19 Public Health Emergency Flexibilities for Hospital Presumptive Eligibility
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- CalOptima Health Board of Directors: August 3 at 2 p.m.
- CalOptima Health Joint Provider and Member Advisory committees: August 10 at 8 a.m.
At this time, all meetings have an option for virtual attendance. 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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