Highlights from LEA Ad-Hoc Advisory Workgroup June 2019 Meeting

On June 5, 2019, the California Department of Health Care Services (DHCS) held a meeting for the LEA Ad-Hoc Advisory Workgroup, comprised of LEA representatives, DHCS, and the California Department of Education (CDE); the meeting is held to make recommendations and discuss issues impacting the LEA Medi-Cal Billing Option Program.

Highlights from the June meeting include:

Erroneous Paid Claims (EPC) Issues

  • On May 15, 2019, Erroneous Payment Correction (EPC) 50577 was approved and is pending installation; the payout for CPT Code 96130 (Psych Assessments) from January 2019 erroneous denials is pending and expected to be complete by mid-June.
  • A problem statement was developed to identify erroneously denied claims related to Remittance Advice Detail (RAD) codes associated with the capitated payment or that the service was covered under a Managed Care Plan. Certain claims associated with the new OT/PT Assessment CPT Codes (effective July 1, 2018) were erroneously denied. DHCS will issue an EPC for those claims incorrectly denied, once EPC 50577 is implemented. There is no additional action necessary by LEAs.
  • FY 2018/19 rates were installed by Conduent in April 2019. EPC 51900 has been initiated to reprocess claims paid with dates of service between July 1, 2018, and the installation date. DHCS is awaiting the EPC installation date from Conduent.
  • In early May, a problem associated with the updated reimbursement rate installation was identified, impacting claims that erroneously denied with RAD code 0090: The combination of procedure code and modifier is not valid on the dates of service billed. This issue appears to be limited to claims with procedure code/modifier combination 92523 52 GN TM. On May 28, 2019, a problem statement was opened at Conduent to correct this issue. Once the system is fixed, an EPC will be run to reprocess the incorrectly denied claims. There is no additional action necessary by LEAs.

SPA 15-021 Update

  • DHCS & CMS had a call on May 20, 2019, on which CMS indicated they do not see a problem with delaying the RMTS implementation date until 2020, but they will only approve this (or not) as part of the SPA approval.
  • The SPA is still not on the formal “clock” as CMS and DHCS are continuing to work collaboratively without it being formally re-submitted. Once they formally re-submit, CMS has 90 days to approve, but DHCS believes it will be a much faster approval since they’ve worked out all the issues prior to this submission.

Upcoming SPAs

  • SPA 19-0009, submitted to CMS March 26, 2019, will include comprehensive vision services and will restructure how school-based services are written into the State Plan, which in-part would include removing any duplicative or unnecessary state plan language. This new approach would also include removing references to all licensing, credentialing and supervision practitioner requirements for the LEA Program. Per CMS’ direction, they are adding the last piece to this SPA as opposed to a new SPA, which was the original intent.

Authorizing Practitioners

  • Nurse Practitioners & Physician Assistants being added as allowable authorizers will occur when the next LEA Provider Manual is published. This will not be retroactive.

For information on attending the next meeting, LEAs should contact the LEA Inbox at LEA@dhcs.ca.gov.

The official meeting minutes for this meeting have not yet been posted; past LEA Ad-Hoc Advisory Workgroup meeting minutes are archived on the DHCS website.