CalOptima Health May 2023 Provider Update

May 3, 2023

In This Issue

In this month’s issue of the Provider Update, read how you can help keep your patients safe from Medi-Cal scams.

You’ll find information about new updates regarding the end of the Public Health Emergency next week, health videos to share with patients, and new codes for recording electronic visits.

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

Provider News

Talk to Your Patients About Avoiding Medi-Cal Scams

The Department of Health Care Services (DHCS) is warning providers about scammers contacting Medi-Cal members and requiring a fee to apply for or renew their Medi-Cal benefits. This is especially concerning due to the ongoing Medi-Cal renewal efforts.

Providers should advise patients that Medi-Cal will never require payment for either the application or renewal process.

Please urge your Medi-Cal patients to be alert for potential scams and educate them on how they can expect to be contacted through official sources.

Both DHCS and CalOptima Health have toolkits for providers to educate patients about what to expect during Medi-Cal renewal.

CMS Shares Updated Information Regarding End of COVID-19 PHE

With the COVID-19 Public Health Emergency (PHE) sunsetting on May 11, the Centers for Medicare & Medicaid Services (CMS) has released updated information to ensure a smooth transition as emergency authorization waivers and other flexibilities come to an end.

CMS has updated its emergencies page with information for providers about the major telehealth and individual waivers initiated during the PHE and guidance for the sunsetting process. The agency has also created provider-specific fact sheets about these waivers and flexibilities.

Additionally, the U.S. Department of Health and Human Services (HHS) has produced its own fact sheet covering what services will and will not be affected by the end of the PHE.

CalOptima Health Offers Health Videos and Other Resources

CalOptima Health offers health-related resources for your patients at no cost. Members can access health videos on asthma management, diabetes, nutrition, tobacco cessation, chronic conditions such as cancer and much more via the CalOptima Health website.

Additional resources include brochures, fact sheets and links to self-assessments. Fact sheets and brochures contain QR codes that patients can scan to be directed to other health videos and materials on our website. All resources are available in English and Spanish, and we are working on offering these resources in other threshold languages.

If additional resources are needed, please contact Population Health Management at 714-246-

8895.

DHCS Adds New Electronic Visit Record Codes for Home Services

In April, DHCS added new codes to the California Electronic Visit Verification (CalEVV) program to simplify service descriptions and more accurately reflect the services provided.

In accordance with All Plan Letter (APL) 22-014, all Personal Care Services (PCS) or Home Health Care Services (HHCS) provided in the home must have a visit record in the CalEVV system or an alternative EVV system.

DHCS has identified new Physical, Occupational and Speech Therapy codes as well as Administration Intravenous and Subcutaneous codes that should be recorded during an EVV visit. Providers are required to use these new codes as of May 1. Additionally, current service descriptions have been updated to include the Healthcare Common Procedure Coding System (HCPCS) code. This will help identify which service needs to be selected for each beneficiary.

Click on this table to see the list of new codes, or visit the DHCS EVV website.

Letter Outlines Abortion Care Amid Potential Drug Disruption

In response to possible supply disruptions of the drug mifepristone due to ongoing legal action, DHCS has issued a Medi-Cal News Article giving guidance on abortion care.

APL 22-022 states that abortion services are a covered Medi-Cal benefit. The American College of Obstetricians and Gynecologists (ACOG) recommends using a combined regimen of mifepristone and misoprostol for abortion services. However, if the combined regimen is unavailable, the recommended alternative is a misoprostol-only regimen.

Medi-Cal covers misoprostol, billed with HCPCS code S0191, when substituted for a combined mifepristone-misoprostol regimen and administered consistent with ACOG clinical guidelines. Separately, Medi-Cal covers the bundle of services and supplies associated with a misoprostol-only regimen for abortion services, billed with HCPCS code S0199.

Use These Best Practices When Treating Chronic Diseases

May is National Osteoporosis, Lupus and Arthritis Awareness Month, and the following are best practices when treating these and other chronic diseases:

Osteoporosis: When treating, address and document the referencing diagnostic evidence, affected sites, physical activity and exercises, alcohol consumption, smoking status, nutritional diet and medications — such as long-term use of glucocorticoids and adrenocorticotropic hormone, antiepileptic drugs, cancer medications, proton pump inhibitors, selective serotonin reuptake inhibitors and thiazolidinediones.
Systemic lupus erythematosus: When treating, address and document the referencing labs, affected sites (skin, joints, heart, lung, kidneys, circulating blood cells and brain) and complications, if known.
Rheumatoid arthritis: When treating, address and document the referencing labs, affected sites, laterality and smoking status. Review and evaluate the patient’s nutritional intake, BMI, BMI-related conditions, disease process and risk factors.
Ankylosing spondylitis: When treating, address and document problem history, examination, referencing diagnostic evidence, affected sites and treatment.
Fibromyalgia: When treating, address and document signs and symptoms, examination and management, risk factors and treatment.

For ICD-10 CM Dx descriptions and Dx codes for these conditions, please see this table.

APL Clarifies Policies for Telehealth Services

On April 4, DHCS distributed APL 23-007: Telehealth Services Policy, which clarified the policy on covered services offered through telehealth, including which services can be offered through telehealth and documentation expectations.

Existing covered services, identified by Current Procedural Terminology 4th Revision (CPT-4) or HCPCS codes and subject to any existing treatment authorization requirements, may be provided via telehealth only if all of the following criteria are satisfied:

The treating provider believes the covered services are clinically appropriate for telehealth delivery based upon evidence-based medicine and best clinical judgment.
The member has provided verbal or written consent.
Medical record documentation substantiates that the covered services delivered via telehealth meet the procedural definition and components of the CPT-4 or HCPCS codes. Providers are not required to document a barrier to an in-person visit (WIC section 14132.72(d)) or document the cost effectiveness of telehealth in order to be reimbursed for covered services.
The covered services meet all state and federal laws regarding confidentiality of health care information and a member’s right to their own medical information.

All providers, except Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) and Tribal Health Providers (THPs), are allowed to be reimbursed for consultations provided via telehealth.

After January 1, 2024, providers must furnish covered services via audio-only and video synchronous interactions to preserve member choice. Also, to preserve a member’s right to access covered services in person, a provider furnishing services through video or audio synchronous interaction must do one of the following:

Offer those same services via in-person, face-to-face contact.
Arrange for a referral to, and the facilitation of, in-person care that does not require a member to independently contact a different provider.

Providers must inform members prior to the initial delivery of covered services via telehealth about the use of telehealth and obtain verbal or written consent from members for the use of telehealth as an acceptable mode of delivering services. Providers need to document in the member’s medical record their consent prior to the initial delivery of the services and make that consent available to DHCS upon request.

In addition to documenting consent, providers are also required to explain the following:

The member’s right to access covered services in-person
The use of telehealth is voluntary and consent for telehealth can be withdrawn at any time by the member without affecting their ability to access Medi-Cal covered services in the future
The availability of non-medical transportation to in-person visits
The potential limitations or risks related to receiving covered services through telehealth compared with an in-person visit, if applicable

DHCS has created model member consent language for MCPs and providers to use.

Members may be established as new patients by providers via telehealth through the following ways:

1. Via synchronous video telehealth visits.

2. Via audio-only synchronous interaction only if one or more of the following criteria applies:

The visit is related to sensitive services, which is defined in Civil Code section 56.06(n) as all health care services related to mental or behavioral health, sexual and reproductive health, sexually transmitted infections, substance use disorder, gender-affirming care and intimate partner violence, and includes services described in Family Code sections 6924–6930, and HSC sections 121020 and 124260, obtained by a member at or above the minimum age specified for consenting to the service specified in the section.
The member requests an audio-only modality.
The member attests they do not have access to video.

3. FQHCs, including Tribal FQHCs, and RHCs may establish new patient relationships through an asynchronous store and forward modality, as defined in BPC section 2290.5(a), if the visit meets all of the following conditions:

The member is physically present at a provider’s site, or at an intermittent site of the provider, at the time the covered service is performed.
The individual who creates the patient’s medical records at the originating site is an employee or subcontractor of the provider, or another person lawfully authorized by the provider to create a patient medical record.
The provider determines that the billing provider is able to meet the applicable standard of care.
A member who receives covered services via telehealth must otherwise be eligible to receive in-person services from that provider.

To ensure proper payment and record of covered services provided via telehealth, all providers must use the modifiers defined in the Medi-Cal Provider Manual with the appropriate CPT-4 or HCPCS codes when coding for services delivered through both synchronous interactions and asynchronous store and forward telecommunications.

Monthly Notices

All Plan Letters (APLs)

On March 28, DHCS distributed APL 23-006: Delegation and Subcontractor Network Certification, which provides Medi-Cal managed care plans (MCPs) with guidance on the requirements for delegating and monitoring subcontractors.

On April 4, DHCS released Revised APL 20-004: Emergency Guidance for Medi-Cal Managed Care Plans in Response to COVID-19. This revised APL covers information on the end of the COVID-19 PHE, Medi-Cal flexibilities that will end or continue, as well as the process of Medi-Cal renewal.

On April 18, DHCS distributed Revised APL 22-004: Strategic Approaches for Use by Managed Care Plans to Maximize Continuity of Coverage as Normal Eligibility and Enrollment Operations Resume. This APL suggests strategies on how MCPs and local counties can ensure members retain Medi-Cal coverage or transition members to Covered California.

On April 18, DHCS released Revised APL 20-021: Acute Hospital Care at Home, which provides guidance for hospitals participating in CMS’ Acute Hospital Care at Home program.

On December 30, 2022, DHCS Revised APL 22-012: Transition of Medi-Cal Pharmacy Benefits from Managed Care to Medi-Cal Rx (Medi-Cal only). This APL provides MCPs with guidance on changes to the oversight and administration of the Medi-Cal pharmacy benefit. Significant updates include: 1. Physician Administered Drugs (PADs) are always a medical benefit when administered outside of a pharmacy setting. 2. Specific therapeutic and non-therapeutic Continuous Glucose Monitoring systems are now a pharmacy-billed medical supply benefit through Medi-Cal Rx, retroactive to October 2022. 3. 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 MCP’s star ratings and will impact their accreditation status.

Policies and Procedures Monthly Update

Click on the link below to find an outline of changes made to CalOptima Health policies and procedures during April 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 May 2023:

Health education webinars

Policy Code Update

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

Addition of Treatment Drugs for Drug-Resistant Tuberculosis (TB) as a Medi-Cal Benefit
Updated Rates for Unclassified Drugs Billed with HCPCS Code J3490
Clinical Laboratory Rate Adjustment Effective July 1, 2022
Discontinuation of COVID-19 Emergency Fee-For-Service Medi-Cal Enrollment
Medi-Cal Enrollment Procedure and Exemptions for Remote Mental Health Services
Breast and Cervical Cancer Treatment Program: End of Medi-Cal Continuous Coverage
Supervision Changes for Non-Physician Medical Practitioners
Update to Wound Debridement CPT Codes
Required ICD-10-CM Code Update for Sebelipase Alfa
Postpartum Care Reminder
National Correct Coding Initiative Quarterly Update for April 2023
Medi-Cal for Kids & Teens Outreach and Education Toolkit
DME Rental and Purchase Policy Update
Exemption of Specific DME Procedure Codes from Payment Reduction
Incontinence Product List Update
Updates to Enteral Feeding Supplies MAPC
Medical Supplies Billing Codes, Units and Quantity Limits List Update
2022–2023 Distinct Part Adult Subacute Annual Rate Update
Mpox Vaccine Administration is Reimbursable for FQHC, RHC, IHS-MOA and Tribal FQHC Providers
DRG Payment System Update to Hospital Acquired Condition V40.0
CDPH Offers New Warmline for COVID-19 Testing and Treatment

For detailed information regarding these changes, please refer to General Medicine Bulletin 585, Durable Medical Equipment and Medical Supplies Bulletin 570 and Medi-Cal NewsFlashes from March 2, March 8, March 10 and March 16.

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

Upcoming Meetings

CalOptima Health Board of Directors: May 4 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.

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