Provider Alerts - February 21, 2019

New Authorization Requirement – Chronic Care Benefits

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Date: February 21, 2019
To: Health Plan of San Joaquin (HPSJ) Providers
From: HPSJ Medical Management Department
Subject: New Authorization Requirement – Chronic Care Benefits
Business: Medi-Cal

Effective April 17, 2019, HPSJ’s benefit coverage for Chronic Care Management will require a prior authorization. This applies to CPT codes 99490 and 99491.

Chronic care management services are provided when medical and/or psychosocial needs of the patient require establishing, implementing, revising, or monitoring the care plan.

  • CPT code 99490 – chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month
  • CPT code 99491 – chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month

CPT codes 99490 and 99491 have a frequency limit of once per month and must meet the following required elements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
  • Comprehensive care plan established, implemented, revised, or monitored

Our HPSJ network providers are important partners in delivering care to our members. We hope this change will be helpful for you and your practice. If you have questions, please contact our UM Department at 209-942-6350.

Reminders
To refer a member to Case Management, Social Work or Behavioral Health services, please call 209-942-6352 or go online at https://www.hpsj.com/disease-management/.

You also can refer HPSJ members through the DRE portal. Just complete a patient search, then click “Referral.”

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