Resubmit Crossover Claims for Medi-Cal Payments |
Providers can resubmit certain Medicare/Medi-Cal crossover claims that were affected by an issue that impacted payments for the Medi-Cal portion.
CalOptima Health identified a gap in its provision of member eligibility files to the Centers for Medicare & Medicaid Services (CMS). The gap impacted the Coordination of Benefits Agreement (COBA) for crossover claims during the period of February–March 2022. This resulted in CalOptima Health receiving a lower claims volume for the Medi-Cal benefit portion. The cause of this gap has been identified and corrected.
If you submitted claims during this period and did not receive payment or a remittance advice from CalOptima Health for the Medi-Cal portion of your claim, please resubmit a hard copy claim along with the remittance advice received from the primary carrier or Medicare to:
CalOptima Health
P.O. Box 11070
Orange, CA 92856
For questions regarding this notice, please contact CalOptima Health’s Claims department at 714-246-8600,
8 a.m.–5 p.m., Monday through Friday. We apologize for any inconvenience and thank you for serving our members.
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Agents to Contact Providers About OneCare Benefits |
Starting this month, CalOptima Health-contracted independent agents will be contacting Orange County providers about OneCare.
CalOptima Health is partnering with iPros Insurance Professionals, a field marketing organization (FMO) that represents more than 20 Medicare Advantage plans. On October 1, iPros’ independent agents began promoting the 2023 OneCare benefits for dual eligible beneficiaries. They will also enroll individuals during the Medicare annual enrollment period from October 15 to December 7, with coverage starting January 1, 2023.
Agents will be contacting and meeting with providers to talk about OneCare’s benefits for their patients and practices.
For more information regarding the FMOs partnerships, please contact CalOptima Health’s OneCare Sales and Marketing department at 657-900-1222 or agentsupportocsales@caloptima.org.
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Report Shows Need for COVID Vaccinations Among Older Adults |
An October 6 report from the Kaiser Family Foundation shows deaths among adults 65 years old and over from COVID-19 jumped during the summer of 2022, underscoring the need for that population to continue receiving booster vaccinations.
According to data from the Centers for Disease Control and Prevention (CDC) in the report, deaths from COVID-19 among those 65 and older topped 11,000 in July and August 2022, more than double the number of deaths from the virus in April. As of October 1, adults over 65 accounted for 16% of the population of the United States, but nearly 72% of the total 1.1 million deaths in the U.S. from COVID-19.
The report attributes the rise in deaths to new COVID-19 variants, waning vaccine immunity and a relatively low rate of booster immunizations. More than 92% of adults over 65 received the primary vaccination, but only 71% received the first booster, and less than 44% received the second.
On September 1, the CDC recommended an updated booster for everyone over the age of 12, particularly older adults. Providers should encourage their patients, especially those over 65, to remain current on their vaccinations. CDC data shows that older adults who received the primary and booster vaccinations had a lower risk of dying from COVID-19.
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CDC Recommends Variety of Vaccines for 2022-23 Influenza Season |
The CDC recommends annual influenza vaccines for everyone 6 months and older. The vaccine has proven to prevent millions of influenza illnesses, tens of thousands of hospitalizations and thousands of deaths each year.
For the 2022–23 influenza season, providers can choose to administer any licensed, age-appropriate influenza vaccine, including quadrivalent inactivated influenza vaccine (IIV4), quadrivalent recombinant influenza vaccine (RIV4) or quadrivalent live attenuated influenza vaccine (LAIV4).
Three vaccines are recommended for people 65 years and older: quadrivalent adjuvanted inactivated (aIIV4), quadrivalent high-dose inactivated influenza vaccine (HD-IIV4) and quadrivalent recombinant influenza vaccine (RIV4).
Click on this table to see more CDC recommendations for administering the influenza vaccine.
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In-Home Service Providers Must Register for Electronic Visit Verification |
Providers offering in-home services need to register with California’s Electronic Visit Verification system (CalEVV) to be compliant with the Department of Health Care Services’ (DHCS) regulations.
Federal laws mandate that California use an EVV for Medi-Cal-funded personal care services (PCS) and home health care services (HHCS) provided in the home. DHCS implemented CalEVV for PCS on January 1, 2022, and is required to implement it for HHCS by January 1, 2023. Emergency remote services (ERS) for personal and home health care are also subject to EVV requirements. Guidance on Community-Based Adult Services ERS is forthcoming.
CalEVV is a telephone- and computer-based application that electronically verifies when in-home PCS or HHCS occur. The system verifies six visit data elements: type of service performed, individual receiving the service, date of service, location of service delivery, individual providing the services, and time the service begins and ends.
The Medi-Cal provider types identified in this table are required to use CalEVV. Please note that DHCS may amend this list at any time due to federal requirements.
See additional CalEVV resources below:
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New Hotline to Handle Reports of Compliance and Ethics Issues |
CalOptima Health has launched a new Compliance and Ethics Hotline telephone number: 855-507-1805. The 24/7 hotline is administered by an independent third-party vendor who will take calls from individuals reporting suspected issues of non-compliance, misconduct, fraud, waste or abuse. All reports are handled confidentially, as appropriate, and callers can choose to be named or remain anonymous. CalOptima Health maintains strict non-retaliation and non-retribution for individuals who make reports in good faith, pursuant to CalOptima Health Policies HH.3012: Non-Retaliation for Reporting Violations, and HH.2019: Reporting Suspected or Actual Fraud, Waste, or Abuse, Violations of Applicable Laws and Regulations. |
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Virtual Continuing Education Workshop Addresses Childhood Lead Poisoning |
A virtual workshop on October 26 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.
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OneCare Connect Highlights Proper Cancer Documentation |
For National Breast Cancer Awareness Month, CalOptima Health’s OneCare Connect program reminds providers about the proper documentation for cancer treatment.
Active cancer cases require documentation of active treatment. The following treatments and conditions should be labeled as active surveillance or watchful waiting:
- Chemotherapy
- Radiation therapy
- Hormone therapy
- Targeted therapy
- Biological therapy
- Scheduled for surgery
- Patient has refused treatment
- Bone marrow transplant
- Evidence still present, but delayed or discontinued treatment
- Other contributing factors — patient benefits vs. risks profile, complications, status is chronic or slow growth
If the cancer has been excised or eradicated, with no evidence of disease and no further treatment, providers should report the history of cancer status (Z85.0–85.85) if that history affects patient care during the encounter. For remission cases, providers should document whether it is partial remission and/or if there are any signs and symptoms after treatment. For relapse cases, providers should document if the disease returns during therapy and/or if symptoms have worsened.
For an active cancer recurrence in the lymphoid, hematopoietic and related tissues, providers should specify in their documentation whether the active cancer is the primary site (site of origin) or secondary (remote or metastatic site) (C00–D49).
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Policies and Procedures Monthly Update |
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Health Education: Trainings and Meetings |
Click below for a list of training webinars and links happening in October 2022:
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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:
• New Laboratory Test for Orthopoxvirus is a Medi-Cal Benefit
• Addition of Novavax COVID-19 Vaccine
• Pregnancy Coverage During the COVID-19 Public Health Emergency
• Certified Nurse Midwives Can Bill for Rho D Immune Globulin Using HCPCS Codes J2790 and J2791
• Rate Update for HCPCS Code J7304 with Modifiers U1 and U2
• CCS Service Code Groupings Policy Update
• Allowable Modifiers Added for CHW and APS Services
• National Correct Coding Initiative Quarterly Update for October 2022
• Provider Manual Revisions
• Medical Supplies: Updates to the List of Covered Wound Care Advanced Dressing
• Coming Soon: Bivalent Booster Dose for Select COVID-19 Vaccines
• LTC Code and Claim Form Conversion: Crosswalks and FAQ are Available
• ICD-10-CM Code Related to COVID-19 End-Dated
• FQHC, RHC and Tribal Clinic Providers: Abortion Services
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- CalOptima Health Board of Directors: November 3 at 2 p.m.
- CalOptima Health Joint Provider and Member Advisory committees: October 13 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.
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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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