Welcome. Overview of California Children s Services (CCS) Break. Getting Paid. Questions???
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1 FRESNO COUNTY DEPARTMENT OF PUBLIC HEALTH CHILDREN S MEDICAL SERVICES CALIFORNIA CHILDREN S SERVICES AGENDA Welcome Overview of California Children s Services (CCS) The CCS Client CCS application and provider requirements Service Authorization Requests (SARs) Service Code Groupings (SCGs) SARs that need separate authorizations Pharmacy Provider Tips Break Getting Paid The Claim Process Remittance Advice Detail (RADs) Common Denials Medi-Cal Share of Cost Emergency Medi-Cal Crossover Claims Timeliness Helpful Resources Questions???
2 WELCOME TO CCS California Children s Services Children s Medical Services Fresno County Department of Public Health 1221 Fulton Mall, 2 nd Floor Fresno, CA (559) Fax: (559)
3 California Children s Services (CCS) Statewide program. Pays for medical treatment of children with certain physical limitations and chronic health conditions or diseases. Medi-Cal, Healthy Families carve out. Payer of last resort. Funded with state, county, and federal tax monies.
4 CCS Eligibility Criteria Be under age 21. Have a CCS medically eligible condition. Reside in Fresno County. Family income of $40,000 or less (reported as AGI on the state tax form), OR Out-of-pocket medical expenses are expected to be more than 20% of family income, OR Have Full-scope Medi-Cal, no share of cost OR Have Healthy Families.
5 Financial Eligibility is NOT Required for: Diagnostic services only. Adopted child with a known CCS eligible medical condition. Medical Therapy Program (MTP) services only. Full-scope Medi-Cal, no share of cost, OR To initiate a Healthy Families Case.
6 CCS Eligible Conditions Most problems that are: Life-threatening Physically disabling and Require medical, surgical, or rehabilitative services CCS medical eligibility is disease specific and covers only what is related to or impacts the CCS eligible condition.
7 FRESNO CCS S KIDS 2% 9% 6% 83% Full-Scope Medi-Cal Healthy Families (17.5% County Funds) Medi-Cal w/ Share of Cost Income $40K (50% County Funds)
8 THE FRESNO CCS TEAM CCS Doctors & Nurses review for medical eligibility; provide case management Admitting Interviewers review for residential & financial eligibility Fiscal Unit & Support Staff assist medical staff with correspondence, provider billing issues Occupational/Physical Therapists provide therapy services to CCS clients
9 How to Apply for CCS ms/pages/ccsforms.aspx
10 How to Become a CCS Provider Have an active National Provider Identifier (NPI) #. Be licensed as a physician by Medical Board of CA. Be certified in your field of practice. Remember, just because a provider is Medi-Cal approved, does not mean they are automatically CCS approved. Once CCS paneled by the state, no recertification is needed.
11 How to Become a CCS Provider rms/pages/ccsforms.aspx For questions, call the Provider Services Unit at: (916)
12 How to Request Services from CCS Request prior authorization. Complete the Service Authorization Request (SAR): * New Referral Client * Established Client * Discharge Planning
13 Facts About the SAR A SAR is the Request and the SAR number is the Authorization. Statewide uniformity. Online access. Service Code Groupings (SCGs) may be shared. Linked to claims payments.
14 SAR Requirements Approved provider name and NPI #. Contact name and phone number. Client demographics. Insurance information, CIN #. Confirmed or presumed diagnosis. Requested services. Documentation, including medical reports. Additional services requested for other providers. Sign and date your form.
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17 Fresno s Electronic SAR (esar) Need Adobe Reader to use. Can be completed online or saved for later use. All SAR forms submitted via will receive a notification receipt from CCS.
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19 Requests for Admission to a Hospital Both a Hospital SAR # and a Dr s SAR # are required. (Both the facility & the doctor must be CCS approved.) No Dr s SAR # = No payment for the doctor and most of the indirect providers that bill under a Dr s Authorization.
20 If Medi-Cal Managed Care has denied your claim(s), please attach a copy of the denial and resubmit your request to our office.
21 Service Code Groupings (SCG) A group of reimbursable codes authorized to CCS-approved providers that allow the provider flexibility in providing medically necessary services to CCS clients. Enables the provider to render care to a CCS client without the need for requesting additional procedure-specific SARs.
22 How Are SCGs Used? An approved provider with a SCG can refer their client for listed services and the services would be authorized when the approved provider name and NPI number are listed as the referring provider on the claim. Secondary providers such as pharmacies and labs may provide listed services previously authorized with a SCG without obtaining another SAR for these services.
23 Service Code Groupings (SCGs) SCG 01 Physician Service (Medications, Labs, Office Visits)* SCG 02 Special Care Centers (includes all codes of SCG 01) (Specialized groups of doctors, center service codes)* SCG 03 - Transplant Centers (includes all codes of SCG 01 & 02) (Medical services related to transplants)* SCG 04 Communication Disorder Centers (Hearing tests, speech therapy, audio rehabilitation) SCG 05 Cochlear Implant (Hearing screening, cochlear implants, comprehensive or diagnostic evaluations)* SCG 06 High Risk Infant Follow-Up (HRIF) (Pediatric evaluation, development testing, office consultations)* SCG 07 Orthopedic Surgeon (includes SCG 01) SCG 08 Rural Health Clinic (RHC) & Federally Qualified Health Center (FQHC) (Provider at one of these clinics is serving in conjunction with a CCS-authorized Special Care Center or authorized specialist/sub-specialist) SCG 09 Chronic Dialysis Clinic (Home Dialysis, IV infusion therapy, dialysis training)* SCG 10 Ophthalmology (Strabismus, cataracts, glaucoma)* SCG 11 Medical Therapy (All physical & occupational therapies, evaluations & testing)* SCG 12 Podiatry (Severe foot deformities)* *Included, but not limited to these examples. Check website for the most current information:
24 You will then be taken to this portion of the page.
25 Service Code Groupings (SCG) A list of the Current SCGs and their codes are online on the State CCS website. The most recent codes added are in bold, underlined, & given a symbol to indicate the effective-date in the SCG. Codes that are end-dated are bold, with a strike-through and a symbol indicating the end-date from the SCG. Q0111-Q0113 a Examples X7588 a
26 Service Code Groupings (SCG) After one year from an effective-date, the symbol is removed, and after one year from an end-date, the code with the strikethrough and symbol is removed completely from the manual page. X7588 a
27 Pharmacy Authorizations If a physician s SCG includes the appropriate drugs to treat the CCS condition, the pharmacy is not required to submit a separate SAR. List of drugs that require separate authorizations is found on the SCG website. Medical supplies not included in the SCG will require a separate SAR. Prescribing physicians must include SAR number on the prescription. The rendering pharmacy must bill using the physician s SAR number. Pharmacy must wait 24 hours from authorization of SAR to process claim. Online billing questions and concerns should be addressed to ACS.
28 Fresno County s Tips for CCS Providers Prior authorization is needed on all requests. CCS will process inpatient and urgent requests within 2 business days. Non-urgent requests will be processed within business days. Use the esar. You will know we received your request. Providers should share their authorized SAR # with other providers, when appropriate. Inform your clients to keep a copy of the CCS-authorized SAR until it expires.
29 10 MINUTE BREAK
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