CalOptima Health Approves $107.5 Million to Support Providers During Medi-Cal Renewal |
Recognizing that the end of the COVID-19 Public Health Emergency (PHE) and the resumption of normal Medi-Cal operations continue to put a strain on health care providers, CalOptima Health is pledging $107.5 million to help during this transition.
On June 1, the CalOptima Health Board of Directors approved a 7.5% supplemental rate increase for contracted Medi-Cal providers – including behavioral health providers – health networks, hospitals and community clinics. These supplemental payments will cover services provided between July 1, 2023, and August 31, 2024.
The rate increases will support providers as certain flexibilities and waivers enacted during the PHE come to an end. They also provide much need financial help while the County of Orange Social Services Agency (SSA) undergoes the process of Medi-Cal renewal, determining whether members still qualify for Medi-Cal. The rate increases are patterned after similar ones initiated by the Board in 2020 to help with COVID-19-related costs, which were renewed several times over the course of the PHE.
Services excluded from the supplemental payments include:
- Pharmacy and non-pharmacy administered drugs (carved out under Medi-Cal Rx)
- Long-term care services
- Durable Medical Equipment, orthotics and prosthetics, and other medical devices
- Crossover claims
- Other supplemental or directed payments, such as Proposition 56
- Cost of administrative service providers
- Claims paid by Letter of Agreement (LOA)
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Quarterly Virtual Meeting to Cover Important Provider Topics |
CalOptima Health Community Network (CCN) providers are invited to the upcoming quarterly virtual learn meeting on June 13 at 1 p.m.
CalOptima Health’s Provider Relations team will review important subjects, such as Medi-Cal renewal, provider directory validation, doula services, dyadic services, electronic visit verification, street medicine and more.
Please register in advance for this webinar using this link.
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Providers and Members Can Receive Annual Wellness Visit (AWV) Incentives |
Reflecting our commitment to quality care, CalOptima Health is offering incentives to providers and members to complete an AWV before the end of the year.
Providers who conduct AWVs with Medi-Cal members who are 45 years or older will be reimbursed $125 for each completed AWV per member per calendar year. A $100 supplemental payment will also be available for uploading completed attestations (including the attestation form, supporting medical record and social determinants of health assessment) to the CalOptima Health Provider Portal.
To be eligible, the AWV must have a date of service on or after April 1, 2023, for members who are 45 years or older as of December 31, 2022. The supplemental payment is per eligible member per provider group per calendar year.
Claims for completing an AWV should be submitted using the following Current Procedural Terminology (CPT) codes and modifiers:
- For new patients: CPT Code 99205, Modifier 33
- For established patients: CPT Code 99215, Modifier 33
Providers should also remind their Medi-Cal members over 45 that they are eligible to receive a $50 gift card from CalOptima Health for completing their AWV.
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CMS Shares Resources for End of PHE |
With the end of the declared COVID-19 PHE on May 11, the Centers for Medicare & Medicaid Services (CMS) is reminding providers of the various resources released and updated over the past few months to help navigate this transition, including:
These documents are relevant for all CMS programs, including Medicare, Medi-Cal and the Children’s Health Insurance Program (CHIP).
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Medi-Cal Providers Must Submit PAVE Applications as Flexibilities End |
Medi-Cal providers who were enrolled using flexibilities instituted during the COVID-19 PHE need to submit an application to continue their enrollment.
In March, the Department of Health Care Services (DHCS) discontinued the Medi-Cal provider enrollment flexibilities authorized by the Section 1135 waiver in place during the PHE.
Providers who were temporarily and provisionally enrolled using these flexibilities and who want to continue their enrollment must submit an application and meet all program requirements. These providers have until June 27 to submit their application via the Provider Application Validation for Enrollment (PAVE) portal. Any temporarily enrolled providers that miss the deadline will have their enrollment discontinued on June 28.
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DHCS Updates Medi-Cal Doula Benefit Materials |
Doula services are now a Medi-Cal-covered benefit, and CalOptima Health is working on implementation of a provider network. In the meantime, DHCS has updated the following materials:
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Doula Services Provider Manual – The billing code section (Pages 2–3) has been updated to include that all claims must be submitted with the modifier XP (separate practitioner; a service that is distinct because it was performed by a different practitioner) appended to the billing code. This is to distinguish the claim from services by the medical provider.
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Medi-Cal Doula Services Recommendation Form – This form is an example of what can be used to access doula services through Medi-Cal. It is not necessary to use this specific form as long as a clinician’s written recommendation is secured with information listed on the form and retained by the doula.
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State Health Letters Discuss Treatment and Risks of STIs |
The California Department of Public Health (CDPH) has released two letters concerning sexually transmitted infections (STI) and their treatment.
A Dear Colleague Letter, sent April 28, informed providers about the use of doxycycline post-exposure prophylaxis (doxy-PEP) to prevent bacterial STIs. CDPH recommends the following:
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Recommend doxy-PEP to men who have sex with men or transgender women who have had one or more bacterial STIs in the past 12 months.
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Offer doxy-PEP using shared decision making to all non-pregnant individuals at increased risk for bacterial STIs, even if they have not been diagnosed with an STI or have not disclosed their risk status.
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Provide comprehensive preventive sexual health counseling and education to all sexually active individuals, including HIV/STI screening, doxy-PEP, HIV pre-exposure prophylaxis/HIV post-exposure prophylaxis, vaccinations, expedited partner therapy and contraception.
Additionally, on May 1, a Health Alert noted an increase in cases of congenital syphilis among women in California’s Central Coast region. Between 2020 and 2021, cases of congenital syphilis in the region rose by 31%, while syphilis cases among people who could become pregnant in the region rose by 49%. The health alert also contains recommendations on how providers can help address this issue. |
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Skilled Nursing Facility Admissions Must Meet CalAIM Prescreening and Review Requirements
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The Skilled Nursing Facility (SNF) Long-Term Care (LTC) benefit is now standardized as part of California Advancing and Innovating Medi-Cal (CalAIM). DHCS has issued guidance on the Preadmission Screening and Resident Review (PASRR) requirements laid out in 42 CFR sections 483.100-138 and All Plan Letter (APL) 23-004. These requirements apply to all Medicaid-certified nursing facilities and admissions, regardless of the payer source.
All general acute care hospitals (GACHs) must complete the PASRR process before discharging a member to a SNF and submit the completed PASRR documents to a managed care plan (MCP) for prior authorization.
As of May 1, MCPs, including CalOptima Health, have the following requirements:
- MCPs must obtain and review PASRR documentation from GACHs or SNFs as part of the prior authorization review process and confirm that the PASRR was completed before approving the authorization request for a member to stay in a SNF. This confirms that the GACH completed a preadmission screening prior to discharging a patient, and the SNF completed the screening before admitting a member directly from the community.
- MCP payment to the provider for SNF services is only allowed if the preadmission screening was completed prior to the member’s admission to the SNF.
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When there is a significant change in a SNF resident’s physical or mental health condition, the MCP must ensure SNFs initiate a resident review by submitting a Level 1 Screening to restart the PASRR process.
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Members Can Appeal and Request State Hearing for ECM, Community Supports Decisions |
On April 24, DHCS sent a reminder about the rights of Medi-Cal and Medicare patients to file appeals concerning Enhanced Care Management (ECM) and Community Supports.
Members have the right to appeal an adverse action for these services and are further entitled to a state hearing following an unsuccessful plan appeal. CalOptima Health must make available full appeal rights to members for covered ECM and Community Supports in compliance with state and federal laws and regulations, contract requirements, and other DHCS guidance, such as APLs and Policy Letters, including APL 21-011.
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DHCS Updates ECM and CalAIM Billing and Invoice Information |
- Member Homelessness Indicator – Identifier for if the member is experiencing homelessness as identified in the ECM Policy Guide or CalAIM 1115 Special Terms and Conditions VIII.62.a. If homeless, enter 1, if not or unknown, enter 0.
- Service Names – Service names were optional but are now required.
- Member Diagnosis Code – If 1 is selected for the Member Homelessness Indicator field, CalOptima Health needs to record one of the IDC-10 Z-codes that specify homelessness: Z59.00 Homelessness unspecified, Z59.01 Sheltered homelessness or Z59.02 Unsheltered homelessness.
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How to Help Your Patients With Osteoporosis |
Osteoporosis is often referred to as a “silent disease” as the progression of the condition cannot be felt. However, with appropriate screening, treatment and member education, the risk of future osteoporosis-related fractures can be reduced.
Osteoporosis primarily affects older adults, many of whom don’t know they have this condition until they break a bone. Even then, nearly 80% of older Americans who suffer bone breaks are not tested or treated for osteoporosis.
Women are particularly at risk as a decrease in estrogen following menopause triggers a period of rapid bone loss. One in two women over age 50 will break a bone due to osteoporosis. For women, the incidence of osteoporosis is more common than that of heart attack, stroke and breast cancer combined.
As a provider, you can support the bone health of your patients by recommending:
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Appropriate calcium and vitamin D intake. For nutritional support, use the Health and Wellness Referral Form located under the Commons Form page of the Providers section of www.caloptima.org
- Regular weight-bearing and muscle-strengthening exercises
- A bone mineral density (BMD) test for women age 65 and older and premenopausal women younger than 65 who are at an increased risk of osteoporosis as determined by a clinical risk assessment tool
If your Medi-Cal patient suffers a fracture, do either of the following within six months:
- Have patient complete a BMD test
- Prescribe osteoporosis medication
You can make osteoporosis screening easier by:
- Following up with members after a fracture to ensure completion of a BMD test
- Advising OneCare members of the $25 no-cost health reward for completing a BMD test or filling a prescription after a fracture (see www.caloptima.org/healthrewards)
- Increasing adherence to osteoporosis medication by providing recommendations to support daily intake
- Reminding members of their no-cost transportation benefit. Call Customer Service at 714-246-8600 for more information
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Providers Should Bill Medi-Cal After Other Health Coverage |
On May 15, DHCS sent a reminder that Medi-Cal is the payer of last resort, meaning that in most cases Medi-Cal only covers costs not paid by other health coverage (OHC). Typical costs paid by Medi-Cal after OHC are wrap payments or co-pays.
A provider enrolled in Medi-Cal fee-for-service (FFS) or as a Medicare provider does not need to be contracted with an MCP in order to bill for routine services for a patient who is dual-eligible or has OHC and is enrolled in an MCP. Providers who are enrolled in Medi-Cal FFS but do not contract with an MCP may still see an MCP member for a limited duration under continuity of care requirements by leveraging a letter of agreement (LOA) or similar mechanism when the service would typically require a prior authorization.
To bill Medi-Cal after OHC, a provider must present acceptable forms of proof to an MCP that all sources of payment have been exhausted, which may include a denial letter from the OHC for the service or an explanation of benefits indicating that the service is not covered by the OHC.
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Streamline the Prescription Process Using These Tips |
CalOptima Health is sharing the following tips for providers to help streamline the prescription process:
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Refer to the OneCare formulary for any prior authorization requirements or limitations: The formulary can be found at www.caloptima.org/en/ForProviders/PharmacyInformation/OneCareMedicarePartD
- Prescribe electronically whenever possible
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Write for a 90-day supply of chronic medication: This reduces a member’s co-pay, as a 90-day supply has the same co-pay as a 30-day supply
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Request medication fill synchronization: Minimize the need for patients to order frequent refills and make multiple trips to the pharmacy by asking the pharmacy to refill chronic medications on the same day
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Remind patients about the option for auto-refills for chronic medications: Automatic prescription refill programs can improve medication adherence, especially for patients receiving multiple medications. Some pharmacies may require patients to request auto-refills for each medication in person or electronically
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Check the CalOptima Health Provider Portal for medication fill history: The Provider Portal is a secure online website where you have access to CalOptima Health patient information, including prescription claims data. To begin your registration process, please visit https://providers.caloptima.org/#/login or contact Provider Relations at 714-246-8600.
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New CalOptima Health Members Need to Complete Initial Health Appointment |
On January 1, DHCS updated the requirements for the Initial Health Assessment, now called the Initial Health Appointment (IHA). As explained in APL 22-030, an IHA still needs to be completed within 120 calendar days of a Medi-Cal member’s enrollment in CalOptima Health. IHA components can be completed over the course of multiple visits, so long as members receive all required screenings consistent with United States Preventive Services Taskforce (USPSTF) guidelines for adults and children.
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 visits.
As a reminder, an IHA at minimum should include:
- A physical examination
- Member’s physical and mental health history
- Identification of health risks
- Assessment of need for preventive screenings or services
- Diagnosis and a plan for disease treatment
- Health education
To support providers with completion of the IHA requirement, CalOptima Health will continue distributing a list of new members monthly and provide the following trainings:
- Provider onboarding/annual training — Coming soon
- Virtual Training CME Event— Wednesday, July 12, 2023
If you have any questions, please contact Stefanie Johnson, Senior Health Educator with CalOptima Health’s Population Health Management department, at stefanie.johnson@caloptima.org or 714-246-8453. |
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Final Progress Report Forms for CalAIM Incentive Payment Program Available |
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APL Lays Out Process for Proposition 56 Value-Based Directed Payments |
On June 27, 2022, DHCS distributed APL 22-011: Proposition 56 Directed Payments for Family Planning. The purpose of this APL is to provide Medi-Cal MCPs with guidance on value-based directed payments, funded by the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Proposition 56), to network providers for qualifying services tied to performance on designated health care quality measures in the domains of prenatal and postpartum care, early childhood prevention, chronic disease management, and behavioral health care. This APL supersedes APL 20-014.
CalOptima Health must make directed payments for qualifying value-based purchasing (VBP) program services for dates of service from July 1, 2019, through June 30, 2022, in the specified amounts for the appropriate procedure codes, in accordance with the CMS-approved preprint. The directed payments must be in addition to whatever other payments eligible network providers would normally receive from CalOptima Health or subcontractors. Services performed after June 30, 2022, are not eligible to receive VBP enhanced payments.
A qualifying service is a specific service, as set forth in the VBP program specifications, provided by an eligible network provider with an individual (Type 1) National Provider Identifier (NPI) within their practice scope from July 1, 2019, through June 30, 2022, to a member who is not dually eligible for Medi-Cal and Medicare Part B (regardless of enrollment in Medicare Part A or Part D).
Federally Qualified Health Centers, Rural Health Clinics, American Indian Health Service Programs and Cost-Based Reimbursement Clinics (as defined in Supplement 5 to Attachment 4.19-B of California’s Medicaid State Plan and WIC section 14105.24) are not eligible network providers for the purposes of the VBP program. Services provided at or by these ineligible provider types are not eligible to receive VBP-directed payments.
CalOptima Health must ensure the payments required by this APL are made within 90 calendar days of receiving a clean claim or accepted encounter for a qualifying VBP program service, for which the clean claim or accepted encounter is received by CalOptima Health no later than one year after the date of service.
How to file a grievance
If you have a contract with a Medi-Cal or OneCare (HMO D-SNP), Medicare-Medicaid Plan, health network or directly with CalOptima Health, follow the contracted providers instructions below. If you do not have a contract with a Medi-Cal or a OneCare health network or with CalOptima Health directly, follow the instructions under non-contracted providers.
Contracted Providers:
To file a Level 1 complaint, please complete a Provider Dispute Resolution Request form, found under the Providers section of the CalOptima Health website. Please see Section R3: Required Documentation for Complaints for tips on how to complete the form.
- If the complaint involves a payment or decision rendered by a CalOptima Health health network, submit the Provider Dispute Resolution Request form directly to the network. For health network contact information, see Section B1: CalOptima Health Department and Program Contact Information.
- If the complaint involves a payment or decision rendered by CalOptima Health directly, submit the Provider Dispute Resolution Request form to the CalOptima Health Claims department. For more information on filing addresses, see Section R4: Addresses for Filing Provider Complaints.
If you are not satisfied with the outcome of the Level 1 complaint, you can file a Level 2 complaint with CalOptima Health’s Grievance and Appeals department. To file a Level 2 complaint, you must submit a request for review in writing within 180 calendar days of receiving a complaint resolution letter. For more information on filing addresses, see Section R4: Addresses for Filing Provider Complaints.
Non-Contracted Providers:
To file a Level 1 complaint, please complete a Provider Dispute Resolution Request form, found under the Providers section of the CalOptima Health website. Please see Section R3: Required Documentation for Complaints for tips on how to complete the form.
- The payment dispute should be filed with the entity that issued the payment (or notice of non-payment).
- If a CalOptima Health network issued the payment, file the complaint with the applicable CalOptima Health network. For CalOptima Health network contact information, see Section B1: CalOptima Health Department and Program Contact Information.
- If the complaint involves payment from CalOptima Health, please submit the form to:
CalOptima Health (OneCare)
Claims Provider Dispute Resolution
P.O. Box 57015
Irvine, CA 92619
CalOptima Health (Medi-Cal)
Claims Provider Dispute Resolution
P.O. Box 57015
Irvine, CA 92619
- If the complaint is not claims related, submit the form to CalOptima Health’s Grievance and Appeals department. For information on where to submit the form, see Section R4: Addresses for Filing Provider Complaints.
- If you are not satisfied with the outcome of the Level 1 Payment Dispute, you can file a Level 2 Payment Dispute with CalOptima Health’s Grievance and Appeals department.
- For OneCare claim appeals, you can file an appeal with CalOptima Health’s Grievance and Appeals department within 60 calendar days of the remittance advice. Grievance and Appeals will process your appeal if you submit a signed Waiver of Liability form, found under the Provider section of CalOptima Health’s website. The Waiver of Liability form indicates that you will not bill the member regardless of the appeal decision. If you do not submit a signed waiver, CalOptima Health’s Grievance and Appeals will dismiss your appeal.
- If the decision is not wholly in your favor, Grievance and Appeals will forward your appeal to Maximus Federal Services, a CMS-contracted independent review entity (IRE).
- CalOptima Health will provide direct reimbursement to CalOptima Health Direct (COD) and CalOptima Health Community Network (CCN) providers. Health networks will reimburse their contracted providers.
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Revised APL Includes Updates on Medi-Cal Pharmacy Benefit |
- Physician Administered Drugs (PADs) are always a medical benefit when administered outside of a pharmacy setting.
- Retroactive to October 2022, specific therapeutic and non-therapeutic Continuous Glucose Monitoring systems are now pharmacy-billed medical supply benefits through Medi-Cal Rx.
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National Committee for Quality Assurance-accredited MCPs are required to report Healthcare Effectiveness Data and Information Set (HEDIS) measures with a pharmacy benefit as noted in Appendix A and Pages 14–15 of the revised APL. HEDIS measures requiring pharmacy data will be considered for the MCPs star ratings and will impact the MCPs accreditation status.
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APL Lists Requirements for Street Medicine Providers |
- A supervising physician must be a practicing street medicine provider with knowledge of and experience in street medicine clinical guidelines and protocols.
- A street medicine provider may choose to serve as the member’s assigned PCP as long as the criteria in the APL are met.
- MCPs may assign members to the street medicine provider as the assigned PCP directly, or to the street medicine provider’s affiliated brick-and-mortar location.
- Street medicine providers who are serving in an assigned PCP capacity are required to undergo the appropriate level of site review process.
- There must be a process for street medicine providers to become the member’s assigned PCP.
- Street medicine providers are required to enroll as a Medi-Cal provider if a state-level enrollment pathway exists. If no pathway exists, MCPs must vet the qualifications of the street medicine provider to ensure they meet standards of participation.
- MCP-contracted street medicine providers that meet all required administrative processes could provide services to a member and receive payment for those services, even if the member is assigned to a subcontractor.
- Street medicine providers can be contracted to provide both PCP and ECM services to a member.
- Street medicine providers are required to verify Medi-Cal eligibility of individuals they encounter in the provision of health care services.
- For managed care members, street medicine providers must comply with the billing provisions for street medicine providers as applicable to the MCP’s policies and procedures.
- Contracted street medicine providers must comply with all applicable MCP data sharing and reporting requirements in accordance with federal and state laws and the MCP contract based on the provider contracting type.
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On November 28, 2022, DHCS distributed APL 22-024: Population Health Management Program Guide, which provided guidance to all MCPs implementing the Population Health Management (PHM) program on January 1, 2023, and informed on the role of the PHM Program Guide. This APL supersedes APLs 17-012 and 17-013. Significant updates in this APL include that effective January 1, 2023, MCPs are required to establish a comprehensive PHM program, must follow the Health Risk Assessment (HRA) requirements for seniors and people with disabilities outlined in the PHM Program Guide, and are no longer required to follow HRA requirements found in APLs 17-012 and 17-013.
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On May 4, DHCS sent out APL 23-010: Responsibilities for Behavioral Health Treatment Coverage for Members Under the Age of 21, which clarifies that MCPs have the primary responsibility for ensuring that all of a member’s medically necessary behavioral health treatment (BHT) services are met across all environments, including on-site at school or during virtual school sessions. The MCP is also responsible for coordinating and covering any gaps in BHT services for members. MCPs must use current clinical criteria and guidelines when determining what BHT services are medically necessary.
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On May 15, DHCS sent out APL 23-012: Enforcement Actions: Administrative and Monetary Sanctions. The purpose of this APL is to provide clarification to MCPs of DHCS’ policy regarding the imposition of administrative and monetary sanctions, which are among the enforcement actions DHCS may take to enforce compliance with MCP contractual provisions and applicable state and federal laws. Significant updates in this APL include revised factors DHCS will consider when taking enforcement action, which consists of probability sampling and an extrapolation methodology approach to assess non-compliance and impact on members as outlined on Page 9 of the APL.
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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 May 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 June 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:
- Important Information Regarding the End of the COVID-19 Uninsured Group Program
- Medi-Cal COVID-19 PHE Revenues and Expenses Audits for NF-B Facilities
- 2023 HCPCS Quarter 2 Update
- Launch of the Dementia Care Aware Warmline
- New Billable Codes for CDPH Genetic Disease Screening Program and PE4PW
- CPT Codes 95250 and 95251 Added as a Medi-Cal Benefit
- Product Codes Added as a Medi-Cal Benefit
- New Medical Policy for Doula Services
- Every Woman Counts 2023 Income Eligibility Guidelines
- Update to Medicare and Pharmacy Rate for HCPCS Codes Q2041 and Q2053
- Updates to Covered Ostomy Supplies
- Family PACT Client Enrollment Policy Update
- Discontinuation of Section 1135 Waiver Flexibilities Relative to COVID-19
- Notice to Providers Regarding the Special Billing of Hemgenix Effective April 1, 2023
- Medication Abortion: Coverage of Misoprostol-Only Regimen
- Policy Update of Mpox Vaccine as a Medi-Cal Benefit
- Mpox Vaccine Reimbursement as the Medicare Rate
- Notification: DRG Payment System Update to Mapper and Hospital Acquired Condition V40.1 after April 2023
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- CalOptima Health Board of Directors: August 2 at 2 p.m.
- CalOptima Health Joint Provider and Member Advisory committees: June 8 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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