Provider Digest | Issue 27

Upcoming grant deadlines, CBI coding updates + more

Don’t miss these July grant deadlines!

DSA Signatory Grants – Apply by July 15

The Round II application window for Data Sharing Agreement (DSA) Signatory Grants closes July 15!

Grants of $35,000-$100,000 are available now for Data Sharing Agreement (DSA) Signatories to build capacity for data exchange or to connect to a qualifying health information organization.

Learn more about grant types, eligibility and how to apply on our website.

If you have questions, contact the Alliance’s Program Development Department at [email protected].

Medi-Cal Capacity Grants – Apply by July 18

The next deadline to apply for the Medi-Cal Capacity Grant Program (MCGP) is July 18. Funding amounts vary from $40,000 to $250,000.

We are currently accepting applications for the following funding opportunities:

Access to Care

• Workforce Recruitment Programs.
  • Community Health Worker Recruitment.
  • Medical Assistant Recruitment.
  • Provider Recruitment.
• Equity Learning for Health Professionals.
• Healthcare Technology.

Healthy Beginnings

• Home Visiting.
• Parent Education and Support.

Healthy Communities

• Community Health Champions.
• Partners for Active Living.
• Partners for Healthy Food Access.

To learn more and apply, visit our MCGP webpage. If you have questions, email [email protected].

Continuous glucose monitors (CGMs) transitioning to Medi-Cal Rx

Starting June 7, 2023, claims and authorizations for continuous glucose monitors (CGMs) have transitioned from the Alliance to Medi-Cal Rx.

Pharmacies are now required to process CGM claims through the Medi-Cal Rx online billing system (Magellan).

The Alliance will no longer process authorization requests for CGMs submitted under CPT codes. Providers and pharmacies are required to submit authorization requests directly to Medi-Cal Rx.

The list of covered CGMs is available in the Medi-Cal Rx Contract Drug List (CDL).

Medi-Cal Rx Processing Information for Pharmacies (Magellan Medicaid Administration, Inc.)
BIN: 022659	PCN: 6334225
Group ID: MediCalRX	Phone: 800-977-2273
Website: www.Medi-CalRx.dhcs.ca.gov

 

How to submit prior authorization requests to Medi-Cal Rx

• Fax to 800-869-4325.
• Medi-Cal Rx provider portal.
• CoverMyMeds®.
• Mail to Medi-Cal Rx Customer Service Center, Attn: PA Request, PO Box 730, Sacramento, CA 95741-0730.

Questions?

Reach out to the Alliance Pharmacy Department at 831-430-5507 for assistance.

2023 Care-Based Incentive code updates

Post-Discharge Care measure

Effective Jan. 1, 2023, transitional care management (TCM) codes 99495 and 99496 have been added to the Post-Discharge Care measure. These codes are Alliance only benefits for contracted primary care providers.

CPT Code	Code Requirements (transitional care management services with all of the following)
99495	Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge. At least moderate level of medical decision making during the service period. Face-to-face visit with physician within 14 calendar days of discharge.
99496	Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge. High level of medical decision making during the service period. Face-to-face visit with physician within 7 calendar days of discharge.

 

Member must have moderate or high complexity medical needs. TCM services start on discharge date and last up to 29 days.

Face-to-face visits

The first face-to-face visit is included in the TCM service. Separate Evaluation/Management service is not separately billable. Medication reconciliation is required.

Non-face to face services

Non-face to face services come after the face-to-face visits.

Clinical staff under the direction of a physician

• Communication (with patient, family, home health agencies).
• Education.
• Assessing support for treatment.
• Assessing community/health resources, then facilitating access to services.

Physician-provided services

• Reviewing discharge summary.
• Ordering labs/diagnostic tests.
• Referrals.
• Scheduling assistance.

Only one individual provider may report these services and only once per patient within 30 days of discharge. Another TCM service cannot be reported by the same individual or group for any subsequent discharge within the initial 30 days.

Dental Fluoride Varnish

As of April 1, 2023, the CDT code D1206 (topical application of fluoride varnish) was removed in line with Medi-Cal updates. Medical providers can keep billing for fluoride varnish application by using code CPT 99188.