Medi-Cal Rx Provider Manual

1 Proprietary & Confidential 2022 California Department of Health Care Services. All rights reserved. Medi-Cal Rx Provider Manual Version January 1, 2022 DHCS Medi-Cal Rx Provider Manual 2 01/01/2022 Revision History Document Version Date Name Comments 10/05/2020 Ashley Sipes Initial Creation Bridgette Devine/ Melissa Ferrante Document Review 11/05/2020 Ashley Sipes Updated according to DHCS feedback Melissa Ferrante Document Review 11/30/2020 Ashley Sipes Updated according to DHCS feedback Melissa Ferrante Document Review 12/16/2020 Ashley Sipes Updated according to DHCS feedback Melissa Ferrante Document Review 12/29/2020 Ashley Sipes Updated according to DHCS feedback Melissa Ferrante Document Review 12/31/2020 Melissa Ferrante Finalized document following DHCS approval 02/01/2021 Ashley Sipes Updated per Informing Materials Request dated 02/01/2021 Melissa Ferrante Document Review 02/03/2021 Ashley Sipes Updated per Informing Materials Request dated 02/03/2021 Melissa Ferrante Document Review DHCS Medi-Cal Rx Provider Manual 3 01/01/2022 Document Version Date Name Comments

2 02/12/2021 Ashley Sipes Updated per Urgent Informing Materials Request dated 02/11/2021 Melissa Ferrante Document Review 02/25/2021 Ashley Sipes Updated per Standard Informing Materials Request dated 2/09/2021 Melissa Ferrante Document Review 03/08/2021 Ashley Sipes Updated per Urgent Informing Materials Request dated 03/04/2021 Rhonda Rollins Document Review 07/20/2021 Ashley Sipes Updated Section & Appendix B pursuant to CCR-21-034 (PED Inquiry Process Update) Erica Hedstrom Document Review 10/01/2021 Ashley Sipes Removed Sections and references regarding SB393 Added Section COVID-19 Vaccine Coverage Melissa Ferrante Document Review 12/01/2021 Ashley Sipes For detailed information regarding updates, please see the December 1, 2021, Medi-Cal Rx Monthly Bulletin found on the Medi-Cal Rx website under Bulletins & News DHCS Medi-Cal Rx Provider Manual 4 01/01/2022 Document Version Date Name Comments Rhonda Rollins Document Review 01/01/2022 Ashley Sipes For detailed information regarding updates, please see the January 1, 2021, Medi-Cal Rx Monthly Bulletin found on the Medi-Cal Rx website under Bulletins & News Rhonda Rollins Document Review DHCS Medi-Cal Rx Provider Manual 5 01/01/2022 Table of Contents Introduction.

3 12 Medi-Cal Rx Pharmacy .. 12 Medi-Cal Rx Vendor .. 13 Billing Overview and Background .. 14 Enrolling as a Medi-Cal Pharmacy Provider .. 14 Participation Requirements .. 14 Provider Application and Validation for Enrollment and Provider Enrollment Division Information .. 15 Provider Guidelines .. 16 Provider Guidelines: Billing Compliance .. 25 Important Contact Information .. 28 Service Support .. 29 Customer Service Center (CSC) .. 29 Software Vendor Certification .. 31 Electronic Funds Transfer (EFT), Check Write Schedule, and Remittance Advices (RAs).. 31 Electronic Funds Transfer (EFT) .. 32 Check Write Schedule .. 32 Remittance Advices (RAs) .. 33 Solving Technical Problems .. 33 Automated Eligibility Verification System (AEVS) .. 34 Medi-Cal Rx Website .. 35 Medi-Cal Rx Provider Portal .. 38 Claims .. 45 Claim Format .. 45 NCPDP Version .. 46 Supported Transaction Types .. 47 Nonsupported Transaction Types.

4 48 Required Data Elements .. 49 NCPDP Batch Format .. 49 Paper Claim(s) .. 49 Web Claims Submission/Direct-Data Entry .. 51 DHCS Medi-Cal Rx Provider Manual 6 01/01/2022 Reimbursement .. 51 Legend and Non-Legend Drugs .. 51 Professional Dispensing Fee .. 52 Drug Price Types .. 54 Situations of Medical Necessity .. 56 340B Pricing Program .. 56 Sales Tax .. 56 Compound Prescriptions .. 57 Drugs Provided to Physicians, Hospitals, Emergency Rooms, Outpatient Clinics, or Nursing Facilities for Dispensing or Administering .. 63 Nursing Facility Emergency Drug Supply .. 63 Pharmacy Discounts .. 63 Items Not Covered .. 64 Continuing Care .. 65 Medical Supply Reimbursement .. 66 Enteral Nutrition Products Reimbursement .. 67 Providers Payment Reduction .. 67 Blood & Blood Derivatives Reimbursement .. 67 Prescription and OTC Smoking/Tobacco Cessation Products for Use During Pregnancy .. 68 Vaccine Administration Fee .. 68 Filing Limitations.

5 69 Timely Filing Limitations .. 69 Six-Month Billing Limit .. 71 Timely Filing Claim Cutback .. 72 Claim(s) Appeal Processes .. 73 Timeliness: 90-Day Deadline .. 73 Supporting Documentation for Appeals .. 74 Acknowledgement of Appeal .. 75 Judicial Remedy: One-Year Limit .. 75 Service Provider (Pharmacy ID) & Prescriber ID .. 76 Service Provider (Pharmacy ID) .. 76 Prescriber ID .. 76 Provider Procedure/Drug Code Limitation (P/DCL) .. 77 DHCS Medi-Cal Rx Provider Manual 7 01/01/2022 Beneficiary Eligibility .. 79 Identification Numbers, Cards, and Claims .. 79 Beneficiary ID .. 79 Beneficiary Identification Card (BIC) .. 80 Health Access Program (HAP) Card .. 81 Special Eligibility/Client Conditions .. 81 Long-Term Care Claims Processing .. 83 Newborns .. 84 Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) .. 85 Family Planning, Access, Care, and Treatment (Family PACT) .. 85 California Children s Services (CCS) Program & Genetically Handicapped Persons Program (GHPP).

6 87 Managed Care Plans (MCPs) .. 91 Retroactive Eligibility .. 91 Eligibility Service Restrictions .. 92 Beneficiary Financial Responsibilities .. 94 Co-Pays .. 94 Deductibles .. 94 Share of Cost (SOC) .. 94 Out-of-Pocket Maximum .. 95 Patient Paid Amount .. 95 Coordination of Benefits (COB) .. 96 COB General Instructions .. 97 Identifying Other Health Coverage .. 98 Medicare Part B Crossover Claims .. 100 Charpentier Claims .. 101 Medicare Part D COB .. 103 Allowed Other Coverage Codes (OCC) for Standard OHC and Medicare Part D .. 104 OCC3 Reject Codes .. 106 Contract Drugs List (CDL) .. 107 Code 1 Restrictions .. 107 Enteral Nutrition Products .. 109 Noncovered Nutrition Products .. 109 DHCS Medi-Cal Rx Provider Manual 8 01/01/2022 Prescription Requirements .. 110 Criteria/Authorization .. 110 Standard Products Criteria .. 111 Specialized Products Criteria .. 112 Elemental and Semi-Elemental Products Criteria.

7 113 Metabolic Products Criteria .. 114 Specialty Infant Products Criteria .. 116 Documentation 119 Billing Requirements and Limitations .. 121 Medical Supplies .. 122 Diabetic Supplies Test Strips and Lancets .. 123 Diabetic Supplies Self-Monitoring Blood Glucose Systems (Glucometers), Control Solutions, and Lancing Devices .. 125 Diabetic Supplies Disposable Insulin Delivery Devices .. 125 Diabetic Supplies Therapeutic Continuous Glucose Monitoring (CGM) Systems .. 130 Prior Authorization Overview, Request Methods, and Adjudication .. 135 Prior Authorization Overview .. 135 NCPDP Prior Authorization (P-type) Transactions .. 136 P2 Transaction PA Reversal .. 136 P3 Transaction PA Inquiry .. 136 P4 Transaction PA Request Only .. 136 Medi-Cal Rx Provider Portal for Electronic Prior Authorization (ePA) .. 136 CoverMyMeds (CMM) ePA Submissions .. 137 Fax PA Submissions .. 137 US Mail .. 138 PA Adjudication .. 139 Program Specifications.

8 143 Limitations .. 143 Dispensing Quantity Limitations .. 143 Medical Supplies Dispensing Quantity Limitations .. 144 Opioid Management .. 146 Benzodiazepine Limitations .. 148 Muscle Relaxant Limitations .. 148 DHCS Medi-Cal Rx Provider Manual 9 01/01/2022 Partial Fills .. 148 Incremental Fills .. 149 Claims Processing Edits .. 149 Dispense as Written (DAW) Codes .. 149 Cost 150 Emergency Fills .. 151 Emergency Dispensing of 72-Hour Supply .. 151 Emergency Dispensing for Out-of-State Providers .. 152 Protocol for Overriding UM During State of Emergency .. 152 Physician Administered Drugs (PAD) .. 152 Pharmacy Administered Immunizations/Vaccines .. 153 Intravenous or Intra-arterial Solutions .. 154 Blood and Blood Derivatives .. 156 Pharmacist Services .. 157 Authorized Drug Manufacturer Labeler Codes .. 158 Compound Processing .. 158 Mass Claim Adjustment(s) .. 162 Electronic Prescribing (ePrescribing) .. 163 ePrescribing Process.

9 163 End of Life Option Act Services .. 164 Pharmacy Billing for End of Life Option Act Services .. 164 Drug Use Review (DUR) .. 165 DUR Program Overview .. 165 Medi-Cal Rx DUR/PPS Codes for Opioid MME Alert .. 166 Patient Counseling Requirements .. 168 Patient Record Keeping (Medication Records) .. 170 COVID-19 Vaccine Coverage .. 171 Pediatric COVID-19 Vaccine Coverage .. 180 COVID-19 Vaccine Administration Reimbursement .. 182 COVID-19 Supplemental Incentive Fee Reimbursement for In-Home Vaccine Administration .. 183 Claim Forms .. 186 Universal Claim Form, Version .. 188 Completion Instructions for the Universal Claim Form .. 190 DHCS Medi-Cal Rx Provider Manual 10 01/01/2022 California Specific Claim Forms (30-1) & (30-4) .. 202 California Specific Pharmacy Claim Form (30-1) .. 202 California Specific Compound Pharmacy Claim Form (30-4) .. 216 Paper Claim Forms (UCF, (30-1) & (30-4)) Additional Tips .. 233 Submission and Timeliness Instructions.

10 233 Tips for Billing Crossover Claims .. 240 Tips for Billing Charpentier Claims .. 243 Claims Inquiry Form .. 246 Type of Inquiries and Timelines .. 247 Acknowledgement, Response, and Review of a Claims Inquiry .. 248 CIF Completion .. 251 Provider Claim(s) Appeal Forms .. 251 Completion Instructions for Provider Claim(s) Appeal Forms .. 251 Beneficiary Reimbursement Claims .. 251 CA-MMIS/Gainwell Beneficiary Claim Intake Process .. 252 Customer Service Center Responsibilities .. 252 Provider Notification(s) and Responsibilities .. 252 Claim Submission .. 253 Reimbursement .. 253 Medi-Cal Rx Program Integrity .. 254 Program Integrity Plan (PIP) Introduction .. 254 What are FWA and Overpayment? .. 255 Difference Between and Indicators of Potential FWA .. 255 How to Report FWA .. 257 Acronyms .. 259 Appendices .. 266 Appendix A NCPDP Standard Payer Sheet .. 266 Appendix B Directory .. 266 Appendix C Aid Codes .. 266 Appendix D NCPDP Reject Codes.