CalOptima Health February 2023 Provider Update

February 1, 2023

In This Issue

In this month's issue of the Provider Update, read about provider on-site visits that will be part of a routine audit of CalOptima Health's Medi-Cal plan.

In addition, find guidance on conducting blood lead screenings for children, information on an upcoming series of dementia care trainings and requirements for the new Initial Health Appointment.

This update also contains the monthly roundup of All-Plan Letters, updates to CalOptima Health's policies, health training webinars and details for upcoming meetings.

Provider News

CalOptima Health Audit: Your Office May Be Contacted for On-Site Visit

CalOptima Health will undergo a routine medical audit of our Medi-Cal plan by the Department of Health Care Services (DHCS) between February 27 and March 10.

For this audit, DHCS will choose several CalOptima Health-contracted providers for on-site visits. DHCS nurse evaluators will contact selected providers directly to schedule these visits. To remain in compliance with DHCS, it is important for providers to respond promptly when contacted by these evaluators.

For questions, please contact CalOptima Health’s Provider Relations department at providerservicesinbox@caloptima.org.

Use Provider Portal to Check OneCare Eligibility and Submit Prior Authorizations

Providers participating in OneCare (HMO D-SNP), a Medicare Medi-Cal Plan, need to verify their patient’s eligibility for the OneCare line of business and submit prior authorizations for covered services in the CalOptima Health Provider Portal.

CalOptima Health’s OneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan) ended on December 31, 2022. The majority of patients transitioned seamlessly into OneCare and continue to have access to care.

Please do not cancel patient appointments unless you have verified that they are ineligible. For eligibility verification, remember to look under the OneCare line of business in the Provider Portal. Do not look for the OneCare Connect line of business.

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, Provider Portal Reference Guide and other resources.

Medi-Cal Wrap Services

Under OneCare, Medi-Cal wrap services are handled by CalOptima Health instead of a member’s health network. However, wrap authorizations for the member need to be submitted in the Provider Portal under the Medi-Cal line of business. Authorizations submitted under the OneCare line of business will produce an error message like the one pictured above.

These non-Medicare-covered 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 Medi-Cal wrap authorization codes, see this table.

Please see this PDF for detailed instructions on how to submit referrals and authorizations, including for Medi-Cal wrap services.

For questions, contact CalOptima Health’s Provider Relations department at providerservicesinbox@caloptima.org.

Medi-Cal Redetermination Begins April 1

Starting April 1, DHCS is returning to regular Medi-Cal eligibility and enrollment operations.

During the declared COVID-19 Public Health Emergency (PHE), Medi-Cal members retained coverage regardless of any changes in circumstances. However, as part of the Consolidated Appropriations Act of 2023 signed by President Biden, the continuous coverage requirements will end after March 31, 2023, regardless of whether the PHE has ended. Counties will then have to determine if members are still eligible for Medi-Cal.

DHCS has updated its PHE Unwinding Plan, which lays out how the agency will handle Medi-Cal redetermination, to account for this new end date.

CalOptima Health members will receive a mailed letter from the County of Orange Social Services Agency (SSA) asking to confirm their contact information as an initial step in this verification effort. Providers can assist by informing their Medi-Cal patients to expect this letter.

If a member has changed addresses or other contact information during the PHE, they should notify SSA by calling 855-541-5411 or visiting https://ssa.ocgov.com.

Blood Lead Screenings a Necessary Part of Child Health Assessments

All CalOptima Health-contracted providers are required to follow the California Department of Public Health (CDPH) Standard of Care on Screening for Childhood Lead Poisoning.

When performing periodic health assessments (PHAs) for children, providers must give parents or guardians oral or written anticipatory guidance. At a minimum, this must include information that children can be harmed by exposure to lead and are particularly at risk for lead poisoning from the time the child begins to crawl until 72 months of age. This anticipatory guidance is required for all children between the ages of 6 months and 6 years and at each PHA.

Testing children for lead at the recommended timeframes provides an opportunity for early diagnosis, identification of lead exposures and follow-up care. The guidelines are as follows:

Providers should test children for lead at 12 months of age and again at 24 months of age
If a blood lead test was not performed at 12 months, catch-up testing is mandated for children between 12 and 24 months of age
If a blood lead test was not performed at 24 months or later, catch-up testing is mandated for children between 24 and 72 months of age

Providers are required to provide testing for lead and follow-up care using the new Centers for Disease Control and Prevention (CDC) blood lead reference value of 3.5 µcg/dL.

Stay up to date on the latest blood lead screening recommendations with the following resources:

For more information on lead poisoning prevention or lead program services, please contact the Orange County Health Care Agency Childhood Lead Poisoning Prevention Program at 714-567-6220 or by visiting www.ochealthinfo.com/lead.

CalOptima Health Introduces New Anticipatory Guidance and Blood Lead Refusal Form

CalOptima Health has created a new Anticipatory Guidance and Blood Lead Refusal form to support providers in meeting the regulatory requirements found in All-Plan Letter (APL) 20-016 (Revised): Blood Lead Screening of Young Children. As part of APL 20-016, providers need to document the following in a child member’s medical record:

The provision of oral or written anticipatory guidance for lead at each PHA
A signed statement of voluntary refusal in instances where the parent or guardian does not consent to test a child member for lead

This form is a resource to support documentation gaps, if any. It is not intended to replace existing processes within your clinical workflows that already support the documentation of anticipatory guidance or blood lead refusals. Providers should follow guidance from their respective health networks on their documentation requirements.

The Anticipatory Guidance and Blood Lead Refusal form is available in all of CalOptima Health’s threshold languages and can be accessed on the provider section of our website. This form supersedes the Evidence of Blood Lead Refusal Form.

For questions about this tool, please contact CalOptima Health’s Quality Improvement department at QI_Initiatives@caloptima.org.

Download and Attest to Blood Lead Screenings in Provider Portal

To ensure compliance with APL 20-016, CalOptima Health issues a Blood Lead Screening Performance report to providers in the CalOptima Health Community Network (CCN) who provide pediatric preventive services to child members. This report is shared quarterly through the Provider Portal and identifies children 6–72 months of age who have not been screened for lead, as required by Title 17 Section 37100 of the California Code of Regulations.

Providers can download the most recent Blood Lead Screening Performance report in the Provider Portal by clicking on “Reports” under the main menu on the left, then “Blood Lead Screening” under Report Type. Search or scroll down to identify and select the provider name and click the “Download” button located in the lower right corner of the Reports screen.

Attestation Requirements

CCN providers are also required to proactively review these quarterly reports, reconcile with internal member medical records for accuracy and screen members for lead if they are due.

Providers must attest to operational and regulatory blood lead requirements via the Provider Portal. Local office administrators and users with the designated role of Primary Care Provider (PCP) may complete the Blood Lead Screening Attestation for qualifying members in the Provider Portal.

To complete the Blood Lead Screening Attestation:

Go to provider.caloptima.org
Log in using your username and password
On the left navigation panel, click Reports
Select Manage Attestation
Select Blood Lead Screening under Attestation Type
Select the radio button next to the provider record for whom the attestation is to be completed
Select the appropriate checkboxes next to the Measurement Period for which the attestation is to be completed
Click Attest
Click the checkbox next to “I agree to the terms of this attestation”
Click Submit

For questions about Blood Lead Screening Performance reports, attestation requirements or Provider Portal access, please contact the Quality Improvement department at QI_Initiatives@caloptima.org.

Transportation Authorizations Need Completed Physician Form

DHCS requires that a Physician Certification Statement (PCS) form be fully completed and signed in order to process requests for and determine appropriate levels of Non-Emergency Medical Transportation (NEMT) services.

This form must be signed by the physician, physician assistant, nurse practitioner, certified nurse-midwife, physical therapist, speech therapist, occupational therapist, dentist, podiatrist, mental health provider or substance use disorder provider giving care to the member and responsible for determining the medical necessity of the transportation.

NEMT services are subject to prior authorization. Incomplete or inaccurate forms, including old request forms and incomplete dates, may cause delays and denials. Once the PCS is submitted, CalOptima Health cannot modify the authorization to a lower level without a new PCS form from the provider. The most current Referral Request for Transportation Services and Physician Certification Statement form can be found on CalOptima Health’s website.

Crisis Resource Guide Lists Available Trauma Supports

Following the recent shootings in Monterrey Park and Half Moon Bay, DHCS has shared a Crisis Resource Guide developed by the California Health & Human Services Agency. The guide contains contact information for a variety of free local and state resources for those needing trauma support. Please share this resource guide with your patients who may need extra support.

Training Series Will Focus on Dementia Care

Providers specializing in dementia care can attend a four-part training series covering the fundamentals of Alzheimer’s, practical dementia care, caring for family care partners and collaboration with community-based organizations.

The Zoom training will consist of four sessions held from 9 a.m. to 12:30 p.m. on February 22, March 1, March 8 and March 15.

To sign up please use this registration link, which will automatically enroll you in all four classes.

New Guidelines in Place for Initial Health Appointments

As explained in APL 22-030, on January 1 DHCS updated the requirements for the Initial Health Assessment, which is now called the Initial Health Appointment (IHA).

The IHA must still be completed within 120 calendar days of a member’s enrollment in CalOptima Health. The updated IHA guidelines include:

Effective January 1, the Staying Healthy Assessment (SHA) is retired.
Providers must complete all preventive screenings for adults and children as recommended by the United States Preventive Services Taskforce (USPSTF).
The IHA must include, at a minimum, a history of the member's physical and mental health, an identification of risks, an assessment of the need for preventive screenings or services and health education, a physical examination, a diagnosis, and a plan for the treatment of any diseases.
IHA components can be completed over the course of multiple visits, so long as members receive all required screenings consistent with USPSTF guidelines. Appropriate assessments from the IHA must be addressed during subsequent health visits.
Providers must make a minimum of three attempts to complete the IHA and must document all attempts in the member’s medical record.
DHCS will measure primary care visits as a proxy for the IHA completion, leveraging Managed Care Accountability Sets (MCAS) measures specific to infant and child/adolescent well-being visits, as well as adult preventive visits.

For members under the age of 21, DHCS has provided these measures:

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screenings will continue to be required in accordance with the American Academy of Pediatrics (AAP)/Bright Futures periodicity schedule, as referenced in APL 19-010.
When a member, a parent or guardian, or local Child Health and Disability Prevention (CHDP) program requests a children’s preventive service, an appointment must be made for the member to have a visit within 10 working days of the request.
Measures will account for both primary care visits and childhood screenings, including, but not limited to, screenings for adverse childhood experiences (ACEs), developmental disorders, depression, autism, vision, hearing, lead and substance use disorders (SUDs).

CalOptima Health will present these changes in detail at upcoming health network and provider forums. The agency will also continue to support health networks and providers by ensuring that members are informed of the importance of completing the IHA.

If you have any questions, please contact Anna Safari, manager of CalOptima Health’s Population Health Management department at asafari@caloptima.org or 657-235-6746.

Monthly Notices

APLs

On November 28, 2022, DHCS released APL 22-025: Responsibilities for Annual Cognitive Health Assessment for Eligible Members 65 Years of Age or Older. This APL gives guidance on the provision of new annual Medi-Cal cognitive health assessments.

On December 27, 2022, DCHS sent out Revised APL 22-018: Skilled Nursing Facilities — Long Term Care Benefit Standardization and Transition of Members to Managed Care. This APL gives updated guidance to managed care plans on this California Advancing and Innovating Medi-Cal (CalAIM) benefit.

Reminder: On October 11, 2022, DCHS distributed APL 22-019: Proposition 56 Value-Based Payment Program Directed Payments. The purpose of this APL provided managed care plans (MCPs) with guidance on value-based directed payments (VBPs). This APL supersedes APL 20-014. The Proposition 56 VBP direct payment program ended on June 30, 2022. Services performed after June 30 are not eligible to receive VBP payments. CalOptima Health must still make VBP directed payments for qualifying services provided between July 1, 2019, and June 30, 2022.

Policies and Procedures Monthly Update

Click on the link below to find an outline of changes made to CalOptima Health policies and procedures during January 2023. The full description of the policies below is available on CalOptima Health’s website at:

https://www.caloptima.org/en/ForProviders/Resources/ManualsPoliciesandGuides.aspx.

Policies and Procedures Monthly Update

Health Education: Trainings and Meetings

Click below for a list of training webinars and links happening in February 2023:

Health education webinars

Policy Code Updates

Based on Medi-Cal Bulletins and NewsFlashes, CalOptima Health has updated the procedure codes and other relevant information for the subjects listed below:

Expanded Use of Bivalent Dosages Approved for Children Six Months and Up
Telehealth Flexibilities and Revisions to the Telehealth Provider Manual
2023 HCPCS Quarter 1 Update
Rate Update for Diagnostic Radiology Code
Updated Rates for Unclassified Drugs Billed with HCPCS Code J3490
Authorized Medi-Cal Submitters Must Register in the Medi-Cal Provider Portal
Payment Error Rate Measurement (PERM) Provider Webpage
Continuity of Care for Transitioning Medi-Cal Members
Clinical Trials Policy Update
PHE Telehealth Policy Clarification for Medication Abortion Update: HCPCS Code S0199
Coming Soon: New HACCP Provider Manual Section
Updated Telehealth, ASW and AMFT Instructions for FQHCs/RHCs, Tribal FQHCs and HIS-MOAs
EOMB/MRN Not Required for HIS-MOA and Tribal FQHC Providers Billing LMFT Services
Intimate Partner Violence Screening and Referrals Survey for Medicaid Primary Care Clinicians

For detailed information regarding these changes, please refer to January General Medicine Bulletin 583 and Medi-Cal NewsFlashes from January 5, January 6, January 6, January 9, January 9 and January 11.

To access the updated Physician Administered Drug Prior Authorization (PAD PA) List, please refer to: https://www.caloptima.org/en/ForProviders/ClaimsandEligibility/PriorAuthorizations.aspx.

Upcoming Meetings

CalOptima Health Board of Directors: February 2 at 2 p.m.
CalOptima Health Joint Provider and Member Advisory committees: February 9 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.

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.

For Questions

Please contact Provider Relations at 714-246-8600 or at providerservicesinbox@caloptima.org