Drug Listings in the Managed Care Sections of the Provider Manual Are Updated As Follows

Noncapitated Drug Updates for Managed Care Plans

Drug listings in the managed care sections of the provider manual are updated as follows.

Dependency Treatment Drugs

Alcohol and heroin detoxification and dependency treatment drugs acamprosate calcium (Campral) and naltrexone HCl (Revia) are noncapitated for most managed care plans effective for dates of service on or after June 1, 2006. However, these drugs are capitated for the following plans:

• Program of All-Inclusive Care for the Elderly (PACE) Special Project (SP) (Health Care Plans [HCPs] 050 – 056)
• Senior Care Action Network (SCAN) SP (HCPs 200 – 201, 204 – 207)
• Positive HealthCare Primary Care Case Management (PCCM) (HCP 915)

AIDS Drugs

AIDS drug darunavir ethanolate (Prezista) is noncapitated for most managed care plans effective for dates of service on or after June 28, 2006. Efavirenz/emtricitabine/tenofovir disoproxil fumarate (Atripla) is noncapitated for most managed care plans effective for dates of service on or after July 14, 2006. However, these drugs are capitated for the following plans:

• PACE SP (HCPs 050 – 056)
• SCAN SP (HCPs 200 – 201, 204 – 207)
• Health Plan of San Mateo County Organized Health System (COHS) (HCP 503)
• CalOPTIMA COHS (HCP 506)

Psychiatric Drugs

Psychiatric drug selegiline (Emsam) is noncapitated for most managed care plans effective for dates of service on or after April 1, 2006. However, this drug is capitated for the following plans:

• PACE SP (HCPs 050 – 056)
• SCAN SP (HCPs 200 – 201, 204 – 207)
• Western Health Advantage Geographic Managed Care (GMC) (HCP 140)
• Kaiser Health Plan GMC (HCP 170)
• Health Plan of San Mateo COHS (HCP 503)
• Positive HealthCare PCCM (HCP 915)

Claims for selegiline that are submitted beyond the six-month billing limit must be submitted hard copy and include a delay reason code. Information about delay reason codes is included in Part 2 claim submission and timeliness sections. A special instruction has been installed in the claims processing system to recognize these claims as timely.

This information is reflected on manual replacement pages mcp cohs 6 and 7 (Part 1), mcp gmc 7 and 8 (Part 1), mcp pre 6 and 7 (Part 1), mcp prim 4 (Part 1) and mcp two plan 6 and 7 (Part 1).

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Border Providers...... (916) 636-1200

CDHS Medi-Cal Fraud Hotline...... 1-800-822-6222

Telephone Service Center (TSC)...... 1-800-541-5555

Provider Telecommunications Network (PTN)...... 1-800-786-4346

EDS  PO Box 13029  Sacramento, CA  95813-4029

For a complete listing of specialty programs and hours of operation, please refer to the Medi-Cal Directory in the provider manual.

Opt Out is a service designed to save time and increase Medi-Cal accessibility. A monthly
e-mail containing direct Web links to current bulletins, manual page updates, training information, and more is now available. Simply “opt out” of receiving this same information on paper, through standard mail. To download the Opt Out enrollment form or for more information, go to the Medi-Cal Web site at , and click the “Learn how...” link under OPT OUT on the right side of the home page.

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Medi-Cal Update – Program and EligibilityNovember 2006

Long Term Care Services Clarification

“Long Term Care (LTC) services” as it appears in the description of an aid code refers to both those services included in the per diem base rate of the LTC provider and those medically necessary services that are required as part of the patient’s day-to-day plan of care in the LTC facility (for example, pharmacy, support surfaces and therapies).

Providers of these services may submit claims with proper documentation. If applicable, a Treatment Authorization Request (TAR) must be submitted to the appropriate Medi-Cal field office or Pharmacy Office, using existing protocols for core versus regionalized services.

This information is reflected on manual replacement pages aid codes 2, 4, 8 and 12 (Part 1).

eTAR Submission Guidelines for Non-Benefit Services

All electronic Treatment Authorization Requests (eTARs) submitted for non-benefit services that do not require a TAR will reject with a message of “TAR not required.” These TARs will not route to a field office for approval and will need to be corrected by the provider as follows:

• Click the “Transaction Login” link on the Medi-Cal Web site () home page and enter a current Medi-Cal user ID and password. Click “Submit.”
• Click the “Online TAR Applications” link.
• Select the “Update TAR” function from the TAR menu.

• Select “Update Rejected Service.”
• In the “Update Patient Information” section, select the special handling code, “Service is a non-benefit and no TAR requirement on procedure file – Review.”
• Add one day to the date(s) of service.

–For example, if the “From” date is 05012006 and the “Thru” date is 05012006, change the “Thru” date to 05022006.

• Resubmit the TAR request and verify that the status is “In Review.”

To use the eTAR system, providers must have a Medi-Cal Pointof Service (POS) Network/Internet Agreement form on file. This form is available on the Medi-Cal Web site () by clicking the “Forms” link on the home page.

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Medi-Cal Update – Program and EligibilityNovember 2006

eTAR Training Seminars for Medical and Vision Providers

First-time electronic Treatment Authorization Request (eTAR) users and individuals with questions regarding the eTAR submission process are invited to attend one of the free medical and vision care training seminars. These instructor-led seminars are available on a first-come, first-served basis. Participants should arrive an hour prior to the conference start time to allow for parking and onsite registration.

Note:These seminars do not include training for eTAR Pharmacy NCPDP or 18-1 submissions.

Medical and Vision
November 14, 2006
San Jose Marriott Hotel
9:00 a.m. – 11:30 a.m. or
1:00 p.m. – 3:30 p.m.
301 South Market Street
San Jose, CA 95113
(408) 280-1300 / Medical and Vision
December 12, 2006
Pasadena Hilton Hotel
9:00 a.m. – 11:30 a.m. or
1:00 p.m. – 3:30 p.m.
168 South Los Robles Avenue
Pasadena, CA 91101
(626) 577-1000
Medical and Vision
December 12, 2006
Ontario Doubletree Hotel
9:00 a.m. – 11:30 a.m. or
1:00 p.m. – 3:30 p.m.
22 North Vineyard Avenue
Ontario, CA 91764
(909) 937-0900

Providers Urged to Avoid Using Social Security Numbers (SSNs)

Providers are reminded to use information on a recipient’s Benefits Identification Card (BIC) for verifying eligibility, billing Medi-Cal or submitting Treatment Authorization Requests (TARs) rather than using the recipient’s Social Security Number (SSN).

Beginning in 2007, providers will be required to use a recipient’s 14-character ID number from a BIC or paper card when submitting claims. Claims submitted with a recipient’s SSN will be denied.

Exceptions

Certain exceptions will apply for hospitals, long term care (LTC) facilities, licensed primary care clinics and emergency medical transportation, as indicated by California Welfare and Institutions Code Section 14045. The exception criteria will be based on Place of Service codes.

The excluded entities will be required to make a good faith effort to obtain the recipient’s BIC information for billing and to provide that information to other providers, such as pharmacies and labs, that may not have direct contact with the recipient.

Eligibility Verification Changes Coming

Providers also will be required to use the 14-character BIC ID when determining patients’ eligibility verification. A patient’s SSN will no longer be allowed for submitting eligibility verification transactions on the Point of Service (POS) device, Medi-Cal Web site or third-party vendor software.

In an emergency (or if a recipient did not bring a BIC to an appointment), providers will still be allowed to use the SSN for eligibility verification using the telephone Automated Eligibility Verification System (AEVS).

Please see future Medi-Cal Updates for more information.

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Medi-Cal Update – Program and EligibilityNovember 2006

Prepare To Use New Claim Forms

The California Department of Health Services (CDHS) is implementing the CMS-1500 and the
UB-04 claim forms on March 26, 2007. CDHS will not accept claims billed on these forms prior to this date.

A transition period beginning March 26, 2007 and ending on close of business May 22, 2007 will allow providers to bill using either the HCFA 1500 claim form and the UB-92 Claim Formor the new CMS-1500 and UB-04 claim forms. Effective May 23, 2007, providers must bill using the CMS-1500 and UB-04 claim forms and entering the National Provider Identifier (NPI) instead of the Medi-Cal provider number.

Important:When billing on the new forms prior to May 23, 2007, the Medi-Cal provider
number must be used instead of the NPI. Implementation of the NPI takes place
on May 23, 2007.

NPI – Will You Be Ready?

Get It.

The compliance date, May 23, 2007, is now only six months away. It’s every provider’s responsibility to obtain a National Provider Identifier (NPI) if required to do so. If you’re not sure if you need one, it’s time to investigate. Get your NPI now so you have time to prepare before the compliance date. This includes sharing your NPI with Medi-Cal. You must register your NPI with Medi-Cal in order to avoid a disruption in your cash flow. To learn more about how to apply, visit the NPI area of the Medi-Cal Web site ()and the Centers for Medicare & Medicaid Services (CMS) Web site at /.

Share It.

Have your NPI and don’t know what to do with it? Share it with health plans you bill and the colleagues who need your NPI to submit their claims (for example, those who bill for ordered or referred services). You should also share it with your billing service, vendor or clearinghouse business associates. Find out when and how the health plans with which you do business will begin accepting the NPI in claims and other standard transactions.

Getting an NPI is free – not having one can be costly.

NPI Hard Copy and Online Registration

HIPAA mandates the use of National Provider Identifiers (NPIs) by providers beginning
May 23, 2007. The California Department of Health Services (CDHS) encourages providers to apply for their NPI at the National Plan and Provider Enumeration System (NPPES) Web site () then register their NPI with Medi-Cal. Early NPI registration with Medi-Cal will assist providers in maintaining uninterrupted claim payments as Medi-Cal transitions from the current provider numbering system to the HIPAA-mandated NPI system.

Medi-Cal and Child Health and Disability Prevention (CHDP) providers are encouraged to use the online Web application to register their NPIs more quickly, accurately and cost-free. The online NPI registration tool became available on the Medi-Cal Web site on September 1, 2006 and may be accessed by clicking the “NPI” link on the Medi-Cal Web site (), then the “Register/Update/Inquire NPIs” link in the “NPI Resources” area.

Please see NPI, page 6

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Medi-Cal Update – Program and EligibilityNovember 2006

NPI (continued)

The registration allows Medi-Cal and CHDP providers to register one NPI for each active
Medi-Cal/CHDP provider number. If a provider has both a Medi-Cal and CHDP provider number, the NPI will be automatically updated for both programs when a Medi-Cal/CHDP provider registers their NPI with Medi-Cal by using either the online NPI collection tool or the registration form.

NPIs registered with Medicare, and taxonomy codes provided in the original NPI application to NPPES, will also be collected on the registration form. NPIs for Non-Physician Medical Practitioners (NMPs) will be collected for providers who currently have NMP data on file with Medi-Cal.

The registration includes a list of agreement forms that contain the current Medi-Cal provider number. Providers can authorize the update of existing agreements on file with their NPI information by indicating the action on the registration form.

Providers With More Than One Active Medi-Cal or CHDP Number

Providers who have more than one active Medi-Cal or CHDP provider number must complete a separate registration for each existing provider number to register a single or subpart NPI. Providers may register only one NPI per provider number.

In most cases, the provider may choose to register either the same NPI or the subpart NPI to replace multiple provider numbers.

Pursuant to Code of Federal Regulations, Title 42, Section 424.57, providers of Durable Medical Equipment (DME), prosthetics, orthotics and medical supplies are required to use a separate NPI for each individual business location, in accordance with the HIPAA-NPI final rule. Medi-Cal providers subject to this provision of the final rule have yet to be determined. CDHS encourages providers to refer to future Medi-Cal Updates, or to the NPI Overview page, for a final determination on
Medi-Cal requirements for this rule.

Separate “Pay-to” and “Mail-to” Addresses, Differing EFT Accounts and PINs

Medi-Cal allows providers to use separate “Pay-to” and “Mail-to” addresses, as well as differing Electronic Funds Transfer (EFT) account information and Personal Identification Numbers (PINs) for each provider number. Medi-Cal policy regarding such addresses and accounts will continue for each NPI registered.

Providers who choose to replace multiple Medi-Cal and CHDP provider numbers with one NPI must designate which Medi-Cal provider number will be the source of the various addresses, accounts and PINs that will be associated with the new NPI number. If a primary Medi-Cal or CHDP provider number is not specified for the new NPI, then the first Medi-Cal provider number on file will be replaced with the new NPI, by default, and be used to determine which addresses, accounts and PINs will be associated with that NPI.

Note:For Medi-Cal and CHDP organizational providers wishing to maintain multiple “Pay-to” or “Mail-to” addresses, differing EFT accounts, or PINs consistent with the number of Medi-Cal and CHDP numbers and locations currently enrolled, CDHS encourages the use of unique NPIs for subparts.

Please see NPI, page 7

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Medi-Cal Update – Program and EligibilityNovember 2006

NPI (continued)

Registering Multiple NPIs for Multiple Medi-Cal and CHDP Provider Numbers

The NPI registration form does not allow registration of more NPIs than existing Medi-Cal/CHDP provider numbers. CDHS is reviewing the NPI final rule requirements relative to accepting multiple NPIs in excess of the existing provider numbers. If your organization has more subpart NPIs than existing Medi-Cal or CHDP provider numbers, CDHS encourages you to refer to future Medi-Cal Updates or the NPI Registration page for a final determination on Medi-Cal requirements for this
NPI rule.

Providers Not Required to Register

In accordance with the NPI final rule, some providers are not required to register an NPI with
Medi-Cal. According to CDHS’ interpretation of the final rule, as it relates to “atypical” providers, the following Medi-Cal provider types are not required to register an NPI:

• Adult Day Health Care Centers
• Blood Banks
• Christian Science Practitioners
• Multipurpose Senior Services Programs

Beginning in November 2006, Medi-Cal and CHDP providers may also register their NPI with CDHS using the hard copy NPI registration form. The NPI registration form will be available on the
Medi-Cal Web site () by clicking “Forms,” then “Provider Enrollment.” Forms can also be obtained by calling the Telephone Service Center (TSC) at 1-800-541-5555 and selecting option 16, followed by option 18.

If the hard copy NPI registration form is used, the NPPES NPI assignment letter must be attached to the completed form. The return address for the form and NPPES letter is printed on the registration form.

NPI Local Educational Agency (LEA) Clarification

After further review of the National Provider Identifier (NPI) final rule and the industry definition of “atypical” providers, the California Department of Health Services (CDHS) has determined that Local Educational Agency (LEA) providers participating in Medi-Cal do not meet the criteria to be “atypical” providers. Therefore, LEA providers are required to apply for an NPI.

LEA providers should apply for an NPI on the National Plan and Provider Enumeration System (NPPES)Web site at . Upon receipt of an NPI, LEA providers are required to register their NPI with Medi-Cal through the National Provider Identifier Collection (NPIC) online system. To access the NPIC online system, click the “NPI” link on the Medi-Cal Web site () home page and then click “Register, Update and Inquire About NPIs.”

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Medi-Cal Update – Program and EligibilityNovember 2006

Electronic Attachments for 837 Version 4010A1 Claims Now Available

In addition to paper and fax attachments, providers now have the ability to submit attachments electronically with their 837 Version 4010A1 electronic claim submissions through an approved third-party vendor. The following guidelines should be used for submitting electronic attachments:

Providers

To submit electronic attachments, providers must be authorized to bill 837 v.4010A1 electronic claims and enter into a business agreement with a third-party vendor that offers the ability to enter an Attachment Control Number (ACN) in the Paperwork (PWK) Segment of the 837 v.4010A1 electronic transactions. For a list of approved third-party vendors, providers may refer to the CMC Developers, Vendors and Billing Services Directory, available on the “Technical Publications” page of the Medi-Cal Web site (). To access the page, click “Technical Specs” under the “Provider Resources” area of the home page.