welcome to california children’s services (ccs) authorization and claims enhancement

Welcome toCalifornia Children’s

Services (CCS)

Authorization and Claims Enhancement

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.

Program Overview

and

Administrative Items(Module A)

Program Overview

What type of services does the CCS program offer?

diagnostic and treatment dental care medical case management, and physical and occupational therapy

Program Overview, cont.

What are some CCS-eligible medical conditions:

Cystic Fibrosis Sickle Cell Disease Heart Disease Cancer Traumatic Injuries


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.)

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

California Healthy Families Program

&

Medi-Cal Managed Care


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


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.


The CCS-eligible medical condition is “carved” into five counties Medi-Cal Managed Care plans:

Santa Barbara San Mateo Solano Napa Yolo

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.



The Healthy Families/Medi-Cal Managed Care plans are responsible for providing:

primary care and prevention services not related to the

CCS-eligible medical condition

Approximately of the CCS program’s caseload are clients who have Medi-Cal eligibility.


80%


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.

Administrative Items

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

Administrative Items, cont.

Important Websiteswww.dhcs.ca.gov/ccs

Paneled Providers and Approved Hospitals

Overview of CCS “Medical Eligibility”

This Computes!

Forms and Publications

Administrative Items, cont.

Important websites

www.medi-cal.ca.gov

Medi-cal rates Claim Completion instructions Provider bulletins Provider manuals

Referral Process(Module B)

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

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


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.


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.


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.


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.

Provider Paneling&

Hospital Approval

(Module C)

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.

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


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


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


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).

Provider Paneling, cont,

The CMS Branch no longer panel dental providers. Dental providers includes:

Dentists

Orthodontists

Maxillofacial Surgeons


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.


Paneling Categories for Physicians:

Full Approval Status

Provisional Status

Temporary Status

Exceptional Status


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.

Hospital Approval

CCS Hospital Approval

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

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

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.

Service Code Groupings (SCG) and

Service Authorization Request (SAR) Forms

(Module D)

Prior Authorization

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

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.

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

Service Code Groupings (SCG)

07-Orthopedic 08-FQHC/RHC 09-Chronic Dialysis Clinics 10-Opthamology 11-Medical Therapy 12-Podiatry


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


Physician Authorizations

The physician’s authorization number should be used only for those services related to the CCS-eligible medical condition.


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.


Pharmacy

The prescribing physician must provide the pharmacy with the CCS authorization number.


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.


The physician must provide the laboratory with the CCS authorization number.


Providers authorized to use the

physicians authorization number must be indicated on the claim as the billing or rendering provider.

The authorized physicians provider number must be indicated on the claim as the referring physician.


Emergency Room Authorizations

Physicians rendering emergency services in a hospital, clinic or outpatient facility and the facility is issued a CCS authorization for a Service Code Grouping (SCG) 01, the physician may utilize the facility’s authorization to bill for services rendered.


The physician must indicate the facility’s provider number as the referring provider.

This excludes surgeries and applies to outpatient services only.

Inpatient HospitalAuthorizations

Inpatient Hospital Authorizations

There are two components to authorizations for an inpatient hospital stay:

Physician Authorization

Hospital Authorization

Inpatient Hospital Authorizations, cont.


The paneled physician with primary responsibility for the care of the CCS client while hospitalized requires an authorization from the CCS program.


Physician Authorization, cont.

If the physician already has an existing Service Code Grouping SAR for this client, a separate SAR is not required.



The physician’s authorization may be shared with other physicians as requested by the authorized physician.


Hospital Authorization

The hospital must also receive an authorization from the CCS program for the anticipated length of stay.

The hospital cannot share the physician’s authorization and the physician cannot share the hospital’s authorization.

Inpatient Surgery Authorizations

Inpatient Surgery Authorizations

There are two components for inpatient surgery authorizations:


Facility Authorization

Inpatient Surgery Authorizations, cont.


Physicians must receive prior authorization from the CCS program for all surgical procedures. The SAR must include all specific procedures anticipated for the surgery.

Please note: Most surgical procedure codes are not included in Service Code Groupings.

Inpatient Surgery Authorizations, cont.


The CCS-approved hospital must receive an authorization for the number of inpatient day required for the surgical procedure and post operative care.

If the CCS client requires additional days in the hospital, the hospital must request a modification to the authorization to include the additional days.

Outpatient Surgery

Authorizations

Outpatient Surgery Authorizations, cont.


Physicians must receive prior authorization for all surgical procedures.

The SAR must include all specific anticipated surgical procedure

codes as well as Service Code Grouping 01.



The physician’s authorization must be shared with the outpatient facility.

Surgery authorizations for elective surgery may be requested for a specified time

period during which the surgery can take place.



The outpatient surgery facility must bill utilizing the physician’s authorization/SAR number.

Remember, you must indicate the authorized physician’s provider number as the referring provider.

Pharmacy Authorizations

Pharmacy Authorizations, cont.

Drugs for treatment of CCS-eligible medical conditions, other that those requiring prior authorization, do not require a separate authorization.

The pharmacy should use the authorization/SAR number of the prescribing physician.

Pharmacy Authorizations, cont.

Compound drugs require prior authorization only if one or more of the components is a drug requiring prior authorization.

If a specific non-generic brand name drug is medically necessary for a CCS client, the specific NDC must be authorized.

Durable Medical Equipment

(DME)

Durable Medical Equipment (DME), cont.

DME services related to the client’s CCS-eligible medical condition must be requested by the CCS-paneled physician.

DME services must be prior authorized.

Durable Medical Equipment (DME), cont.

The CCS program requires that the appropriate modifier be included on the request for DME:

NU- New equipment, purchaseRR- RentalRP- Repair and replacement

Physical, Occupational & Speech Therapy

Physical, Occupational & Speech Therapy, cont.

Requests for therapy services must be submitted to the CCS program for review.

Requested therapy must be from a CCS-paneled therapist.

The request must be for the CCS-eligible medical condition.


Requests for therapy must include:

Specific procedure codes

Number of therapy visits requested

Time period of requested services


Requests for therapy must include: Copy of the physician’s prescription

Documentation from the physician demonstrating medical necessity

Current therapy report, if applicable

Home Health Agency Services

Home Health Agency, cont.

Home health agency (HHA) services must be related to the CCS-eligible medical condition.

Home health agency services must be requested by the authorized physician.

The request must be submitted to the CCS program.


The physician may request home health services using the CCS/GHPP Discharge Planning SAR.

The CCS program may authorize the initial home assessment and up to three additional visits if requested by the discharging physician.

For additional HHA visits, a request and the unsigned plan of treatment must be submitted for prior authorization.


Home health services not requested on the Discharge Planning SAR or requested prior to hospitalization must be submitted within three days of the date the services started.

Services provided during this three day grace period must be included in the request.

Medical Supplies

Medical Supplies, cont.

Medical supplies related to the client’s CCS-eligible medical

condition require prior authorization.

Medical supplies may be requested and authorized with or without the two digit manufacturer code.


If the five-digit medical supply code and a specific two-digit manufacturer code is requested on the SAR and authorized, the provider must enter

the entire seven-digit code on the claim.

The provider must not substitute another manufacturer code when billing.


The following medical supply groupings may now be requested on the SAR and authorized if appropriate:

Tracheostomey Care Supplies

Respiratory Suction Supplies

Oxygen Delivery Supplies, Accessories and Refills

Enteral Feeding Supplies – Bolus/Gravity

Enteral Feeding Supplies – Pump

Service Authorization Request (SAR) Forms

SAR Forms, cont.

SAR forms are used by providers to request authorization of services from the CCS program.

Requested services must be procedure code specific or by Service Code Grouping, if applicable.

Inpatient admissions must be requested by days.

SAR Forms, cont.

There are three different types of SAR forms:

CCS/GHPP New Referral SAR

CCS/GHPP Established Client SAR

CCS/GHPP Discharge Planning SAR

SAR Forms, cont.

The referral SAR is used to:

Refer a potential CCS client to the CCS program

Request authorization of an initial service

Request must be procedure code specific

SAR Forms, cont.

The established client SAR is used to:

Request authorization of services related to the CCS-eligible medical condition for an established CCS client.

The request must be procedure code specific or by Service Code Grouping, if applicable.

SAR Forms, cont.

The discharge planning SAR is used to:

Request authorization of services related to the CCS-eligible medical condition for a CCS client being discharged from an inpatient hospital stay.

The request must be procedure code specific or by Service Code Grouping, if applicable.

SAR Forms, cont.

The requested services may include, but are not limited to:

Medical Supplies

Community Services

Other medically necessary services related to the CCS-eligible medical condition

SAR Forms, cont.

Submission of SAR Forms

Providers are to submit SARs to the appropriate CCS county or State CCS regional office based on the client’s county of residence.

SAR Forms, cont.

Online access to SAR Forms

SAR forms are available on the CMS Website:

www.dhcs.ca.gov/pcfh/cms/ccs/publications

Providers can complete them on line and print out the form and either mail or fax them to the appropriate CCS county or State CCS regional office based on the client’s county of residence.

SAR Forms, cont.

Completions of SAR forms

SAR form completion instructions are located on pages D 14 – D 25 of your workbook.

SAR Forms, cont.

SAR Status

Once a SAR has been received and processed by the CCS program, the provider will receive written notification from the CCS program regarding the status of the submitted SAR.

SAR Forms, cont.

There are three types of SAR status a provider may receive:

Approved

Cancelled

Modified

If a SAR is denied, the provider will receive a denial letter from the CCS program. This denial may be used as documentation for follow up.

welcome to california children’s services (ccs) authorization and claims enhancement

Documents

ccs clients

ccseligible condition

authorization of ccs

childs ccs eligible

ccs eligibility requirements

program eligibility

ccs programs caseload

ccs county offices