Current OHC policy requires Medi-Cal providers to establish beneficiary proof of non-coverage by attaching an OHC EOB or denial letter to the claim. Policy requires that OHC documentation must include six specific elements in order to be valid for billing. This means providers have the option of either getting an EOB or a denial letter. Large commercial OHCs (e.g. United Healthcare, Kaiser, etc.) are increasingly telling providers that they will no longer issue denial letters or letters of non-coverage.

 

Providers are also given the option to just bill the plans for denial. The problem with that is when providers bill many of these commercial OHCs they run into two issues - Claims reject outright because providers are not contracted and/or Claims deny but providers don't get the right denial (e.g. the statement of denial is insufficient to establish proof of non-coverage).

 

These options are causing some providers to hold or delay service until OHC denial documents can be obtained. It is also frustrating that Medicare Advantage and commercial MCOs plans routinely do not provide coverage for supplies like incontinence supplies.

 

CAMPS initiated a dialogue with DHCS staff to determine if their existing policy could be changed to not require proof of denial for certain items, like incontinence supplies. We suggested that the policy be amended to not require an OHC denial for any Medicare Advantage plans for incontinence because Medicare never covers these supplies. CAMPS would also suggest the same for the top 5 private/commercial OHC carriers because they represent 86% of the problem and these plans never pay for incontinence supplies.

 

We also recently learned that CMS issued new guidance on 1/4/19, "Strategies to Support Dual Eligible Individual's Access to DME, O & P, and Supplies. This directive would suggest our policy recommendation and more to eliminate OHC denials for items that are not covered by Medicare.

 

Effective for dates of service on or after January 1, 2019, the ostomy HCPCS billing codes have the following updates:

• Contracts for ostomy supplies have ended and the maximum acquisition cost (MAC) is no longer guaranteed.
   
• Claims are no longer restricted to contracted ostomy products. The Universal Product Number (UPN) and UPN qualifier are not required on the claim. Any manufacturer's product that meets the ostomy billing code descriptions is eligible for reimbursement.
   
• The maximum allowable product cost (MAPC) for certain ostomy billing codes is updated. Documentation of product cost ("By Report") is not required as an attachment to the claim for billing codes with a MAPC (price on file).
   
• The claim quantity limits for certain ostomy billing codes are updated. An approved authorization is required if the recipient requires quantities in excess of the quantity limits.

Effective for dates of service on or after January 1, 2019, products from the manufacturers Bard Medical, Coloplast, Cure Medical, LLC and Hollister Incorporated are added to the List of Contracted Intermittent Urinary Catheters.

Effective for dates of service on or after April 1, 2019, products from the manufacturers Bard Medical/Rochester and ConvaTec Inc. are deleted from the List of Contracted Intermittent Urinary Catheters.

The maximum acquisition cost (MAC) for products deleted from the list is no longer guaranteed by the manufacturer.