Welcome to California Children’s Services (CCS) Authorization and Claims Enhancement

1. Welcome toCalifornia Children’s Services (CCS) Authorization and Claims Enhancement

2. What is CCS • California Children’s Services (CCS) is a statewide program that treats children with certain physical limitations and chronic health conditions or diseases. • The California Department of Health Care Services manages the CCS program.

3. Program Overviewand Administrative Items(Module A)

4. Program Overview What type of services does the CCS program offer? • diagnostic and treatment • dental care • medical case management, and • physical and occupational therapy

5. Program Overview, cont. What are some CCS-eligible medical conditions: • Cystic Fibrosis • Sickle Cell Disease • Heart Disease • Cancer • Traumatic Injuries

6. Program Overview, cont. What are CCS eligibility requirements? • California resident • Under 21 years of age • Have a CCS-eligible medical condition • Family adjusted gross income of $40,000 or less in the most recent tax year. (Exception: Family’s out of pocket expenses for CCS-eligible condition exceeds 20% of family’s adjusted gross income.)

7. Program Overview, cont. CCS provides services to approximately _______ children statewide. These services are provided through a network of: • CCS paneled specialty providers • CCS paneled subspecialty providers • CCS approved hospitals • Special Care Centers 175,000

8. California Healthy Families Program&Medi-Cal Managed Care

9. Program Overview, cont. The CCS program is responsible for case management and authorization of services only related to the CCS-eligible medical condition for: • Healthy Families Subscribers • Medi-Cal Managed care beneficiaries

10. Program Overview, cont. • The CCS-eligible medical condition is “carved out” of Healthy Families and Medi-Cal Managed Care plans responsibility. • The “carve out” means that Healthy Families and Medi-Cal Managed Care plans are not capitated to provide services for a child’s CCS eligible condition.

11. Program Overview, cont. The CCS-eligible medical condition is “carved” into five counties Medi-Cal Managed Care plans: • Santa Barbara • San Mateo • Solano • Napa • Yolo

12. Program Overview, cont. • Requests for authorization of CCS services are submitted • No prior billing to Healthy Families/Medi-Cal Managed Care is necessary. to the appropriate CCS county office.

13. Program Overview, cont. The Healthy Families/Medi-Cal Managed Care plans are responsible for providing: • primary care and • prevention services notrelated to the CCS-eligible medical condition

14. Program Overview, cont. Approximately of the CCS program’s caseload are clients who have Medi-Cal eligibility. 80%

15. Program Overview, cont. The remaining 20% of the CCS program’s caseload includes: • CCS clients with no other program eligibility and referred to as CCS-only clients, or • CCS clients enrolled in the Healthy Families (HF) program and referred to as CCS/HF clients.

16. Administrative Items Telephone listings for State CMS Branch, CCS county offices, Medi-Cal, and EDS are located in your workbook on pages A8-A18.

17. Administrative Items, cont. Important Websites www.dhcs.ca.gov/ccs • Paneled Providers and Approved Hospitals • Overview of CCS “Medical Eligibility” • This Computes! • Forms and Publications

18. Administrative Items, cont. Important websites www.medi-cal.ca.gov • Medi-cal rates • Claim Completion instructions • Provider bulletins • Provider manuals

19. Referral Process(Module B)

20. CCS Referral Process What is a CCS referral? • A request directed to the CCS program to authorize medical services for a potential CCS client who meets the following criteria: • Is from birth up to 21 years of age • Has or is suspected of having a CCS eligible medical condition • Is a California Resident

21. CCS Referral Process, cont. Who can make a referral to the CCS Program? • Family • School • Public Health Nurse • Family Doctor • Physician Specialist • Anyone can make a referral to the CCS program

22. CCS Referral Process, cont. CCS referrals should be made to the CCS program as early as possible because CCS does not pay for services provided before the date of referral, unless the applicant is full-scope Medi-Cal, no share of cost.

23. CCS Referral Process, cont. How are referrals made to the CCS Program? • New Referral Service Authorization Request (SAR) Form. • Medical report or letter with a specific request for services from CCS. • Written request by a parent/legal guardian. • By Telephone.

24. CCS Referral Process, cont. It is important that providers send medical reports documenting the suspicion or confirmation of a CCS eligible medical condition to the appropriate CCS county or State Regional Office.

25. CCS Referral Process, cont. • A case may be opened for diagnostic services to confirm the presence or absence of the suspected CCS-eligible medical condition. • A case may be opened for treatment when a CCS-eligible medical condition is confirmed and all other program eligibility requirements have been met. • The CCS program encourages all families to apply and sign the CCS Program Services Agreement.

26. Provider Paneling&Hospital Approval(Module C)

27. Provider Paneling What is Paneling? • The process of the CCS program to review and approve providers by ensuring they meet specific criteria and are qualified to provide services for CCS clients with special health care needs. • The CMS Branch requires that all physicians be CCS paneled in order to be issued an authorization to provide services to CCS clients.

28. Provider Paneling, cont. In addition, CCS paneling is required for the following allied health care providers: • Audiologists • Dietitians • Occupational Therapists • Orthotists • Pediatric Nurse Practitioners • Physical Therapist

29. Provider Paneling, cont. In addition, CCS paneling is required for the following allied health care providers: • Prosthetists • Psychologists • Registered Nurses • Respiratory Care Practitioners • Social Workers • Speech-Language Pathologists

30. Provider Paneling, cont. It is important to note that all providers applying for CCS paneling must have the following: • A National Provider Identifier (NPI) • NPI registered with the DHCS

31. Provider Paneling, cont. Exception: The following are exempt from the provider number requirements since the facility bills for services rendered via the facility’s provider number: • Allied Health providers, who are employees of a hospital or facility. • Physicians who are employees of a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC).

32. Provider Paneling, cont, The CMS Branch no longer panel dental providers. Dental providers includes: • Dentists • Orthodontists • Maxillofacial Surgeons

33. Provider Paneling, cont, • Dental providers requesting to participate in the CCS program must have an active Denti-Cal provider number and or NPI provider number. • Provider requirements for paneling are listed by provider type on pages C 4 – C 9.

34. Provider Paneling, cont, Paneling Categories for Physicians: • Full Approval Status • Provisional Status • Temporary Status • Exceptional Status

35. Provider Paneling, cont, A CCS panel application can be obtained by: • Accessing the CCS website and clicking on the “Forms and Publications” link. • Calling the Provider Services Unit at (916) 322-8702 and request an application.

36. Hospital Approval

37. CCS Hospital Approval The CCS program approves and assigns various types of approval levels to inpatient hospitals, based on CCS standards and requirements.

38. CCS Hospital Approval, cont. A hospital may receive one of the following approval levels: • Tertiary Hospital • Pediatric Community Hospital • General Community Hospital • Special Approval • Limited Approval

39. CCS Hospital Approval, cont. Hospital approval levels and CCS standards and requirements can be found on the CCS website. www.dhcs.ca.gov/ccs Under the “Forms and Publications” Manual of Procedures link.

40. Service Code Groupings (SCG) and Service Authorization Request (SAR) Forms (Module D)

41. Prior Authorization The CCS program requires prior authorization for health care services related to a CCS client’s CCS-eligible medical condition.

42. Service Code Groupings (SCG) What are service code groupings? • Groups of codes that are authorized to CCS-paneled or approved providers for the care of a CCS client’s CCS eligible medical condition. • The SCG contains a listing of codes that allow the provider to care for the CCS client’s CCS eligible medical condition without needing to obtain repeated single prior authorizations.

43. Service Code Groupings (SCG), cont. • 01-Physician • 02- Special Care Center • 03-Transplant • 04-Communiation Disorder Center • 05-Cochlear Implant Centers • 06-High Risk Infant

44. Service Code Groupings (SCG) • 07-Orthopedic • 08-FQHC/RHC • 09-Chronic Dialysis Clinics • 10-Opthamology • 11-Medical Therapy • 12-Podiatry

45. Service Code Groupings (SCG), cont. Physician Authorizations The physician’s authorization number may by shared with other health care providers that the physician has requested services, such as: • Laboratory • Pharmacy • Radiology • Physician Specialists

46. Service Code Groupings (SCG), cont. Physician Authorizations The physician’s authorization number should be used onlyfor those services related to the CCS-eligible medical condition.

47. Service Code Groupings (SCG), cont. Pharmacy • Drugs prescribed by the authorized physician are covered in the Physician’s SCG and do not require a separate authorization. However, drugs listed on page D 6 does require prior authorization. • Medical supplies always require prior authorization.

48. Service Code Groupings (SCG), cont. Pharmacy The prescribing physician must provide the pharmacy with the CCS authorization number.

49. Service Code Groupings (SCG), cont. Diagnostic Laboratory/Radiology • Laboratory and Radiology tests related to the client’s CCS-eligible medical condition and requested by the authorized physician are covered if they are listed in the Physician’s SCG. • Laboratory and Radiology tests not covered in the Physician’s SCG require a separate authorization.

50. Service Code Groupings (SCG), cont. The physician must provide the laboratory with the CCS authorization number.