This week the Assembly Budget Subcommittee adopted the CAMPS proposal to freeze Medi-Cal rates using the 1/1/16 Medicare rates. Current law requires that DME be reimbursed at 80% of the Medicare rate or 100% of Medicare for custom rehab equipment. CAMPS has sought budget trailer bill language to change that percentage to 100% of the Medicare rate for all DME and to use the Medicare rates in effect as of January 1, 2016. Currently Medi-Cal is using those rates but could use the subsequent Medicare rates that are much lower based upon CB rates.

 

This provision has now been included in the Assembly version of the state budget that will now move to a two House conference committee where differences between the Assembly and Senate versions of the budget will be reconciled. There is no comparable DME provision in the Senate version of the budget so we will be advocating to adopt the Assembly provision. If successful there a final budget will be adopted by the Legislature by June 15th and sent to the Governor. The Governor retains the ability to "blue pencil" or delete specific budget appropriations or strike specific language. We are happy with our early success but still haver hurdles to overcome. We will keep you informed.

Effective for dates of service on or after July 1, 2017, claims for covered medical and incontinence supplies and enteral nutrition products provided upon a prescription are eligible for reimbursement only if the prescription is written by a physician. Title 42 Code of Federal Regulations (CFR) 440.70 requires Medicaid programs only reimburse providers for medical supplies and enteral nutrition products that are ordered by a physician. In addition, the regulation requires a recipient's need for medical supplies be reviewed by a physician annually.

Medi-Cal is in the process of implementing the Patient Protection and Affordable Care Act (ACA) Ordering, Referring and Prescribing (ORP) requirements. To support billing providers' compliance with these requirements, Medi-Cal has created the ORP Provider Validation Lookup Tool. The web-based tool gives billing providers the ability to verify an ORP provider. This is done using the ORP provider Type 1 (individual) National Provider Identifier (NPI) to verify that an ORP provider is known to Medi-Cal and if the ORP provider is active for the specified date of service in advance of billing Medi-Cal. This will allow the billing provider to resolve any issues with invalid NPIs or non-enrolled ORP providers before submitting a claim.

A beta version of the ORP Enrollment Validation Lookup Tool has been released. Please use the beta version of the tool to set up processes and procedures for validating ORP provider enrollment when fulfilling/billing a service. Medi-Cal will release a final version of the tool prior to enforcing ORP requirements on claims (that is, denying claims for failure to provide a valid Type 1 [individual] NPI for an enrolled ORP provider).

The tool will validate ORP provider enrollment and display a response along with a transaction number. Users should record the transaction number in the event of a discrepancy between the ORP Enrollment Validation Lookup Tool response and claim adjudication.

The ORP Provider Validation Lookup Tool can be accessed from the Ordering, Referring and Prescribing (ORP) Web page on the Medi-Cal website along with more information and frequently asked questions about ORP requirements.

Effective for dates of service on or after July 1, 2017, the incontinence billing code A4520 (incontinence garment, any type [e.g. brief, diaper], each) will no longer be reimbursable. All Medi-Cal covered incontinence medical supplies meet one of the descriptions of the billing codes on the List of Incontinence Medical Supply Billing Codes spreadsheet.

All incontinence medical supply billing codes are reimbursable only for recipients age 5 and older with a chronic pathologic condition causing the recipient's incontinence. The primary ICD-10-CM diagnosis code and the secondary ICD-10-CM diagnosis code must be entered on claims to reflect the condition causing the incontinence and the type of incontinence.

Authorization is required for incontinence claims exceeding the quantity limit or the $165 cost limit. The quantity billed with or without authorization must not exceed a one-month supply (total quantity approved divided by the number of months approved) in a 27-day period.

The maximum amount reimbursed to providers for incontinence medical supply billing codes is the lesser of: