California Children’s Services (CCS) Genetically Handicapped Persons Program (GHPP) Authorization and Claims EnhancementClass #: 22 Presenter: Harry Chang/Barbara SasakiID: U

Purpose and Objectives

The purpose of this module is to provide an overview of the California Children’s Services (CCS) Program and the Genetically Handicapped Person Program (GHPP) and highlight important program requirements required from Providers and Beneficiaries.

Purpose

Understand the CCS & GHPP Program requirements

Identify important CCS & GHPP contact information

Objectives

Resources

Medi-Cal Subscription Service (MCSS)

MCSS is a free subscription service that enables providers and others interested in Medi-Cal to receive subject-specific links to Medi-Cal news, Medi-Cal Update bulletins, urgent announcements and/or System Status Alerts via email.

For more information and subscription instructions, visit the MCSS Subscriber Form at (www.medi-cal.ca.gov/mcss).

Provider Manual References – Part 2

California Children’s Services (CCS) Program (cal child)

California Children’s Services (CCS) Program Eligibility (cal

child elig)

California Children’s Services (CCS) Program County Office Directory (cal child county)

California Children’s Services (CCS) Program Special Care

Centers (cal child spec)

Genetically Handicapped Persons Program (GHPP)

(genetic)

Department of Health Care ServicesSystems of Care Division

The Systems of Care Division (SCD) of the Department of Health Care Services (DHCS) is responsible for the administration and oversight of programs that focus on children and adults with special health care needs. SCD focuses on high-risk, high-cost child and adult populations and programs:

• California Children’s Services (CCS) • High-Risk Infant Follow-up Program (HRIF) • Medical Therapy Program (MTP) • Child Health and Disability Prevention (CHDP) Program • Health Care Program for Children in Foster Care (HCPCFC) • Newborn Hearing Screening Program (NHSP) • Genetically Handicapped Person Program (GHPP) • Palliative Care Waiver Program

The mission of SCD is to assure access to health care services for children and adults with special health care needs.

http://www.dhcs.ca.gov/Pages/default.aspx

California Children’s Services (CCS)Health and Safety Code, Section 123800 et seq. is the enabling statute for the CCS program and is governed by the Welfare and Institutions Code Section 14094-14094.3 and the California Code of Regulations (Title 22, Section 51013)

Program providing healthcare services for children that meet 1) residential, 2) financial, & 3) medical eligibility requirements and are between birth and up to 21 years of age.

• Residential: Must be residing in the county that they are seeking services for

• Financial: Must have an Adjusted Gross Income (AGI) < $40,000 or related medical costs of 20% of AGI

• Medical: Full description of all CCS Program eligible conditions can be found here: http://www.dhcs.ca.gov/services/ccs/Pages/medicaleligibility.aspx

• MTP/MTU: Sub program that provides OT/PT and other related services that are delivered in public school settings

• Inquiries/Questions: Refer to pg. 9 for County contact information and statuses or found online (http://www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx)

SAR and client inquiries should be directed to county offices

What is CCS?

Affordable Care Act (ACA)/Managed Care Plans (MCPs)

• Many Medi-Cal eligible children with CCS Program-eligible medical conditions are enrolled in Medi-Cal managed care plans. Services to treat a child’s CCS Program-eligible medical condition are “carved out” of the plan’s fiscal responsibilities.

• The Medi-Cal MCPs in these six counties are responsible to pay for primary AND preventative care AS WELL AS the CCS eligible medical condition diagnosis and treatment.

CCS and ACACounty Organized Health

Systems (COHS)Santa Barbara CenCal Health

San Mateo Health Plan of San Mateo

Solano Partnership Health Plan

Marin Partnership Health Plan

Napa Partnership Health Plan

Yolo Partnership Health Plan

CCS Billing Statuses

OHC Medi-Cal OTLICP *CCSPrivate Federal Federal State

*Except for those counties where CCS services are carved in.

Client statuses:• CCS/Medi-Cal, Full Scope: CCS clients who are eligible for full-scope no Share of Cost

(SOC) Medi-Cal.

• CCS/Medi-Cal, Share of Cost: CCS clients who must pay a determined portion of the medical costs prior to Medi-Cal coverage.

• CCS Only: CCS clients who are not eligible for Medi-Cal.

• CCS/OTLICP: CCS Clients who prior to 2014 were, or would have been, enrolled in California’s State Children’s Health Insurance Program (SCHIP).

Commercial Health Insurance/Other Health Coverage (OHC):• Providers must submit an Explanation of Benefits (EOB) or a valid denial letter from the OHC

with every claim.

Payer of last resort:

GHPP Health Care Services

GHPP provides authorization for health care services for adults with genetic diseases specified in the California Code of Regulations (CCR), Title 17, Section 2932.

GHPP Referral Requirements Residential: Must be a resident of California

Financial: No income limits• Clients between 200% – 299% of Federal Poverty Level (FPL) are

required to pay a fee of 1.5% of their AGI.• Clients at or above 300% of FPL are required to pay a fee of 3%

of their AGI.

Medical: Full description of all GHPP Program eligible conditions can be found here: http://www.dhcs.ca.gov/services/ghpp/Pages/MedicalEligibility.aspx

Over the age of 21 years

Affordable Care Act (ACA)/Managed Care Plans (MCPs)• Some GHPP clients are also Medi-Cal eligible and are enrolled in Medi-Cal’s MCPs. In such cases the plans

are capitated and are responsible for providing comprehensive health care to these GHPP clients, including services to treat their GHPP-eligible conditions.

• Providers must submit claims for authorized services rendered to the GHPP/Medi-Cal clients enrolled in these plans to the plan directly.

GHPP & ACA

GHPP Billing StatusesClient statuses:

• GHPP/Medi-Cal: GHPP clients enrolled in Medi-Cal MCPs

• GHPP/Other Health Coverage (OHC): GHPP clients with other health coverage either Medi-Cal, Commercial or Private.

• Providers must submit an Explanation of Benefits (EOB) or a valid denial letter from the OHC with every claim.

Payer of last resort:

OHC Medi-Cal GHPPPrivate Federal Federal

GHPP Contact InfoInquiries/Questions/Referrals:

P: 916-327-0470

P: 800-639-0597 (Toll-Free)

F: 916-440-5318

Genetically Handicapped Persons Program

1515 K Street, Suite 400

MS 8100, P.O. Box 997413

Sacramento, CA 95899-7413

Referral Process

Service Authorization Requests (SARs)Requests for authorization of services

CCS requests are submitted to the local CCS county office where the child resides. (See pg 10-17)

Independent Counties: have delegated authority to approve Financial, Residential, and Medical eligibility; population greater than 200,000

Dependent Counties: have delegated authority to approve Financial, Residential eligibility, the state is responsible for Medical eligibility; population less than 200,000

GHPP requests are submitted to the State office. Fax: (916) 440-5318

Type of SARs - New Referral & Established

Referral ProcessWho can make a referral to the GHPP or CCS Program? •Anyone can make a referral to the GHPP or CCS Program•Family Doctor•Physician Specialist•Public Health Nurse•Family•School

Minimum requirements:•Applicant Info: First & Last Name, DOB, Address, & Contact Number•Parent or Legal Guardian: First & Last Name•Services requested: A statement listing the services requested for the applicant•Person/Agency requesting services: Name and address of individual or agency requesting services•Related medical documentation

Referral Process CCS and GHPP referrals should be made to the CCS Program or GHPP

as early as possible.

CCS and GHPP does not pay for services provided before the date of referral, unless the applicant is full-scope Medi-Cal, no share of cost.

Once all eligibility is verified, the case will remain open for a maximum of 365 days before being reconsidered for eligibility.

Diagnostic and Treatment Services A case may be temporarily opened to confirm CCS or GHPP medical

eligibility of the client; no other services may be authorized during this period.

Only services related to the CCS-eligible or GHPP-eligible condition will be covered

Provider Electronic Data Interchange

Provider Electronic Data Interchange (PEDI)

Is an on-line interface application for approved Providers, Hospitals and Managed Care Plans to search for California Children Services (CCS) and Genetically Handicapped Persons Program (GHPP) Service Authorization Requests (SARs).

SARs for all counties and GHPP are included.

PEDI is accessed via a secure Department of Health Care Services (DHCS) website, and encompasses security measures for access.

Provider Electronic Data Interchange (PEDI)

https://cmsprovider.cahwnet.gov/PEDI/piplogin.jsp

Provider Electronic Data Interchange (PEDI)

PEDI will allow you to:

Determine if the CCS Independent County, Regional Office or GHPP has entered your Request for Service.

Determine the status of your Request for Service (i.e. authorized, denied, modified, or cancelled).

Print copies of SAR’s, Notices of Action, or Denial letters. Search CCS and GHPP Client Eligibility and generate various Activity and Client

Reports. Information obtained through PEDI is real time.

For additional information or an Application, please contact the DHCS CMS Net Help Desk at (866) 685-8449.

Provider Paneling

Provider PanelingWhat is Paneling?

Paneling is a process that the CCS program uses to determine if a provider meets the advanced education, training and/or experience requirements for his or her provider type in order to render services to provide services for CCS clients or applicants with special health care needs. Must be a Medi-Cal Provider before becoming a

CCS Provider Providers are not required to be paneled with GHPP.

If there are any questions regarding the submission of the application please contact the Provider Services Unit at (916) 322-8702.

Paneling Requirements A National Provider Identifier (NPI) OR the facility/employer’s NPI:

For some Allied Health Providers For physicians of a Rural Health Clinic (RHC) or Federally

Qualified Health Center (FQHC) National Provider Identifier (NPI) registered with the DHCS Medi-Cal. Current Medical License Must Be Board Certified Current Board Certificate in Specialty or Subspecialty

Specialty Physicians Current medical license from the Medical Board of California or from

the Osteopathic Medical Board of California Must be board certified by the American Board of Medical Specialties

Physicians who are not board certified, but who are board eligible by training and experience for the certifying examination, may participate in the CCS Program for no more than three years.

28

Paneling RequirementsFamily Practice Physicians Be currently licensed as a physician by the California Board of Medical Quality

Assurance Be certified by the American Board of Family Practice Be approved for participation in the Child Health and Disability Prevention

(CHDP) Program. Providers not working for a CHDP-approved facility must have

documented experience treating children with CCS Program-eligible medical conditions for at least five years, or have treated 100 or more such children.

Podiatrists Podiatrists must be licensed to practice podiatric medicine by the California

Board of Podiatric Medicine Be certified by the American Board of Podiatric Surgery or the American Board

of Podiatric Orthopedics Have documented experience treating children with CCS Program-eligible

medical conditions for at least five years, or have treated 100 or more such children

Allied Health Provider Paneling

SCD requires that all physicians and some Allied Health Professionals be CCS paneled in order to be issued an authorization to provide services to CCS clients.

Refer to the workbook for special requirements for Allied Health Provider Paneling.

The following provider types require paneling:

* Provider types with program participation limitations

Occupational Therapists Physical Therapists Respiratory Care Practitioners

Orthotists & Prosthetists Podiatrists Social Workers

Audiologists Pediatric Nurse Practitioners * Psychologists Speech-Language Pathologists

Dietitians Physicians Registered Nurses

Paneling Categories for Physicians

Full Approval Status Physician applicants who meet all criteria required for

paneling.

Provisional Status If the physician is board eligible for the American Board of

Medical Specialties, provisional paneling status will be given to the physician for three years upon completion of residency or fellowship training.

Exceptional Status The provider does not qualify for either status above and

requires CCS Medical Director review.

Web-Based Paneling Application Submission

This application allows providers to apply on-line for California Children's Services (CCS) Paneling and immediately view the status of the submitted application.

Providers may track their application status on line with a unique tracking number.

Providers will receive an immediate on-line approval or requested to submit additional documentation necessary to process their paneling applications.

Web Paneling URL: https://cmsprovider.cahwnet.gov/PANEL/index.jsp

For questions related to CCS paneling, please contact the Provider Services Unit at 916-322-8702.

Hospital & Special Care CentersStandards The CCS Program approves and assigns various types of hospital approval levels

Tertiary, Pediatric Community, General Community, Special Hospital, and Limited Hospital Hospital standards can be found at the following link: http://

www.dhcs.ca.gov/services/ccs/Pages/ProviderStandards.aspx

Special Care Centers SCCs provide comprehensive, coordinated health care organized around a specific condition or

system. SCCs are comprised of multi-disciplinary, multi-specialty providers who evaluate the client's medical condition and develop a family-centered health care plan to facilitate the provision of timely, coordinated treatment.

CCS Special Care Centers and Standards can be found at: http://www.dhcs.ca.gov/services/ccs/Pages/providerstandards.aspx

GHPP Special Care Centers and Standards can be found at: http://www.dhcs.ca.gov/services/ghpp/Pages/SpecialCareCenters.aspx

Approved CCS Providers "Approved Hospital" means a facility which has been determined by

the CCS program to meet the requirements in order to render services to a CCS applicant or client.

"Approved Prosthetic/Orthotic Facility" means a facility which has been determined by the CCS program to meet the requirements in order to render services to a CCS applicant or client.

"Paneled Non-PMF Provider" means providers required to be paneled but not required to obtain a Medi-Cal provider number.

"Paneled Provider" means an individual who has been determined by the CCS program to meet the advanced education, training, and/or experience requirements for his/her provider type in order to render services to a CCS applicant or client.

This site contains a list of approved Providers:http://www.dhcs.ca.gov/services/ccs/Pages/CCSProviders.aspx

SARs & SCGs

Authorization The GHPP and CCS Program requires prior authorization for health care

services related to a CCS or GHPP client’s eligible medical condition. Services may be authorized for varying lengths of time during the client’s

program eligibility period. SARs should be submitted to client’s County CCS office.

Service Authorization Requests (SARs) are used: To refer/enroll new clients into the Program. By providers to request services for eligible clients. To approve requested services for eligible clients.

o Should be accompanied by supporting medical documentation

Fillable forms can be found here: New Referral SAR http://

www.dhcs.ca.gov/formsandpubs/forms/Forms/ChildMedSvcForms/dhcs4488.pdf

Established Client SAR http://www.dhcs.ca.gov/formsandpubs/forms/Forms/ChildMedSvcForms/dhcs4509.pdf

Service Code Groupings (SCGs)What are service code groupings?

SCGs are groups of reimbursable codes that are authorized to CCS Program-paneled or approved providers for the care of a client’s CCS Program or GHPP-eligible medical condition.

A SCG SAR enables the provider to render care to a CCS client without needing to obtain repeated single authorizations for services.

Currently there are 12 SCGs, as indicated in the list below:

01 – Physician 05 – Cochlear Implant Centers 09 – Chronic Dialysis Clinics

02 – Special Care Center 06 – High Risk Infant Follow-up 10 – Ophthalmology

03 – Transplant 07 – Orthopedic Surgeon 11 – Medical Therapy

04 – Communication Disorder Center

08 – Rural Health Clinic/Federally Qualified Health Center

12 – Podiatry

SCG Descriptions 01-Physician A list of procedure codes specifically for physicians.

02- Special Care Center Special Care Centers (SCCs) includes all procedure codes available in preceding physician SCG 01 in addition to procedure codes for diagnostic studies relative to SCC-unique services.

03-Transplant The Transplant Center SCG includes all procedure codes available in preceding physician SCG 01 and Special Care Centers SCG 02 in addition to procedure codes for diagnostic studies relative to Transplant Center unique services.

04-Communiation Disorder Center A list of procedure codes specifically for Communication Disorder Centers.

05-Cochlear Implant Centers A list of procedure codes specifically for Cochlear Implant Centers.

06-High Risk Infant A list of procedure codes specifically for High Risk Infant Follow-Up services

07-Orthopedic The orthopedic surgeon SCG includes all codes available in preceding physician SCG 01 in addition to procedure codes for diagnostic studies relative to CCS-eligible orthopedic services.

08-FQHC/RHC A list of procedure codes specifically for Rural Health Clinic (RHC) and Federally Qualified Health Center Code Group 08 (FQHC) all-inclusive per visit codes.

09-Chronic Dialysis Clinics A list of procedure codes specifically for Chronic Dialysis Clinics.

10-Ophthamology A list of procedure codes specifically for Ophthalmologists diagnosis and treatment.

11-Medical Therapy A list of procedure codes specifically for Physical and occupational therapists diagnosis and treatment.

12-Podiatry A list of procedure codes specifically for Podiatrists diagnosis and treatment.

SCG Descriptions

Sharing SARs – Physician AuthorizationThe physician’s authorization SCG 01 number is shared with other health care providers that the physician has requested for diagnostic services, supplies or equipment, such as:

1. Physician Specialists- Initial referral consultation visits

2. Laboratory- Laboratory tests related to the client’s eligible medical condition and requested by the authorized physician or physician designee if the service codes are listed in the physician SCG (01).

3. Radiology- Radiology tests related to the client’s eligible medical condition and requested by the authorized physician or physician designee if the service codes are listed in the physician SCG (01).

4. Pharmacy- Drugs prescribed by the authorized physician or physician designee are covered in the physician SCG and do not require a separate authorization. Specific drugs require authorization when prescribed separately or included in a compound.

5. Medical Supplies- A separate SAR is required for medical supplies if the billing limits of the product(s) (for example, quantity) are exceeded, in accordance with Medi-Cal policy, or there is no specific code for the medical supply.

Durable Medical Equipment (DME) The CCS Program requires that DME requests must be requested by a CCS–paneled physician. The GHPP does not require physicians to be paneled.

The provider prescribing the DME must have a SCG SAR that includes the dates of service on which the DME is dispensed. The “date of delivery” to the beneficiary is the “date of service”.

In addition to the Medi-Cal Provider Manual DME requirements, the CCS Program and GHPP require the following information with the SAR:

Signed prescription Detailed description of DME Rental or purchase Appropriate HCPCS code List of any additional billable accessory (description, HCPCS code,

and quantity of each)

Durable Medical Equipment (DME) The CCS and GHPP Program requires that the appropriate modifier be included on the request for DME items:

NU- New equipment, purchase

RR- Rental

RA – Replacement - Used to indicate replacement vision care frames and lenses.

RB - Replacement as part of a repair - Used to indicate replacement parts during repair of Durable Medical Equipment (DME), including parts of eyeglass frames.

Inpatient Hospital AuthorizationsThere are two components to authorizations for an inpatient hospital stay:

Physician Authorization

Hospital Authorization Designated Public Hospital Authorization - # of per diem days

requested for inpatient episodeo The anticipated inpatient admissiono The number of per diem days approved for the inpatient episode

Private Hospital Authorization – Diagnosis Related Group (DRG); authorization for 1 day, typically admission date

The paneled physician with primary (Admitting/Attending) responsibility for the CCS client while hospitalized requires an authorization from the CCS Program.

If the admitting physician already has an existing SCG SAR for the client, a separate SAR is not required.

The admitting physician’s authorization may be shared with other physicians as requested by the authorized physician.

Surgery AuthorizationsA separate SAR from the Inpatient Hospital Authorizations.

Is composed of two components: Physician: Authorization from the Program for all related surgical

procedures.o The SAR must include all specific procedure codes anticipated for

the surgery.

Facility authorization: Hospitals must submit a separate SAR for the number of inpatient days required for the surgical procedure and postoperative care.

o If the CCS client requires additional time in the hospital, the hospital must request a modification of the authorization to include the additional days. (Does not apply for DRG facilities.)

Outpatient Surgery AuthorizationsCCS/GHPP Program: Physician AuthorizationThe paneled physician must request authorization for surgery with all specific anticipated procedure codes and an SCG 01 code. Surgery authorizations for elective surgery may be requested for a specified time period during which the surgery can take place.

Note: An SCG 51 code authorization for surgery may be issued when requested and there is confirmation that there is a CCS Program-eligible medical condition requiring surgery and all CCS Program eligibility requirements are met.

Outpatient Surgery Facility AuthorizationThe physician’s authorization must be shared with the outpatient surgery facility. The outpatient surgery facility must bill utilizing the physician’s authorization and indicate the authorized physician’s provider number as the referring provider.

Note: Outpatient facilities are not required to be CCS or GHPP approved.

Physical, Occupational, and Speech Therapy Authorizations

SARs for physical, occupational and speech therapy services must be submitted to the local CCS County Program or the State SCD GHPP office.

The requested therapy must be for the treatment of the client’s CCS Program- or GHPP-eligible medical condition.

Requests must include: 1. procedure codes

2. number of therapy visits

3. time period

4. physician prescription

5. medical necessity

6. current therapy report

Note: The CCS Program’s therapy SARs will only be accepted for review from CCS-paneled therapists. GHPP therapy providers are not required to be paneled.

Home Health Agency Service AuthorizationsHome Health Agencies (HHA) services, related to the client’s CCS Program- or GHPP-eligible medical condition and requested by the authorized physician for the CCS Program or GHPP client, may be requested by submitting a SAR to the appropriate program.

An authorized physician treating client as an inpatient may proactively request authorization for anticipated post-discharge HHA services at the same time as the inpatient request.

The physician may request HHA services using the CCS/GHPP New Referral SAR form.

The CCS Program or the GHPP may authorize the initial home assessment and up to three additional visits if requested by the discharging physician at the time of the CCS Program or the GHPP client’s discharge from the inpatient stay. For additional, medically necessary HHA visits, a SAR and the signed plan of treatment must be submitted for authorization.

HHA services not prior requested by the physician, must be submitted within three working days of the date the services started.

SAR Status NotificationOnce a SAR has been received and processed by the GHPP or CCS Program, the provider will receive written notification from the GHPP or CCS Program regarding the status of the submitted SAR. There are four types of SAR status a provider may receive:

Authorized (Example located within your workbook) Denied Modified Cancelled

If a SAR is denied, the family will receive a denial letter from the GHPP or CCS Program with instructions on how to appeal. This denial may be used as documentation for follow up.

Modifying a SAR

Begin date (may only be back-dated)

End date (may only be extended)

Units (may only be increased)

Quantity (may only be increased)

Inpatient Number of Days (Now tied to DRGs)

Additional codes/service code groupings may be added (additions only, codes may not be changed)

Authorized By, Primary and Secondary DX may be modified

Special Instructions may be deleted or changed

SARs may by modified for one or more of the following reasons:

Cancelled SARs

Once a SAR has been “Authorized,” or “Modified” the SAR may only be “Cancelled”.

Cancelled SARs are still valid for the specific date range of the cancelled SAR.

For example: If the SAR status is Cancelled and the effective date range of the SAR is January 1, 2013 – January 15, 2013, providers are authorized to bill for those dates of service.

Objectives Met

• Identified CCS program and GHPP requirements

• Identified important SCD, CCS, GHPP, DHCS and DHCS FI contact information

California Children’s Services (CCS) Genetically Handicapped Persons Program (GHPP) Authorization and Claims EnhancementClass #: 22Presenter: Harry Chang/Barbara Sasaki ID: U

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