Because timely screenings are crucial for preventing serious health conditions for our members, CalOptima Health has decided to remove prior authorizations for the following services for members in CalOptima Health OneCare (HMO D-SNP), a Medicare Medi-Cal Plan:

• Colon cancer screening — Colon cancer is the second most common cause of cancer deaths in the U.S., and more than 150,000 people are diagnosed annually. With appropriate screening, colorectal polyps can be found and removed before they become cancerous.

• Breast cancer screening — Breast cancer is the most common type of cancer in women. One in every eight women in the U.S. will be diagnosed with breast cancer and more than 300,000 people in the U.S. are diagnosed annually. Women who receive regular breast cancer screenings have a 26% lower breast cancer death rate than women who aren’t regularly screened.

• Diabetic eye exam — Diabetic retinopathy is the leading cause of blindness in working-age adults, and, if left untreated, it can cause permanent vision loss. Early treatment can prevent or delay blindness from diabetic retinopathy in more than 90% of diabetics. The annual eye exam is the only way to monitor changes in the eyes of diabetic members.

We have partnered with Exact Sciences Laboratories to send Cologuard kits to CalOptima Health Community Network (CHCN) members who are due for colorectal cancer screening. The Cologuard test is an easy-to-use, at-home screening test covered by CalOptima Health at no cost to your patients.

Here’s what to expect:

• Exact Sciences Laboratories will ship the collection kit directly to eligible members.
• Staff from Exact Sciences Laboratories will provide telephonic reminders to members and will be available to answer any questions.
• Members collect their sample and return the test via UPS using the prepaid shipping label.
• Results are usually ready within two weeks.
• The member’s primary care provider will receive a copy of the results.

For more information, please visit www.cologuardhcp.com/resources.

CalOptima Health will undergo a routine medical audit of our Medi-Cal plan by the Department of Health Care Services (DHCS) between January 27 and February 7, 2025.

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

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

CalOptima Health and AltaMed Health Services—AHN announced a new agreement regarding financial responsibility for certain claims. As of November 1, 2024, AHN has assumed financial responsibility for all facility claims related to emergency room and inpatient or outpatient surgery services rendered to CalOptima Health Medi-Cal patients assigned to AHN as their health network.  

Due to this change, claims with a date of service on or after November 1, 2024, should be directed to AHN.

For electronic claims, there are two Payer IDs available:  

• ALTAM or 95712 — Please consult with your biller/clearinghouse to determine which Payer ID you should use.  

For paper claims and other correspondence, the address is:  

AHN  

c/o Altura MSO Inc.  

P.O. Box 7280  

Los Angeles, CA 90022-7280  

If you have any additional questions, please contact AHN’s provider support line at 855-848-5252.

During the Doula Implementation Workgroup meeting on September 27, 2024, DHCS distributed updated guidance regarding coding information required for doula claims.

The updates include:

• As of November 1, 2024, doulas must include a diagnosis code on claims for services for both fee-for-service (FFS) and managed care delivery systems, as required by federal law.
• Under Medi-Cal’s doula policy, doulas must only use diagnosis codes that describe/identify what occurred at the service and are not being used for medical and/or diagnostic purposes.

To assist doulas with submitting claims, DHCS created the Doula Billing Code Crosswalk that identifies which diagnosis codes may be billed with each Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code. Doulas can generally choose between several diagnosis codes for each billing code. Claims will be denied if they do not have a diagnosis code or don’t follow the paired diagnosis and billing codes shown in the crosswalk.

The diagnosis code should be entered in field 21A on the Centers for Medicare & Medicaid Services (CMS) 1500 form without a decimal point. The diagnosis code crosswalk will be published in the Medi-Cal Provider Manual: Doula Services, and DHCS will also share a Medi-Cal Provider Bulletin about this new requirement.

If a doula receives a claim denial and does not understand the reason for the denial, they can take these steps:

• For members in managed care, contact the member’s managed care plan (MCP) for guidance.
• For members with Medi-Cal FFS, contact the DHCS Telephone Service Center at 1-800-541-5555.
• Reach out to DHCS directly via email at DoulaBenefit@dhcs.ca.gov for other questions or assistance.

DHCS recently made a strong recommendation to Medi-Cal MCPs regarding timely filing requirements for Intermediate Care Facilities for the Developmentally Disabled (ICF/DD) home and subacute providers. The recommendation is to implement a grace period that waives timely filing requirements during the first year of the transition to managed care for these providers.

The transition to managed care for ICF/DD home and subacute care providers represents a significant shift in operations for these providers who are accustomed to the 180-day timely filing standard for FFS. Serving as a new Medi-Cal provider, sometimes for several different MCPs, coupled with the Long-Term Care claim form and code conversion, has presented claims and billing challenges for ICF/DD home and subacute care providers.

To address these challenges, DHCS recommends the following:

• If an ICF/DD home or subacute care provider has made a good faith effort to submit claims in a timely manner, MCPs should waive their timely filing requirements by allowing a grace period.
• MCPs should work with their ICF/DD home and subacute care provider network to determine a timely filing window or period that meets the needs of both the providers and the plan.

CalOptima Health's exisiting policies extend past DHCS's timely filing deadline, so there are no changes to our current processes.

DHCS recently distributed the Enhanced Care Management (ECM) Referral Standards and Form Templates and the CalAIM Enhanced Care Management Policy Guide.

The ECM Referral Standards define the set of information all MCPs will collect via ECM referrals.

• Effective January 2025, entities making referrals to ECM will be able to submit batch referrals and submit the same information in their ECM referrals across counties and MCPs rather than navigating different referral forms.
• MCPs may not require additional documentation (e.g., ICD-10 codes, supplemental checklists, Treatment Authorization Request [TAR] forms) from referring partners or ECM providers beyond the information provided in the ECM referral.

Additionally, DHCS released updated requirements for MCPs to expand the use of ECM presumptive authorization.

• Effective January 2025, select ECM providers already contracted in an MCP’s ECM provider network will be able to directly authorize ECM for members and be paid for ECM services during a 30-day time frame without waiting for an MCP’s authorization decision.

CalOptima Health will be compliant with these ECM referral standards and presumptive authorization by January 1, 2025.

On October 18, 2024, DHCS shared the finalized Managed Care Accountability Set (MCAS) requirements for Measurement Year (MY) 2024/Reporting Year (RY) 2025 for Medi-Cal MCPs.

The MCAS is a set of performance measures that DHCS selects for ​annual reporting by MCPs to assess quality and health equity efforts. Current and prior year MCAS lists can be found on DHCS’ website here.

On September 30, 2024, CMS issued National Coverage Determination (NCD) 210.15, which outlines Medicare coverage for pre-exposure prophylaxis (PrEP) using antiretroviral drugs approved by the U.S. Food and Drug Administration (FDA) for individuals at increased risk of HIV acquisition.

CMS has determined that the cost of coverage under NCD 210.15 does not meet the significant cost threshold. Therefore, CalOptima Health is required to assume the costs of PrEP drugs for HIV under NCD 210.15 as of September 30, 2024.

Though the guidance is effective immediately, please note that the impact is minimal as very few OneCare members receive these drugs. Please take the appropriate actions to ensure the following services are billed under Part B:

• FDA-approved PrEP using antiretroviral drugs to prevent HIV in individuals at increased risk of acquiring HIV

• Administration of injectable PrEP using antiretroviral drugs to prevent HIV

• Supplying or dispensing the drug regardless of the route of administration (oral and injectable)

• Individual counseling (up to eight visits every 12 months), including:
• HIV risk assessment (initial or continued assessment of risk)
• HIV risk reduction
• Medication adherence

• HIV screenings (up to eight times every 12 months using FDA-approved laboratory tests and point-of-care tests)

• Hepatitis B virus screening (one time only)

For more information on the NCD and related information, please see:

• CMS PrEP for HIV & Related Preventive Services
• CMS NCD 210.15 

Click on the link below to find an outline of changes made to CalOptima Health policies and procedures during September 2024. The full description of the policies below is available on CalOptima Health’s website at:

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

Policies and Procedures Monthly Update

Click below for training webinars and meetings happening in November 2024:

Health education webinars

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

• 2024 HCPCS Quarter 4 Update
• Newborn Gateway: Reminder on How to Inform Families
• Select Injections No Longer Reimbursable for Licensed Midwives
• Surgery CPT Codes 54401 and 54405 Update
• Policy Update for CPT Code 90683
• ICD-10-CM Diagnosis Codes Required for Doula Services
• Updated Licensed Midwives Billing Codes
• Policy Updated for HCPCS Code J9205
• Billing Requirement Updated for Abortion CPT Codes 59820, 59821, 59840 and 59841
• TAR Requirement and Frequency Limit Removed for CPT Codes 95115 and 95117
• Policy Update for Telehealth E-Consult Services
• Updated Mailing Addresses for GHPP
• Provider Manual Revisions
• TAR Requirement Update for Repairs on CRT Power Wheelchairs
• Annual FQHC and RHC Medicare Economic Index Percentage Increase
• CBAS Provider Assistance Phone Number Updated
• NPs, PAs and CNSs Can Prescribe HHA Services
• Reminder for Split Billing Inpatient Services
• Licensed Midwife Billing Training in October 2024
• CHDP Gateway Is Rebranded as Children’s Presumptive Eligibility
• 2025 ICD-10-CM/PCS Codes Update
• DRG Payment System Update to Mapper V42.0 After October 1, 2024
• Long-Term Care Code and Claim Form Conversions: Share of Cost Reminders
• December 2024 Opt-In Deadline for SNF Workforce Standards Program

For detailed information regarding these changes, please refer to General Medicine Bulletin 604, Durable Medical Equipment and Medical Supplies Bulletin 589, Community-Based Adult Services Bulletin 601, Home Health Agencies/Home Community-Based Services Bulletin 601, Inpatient Services Bulletin 601, and Medi-Cal NewsFlash from September 18, September 27, October 1, October 4, October 7 and October 16.

• CalOptima Health Board of Directors: November 7 at 2 p.m.
• Joint Meeting of the Provider and Member Advisory Committees: December 12 at Noon

All meetings have an option for virtual attendance. Visit the CalOptima Health website for more information.