| Date: | November 15, 2019 |
| To: | Health Plan of San Joaquin (HPSJ) PCPs and Specialists |
| From: | HPSJ Claims Department |
| Subject: | Proposition 56: Supplemental Payment Update 2019 |
| Business: | Medi-Cal Managed Care |
The Department of Health Care Services (DHCS) has extended the Supplemental Payment Program through Proposition 56 as listed below.
- All supplemental payments will be going through our payment processing vendor, Change Healthcare, in separate checks rather than the regular FFS payments.
- The Remittance Advice (RA) will identify the supplemental payment with SUPP indicated on the claim line level.
Listing for the Supplemental Payment Program through Proposition 56.
Physician Services – Supplemental payment for qualified network providers (excluding FQHC’s, RHC/IHC’s and Cost-Based Reimbursement Clinics and members dually eligible for Medi-Cal and Medicare Part B, regardless of enrollment in Medicare Part A or Part D) for the following fiscal year and codes:
- FY 2017-18 (dates of service between July 1, 2017 and June 30, 2018)
- FY 2017-18 (dates of service between July 1, 2017 and June 30, 2018)
- FY 2018-19 (dates of service between July 1, 2018 and June 30, 2019)
- FY 2019-20 (dates of service between July 1, 2019 and December 31, 2021) extended in end date is due to the bridge period.
|
CPT |
Description |
Directed |
Directed |
|
99201 |
Office/Outpatient Visit New |
$10.00 |
$18.00 |
|
99202 |
Office/Outpatient Visit New |
$15.00 |
$35.00 |
|
99203 |
Office/Outpatient Visit New |
$25.00 |
$43.00 |
|
99204 |
Office/Outpatient Visit New |
$25.00 |
$83.00 |
|
99205 |
Office/Outpatient Visit New |
$50.00 |
$107.00 |
|
99211 |
Office/Outpatient Est |
$10.00 |
$10.00 |
|
99212 |
Office/Outpatient Est |
$15.00 |
$23.00 |
|
99213 |
Office/Outpatient Est |
$15.00 |
$44.00 |
|
99214 |
Office/Outpatient Est |
$25.00 |
$62.00 |
|
99215 |
Office/Outpatient Est |
$25.00 |
$76.00 |
|
99381 |
Preventative Med Service/New |
|
$77.00 |
|
99382 |
Preventative Med Service/New |
|
$80.00 |
|
99383 |
Preventative Med Service/New |
|
$77.00 |
|
99384 |
Preventative Med Service/New |
|
$83.00 |
|
99385 |
Preventative Med Service/New |
|
$30.00 |
|
99391 |
Preventative Med Service/Est |
|
$75.00 |
|
99392 |
Preventative Med Service/Est |
|
$79.00 |
|
99393 |
Preventative Med Service/Est |
|
$72.00 |
|
99394 |
Preventative Med Service/Est |
|
$72.00 |
|
99395 |
Preventative Med Service/Est |
|
$27.00 |
|
90791 |
Psychiatric Diagnostic Eval |
$35.00 |
$35.00 |
|
90792 |
Psychiatric Diagnostic Eval w/Medical Services |
$35.00 |
$35.00 |
|
90863 |
Pharmacologic Management |
$5.00 |
$5.00 |
Family Planning, Access, Care and Treatment (Family PACT) – Supplemental payment for services rendered by any qualified provider (in/out of network) when the services performed are billed with a Family Planning diagnosis code (see Medi-Cal Manual for list of diagnosis codes for FPACT) for the following fiscal years and codes. Where applicable, subject claims received and paid prior to implementation will be paid retroactively.
- FY 2017-18 (dates of service between July 1, 2017 and June 30, 2018)
- FY 2018-19 (dates of service between July 1, 2018 and June 30, 2019)
- FY 2019-20 (dates of service between July 1, 2019 and December 31, 2021) extended end date is due to the bridge period.
|
Family Planning, Access, Care and Treatment (Family PACT) |
|||||
| Codes | Amount | Codes | Amount |
Codes |
Amount |
|
99201 |
$81.18 |
99204 |
$244.26 |
99213 |
$85.08 |
|
99202 |
$121.59 |
99211 |
$42.56 |
99214 |
$132.95 |
|
99203 |
$202.77 |
99212 |
$64.17 |
|
|
*FY 19 & part of FY20 will be retro-active, providers will start receiving payments soon
Family Planning Services – supplemental payment to providers qualified to offer family planning services for specific family planning procedure codes. Where applicable, subject claims received and paid prior to implementation will be paid retroactively.
- FY 2019-20 (dates of service between July 1, 2019 and December 31, 2021) extended end date is due to the bridge period.
- Long-Acting Reversible Contraceptives (LARCs) – 400%
- Other Contraceptives(other than oral contraceptives) when provided as a medical benefit – 300%
- Emergency Contraceptives when provided as a medical benefit – 200%
- Pregnancy Testing – 200%
- Sterilization – 200%
|
Procedure Code |
Description |
Supplemental Payment |
|
J7296 |
LEVONORGESTREL-RELEASING IU COC SYS 19.5 MG |
$2,727.00 |
|
J7297 |
LEVONORGESTREL-RLS INTRAUTERINE COC SYS 52 MG |
$2,053.00 |
|
J7298 |
LEVONRGESTREL-RLS INTRAUTERINE COC SYS 52 MG |
$2,727.00 |
|
J7300 |
INTRAUTERINE COPPER CONTRACEPTIVE |
$2,426.00 |
|
J7301 |
LEVONRGESTREL-RLS INTRAUTERINE COC SYS 13.5 MG |
$2,271.00 |
|
J7307 |
ETONOGESTREL CONTRACPT IMPL SYS INCL IMPL & SPL |
$2,671.00 |
| J3490, U8 | DEPO-PROVERA |
$340.00 |
|
J7303 |
CONTRACEPTIVE VAGINAL RING |
$301.00 |
|
J7304 |
CONTRACEPTIVE PATCH |
$110.00 |
| J3490, U5 | EMERG CONTRACEPTION: Ulipristal acetate 30 mg |
$72.00 |
| J3490, U6 | EMERG CONTRACEPTION: Levonorgestrel 0.75 mg(2) & 1.5mg(1) |
$50.00 |
|
11976 |
REMOVE CONTRACEPTIVE CAPSULE |
$399.00 |
|
11981 |
INSERT DRUG IMPLANT DEVICE |
$835.00 |
|
58300 |
INSERT UNTRAUTERINE DEVICE |
$673.00 |
|
58301 |
REMOVE INTRAUTERINE DEVICE |
$195.00 |
|
81025 |
URINE PREGNANCY TEST |
$6.00 |
|
55250 |
REMOVAL OF SPERM DUCT(S) |
$521.00 |
|
58340 |
CATHETER FOR HYSTEROGRAPHY |
$371.00 |
|
58555 |
HYSTEROSCOPY DX SEP PROC |
$322.00 |
|
58565 |
HYSTEROSCOPY STERLIZATION |
$1,476.00 |
|
58600 |
DIVISION OF FALLOPIAN TUBE |
$1,515.00 |
|
58615 |
OCCLUDE FALLOPIAN TUBE |
$1,115.00 |
|
58661 |
LAPAROSCOPY REMOVE ADNEXA |
$978.00 |
|
58670 |
LAPAROSCOPY TUBAL CAUTRY |
$843.00 |
|
58671 |
LAPAROSCOPY TUBAL BLOCK |
$892.00 |
|
58700 |
REMOVAL OF FALLOPIAN TUBE |
$1,216.00 |
Women’s Health (Pregnancy/Abortion) HYDE – Supplemental payment for abortion services rendered by qualified providers (in/out of network) who are eligible to provide and bill for the following CPT codes will receive an associated supplemental payment in order to bring their payment total to the amount identified below. Where applicable, subject claims received and paid prior to implementation will be paid retroactively, for the following fiscal years and codes:
- FY 2017-18 (dates of service between July 1, 2017 and June 30, 2018)
- FY 2018-19 (dates of service between July 1, 2018 and June 30, 2019)
- FY 2019-20 (dates of service between July 1, 2019 and December 31, 2021) extended end date is due to the bridge period.
- 59840 $400
- 59841 $700
*FY18 was paid through the normal Medi-Cal fee schedule (no additional payment due
*FY19 & FY20 will be retro-active, providers will start receiving payments soon
Ground Emergency Medical Transportation (GEMT) – Supplemental payment for each qualifying emergency ambulance transport billed for specified codes and fiscal years, not to exceed $339:
- FY 2018-19 (dates of service between July 1, 2018 and June 30, 2019) o A0429 (BLS Emergency) o A0427 (ALS Emergency) o A0433 (ALS2)
- FY 2019-20 (dates of service between July 1, 2019 and December 31, 2021) extended end date due to the bridge period. o A0225 (Neonatal Emergency) o A0429 (BLS Emergency) o A0427 (ALS Emergency) o A0433 (ALS2)
o A0434 (Specialty Care Transport) ….not to exceed $ 400.72
Developmental Screening – supplemental payment to support developmental screenings is still in the developmental stage. We are awaiting the APL with the technical specifications and further details. However DHCS is giving us the code and limited details so that all MCP’s and their delegated providers are given adequate time to prepare. Effective for dates of service beginning January 01, 2020
96110* (Developmental Screening) $59.90
*Please note the KX modifier denotes screening for autism. Claims with KX modifier are excluded from the supplemental Prop 56 directed payment.
Trauma Screening – the draft APL has been released for supplemental payment to support trauma screenings. We are awaiting the final APL with the technical specifications and further details. However DHCS is giving us the codes and limited details so that all MCP’s and their delegated providers are given adequate time to prepare.
Effective for dates of service beginning January 01, 2020
Supplemental payment for trauma screenings rendered by Network Providers are:
- G9919** (Adverse Childhood Event Screening, high risk-score of 4 or greater)$29
- G9920** (Adverse Childhood Event Screening, low risk-score between 0-3) $29
Network Providers must meet the following criteria to be eligible for the payment:
- The Network Provider that rendered the screening must be on the DHCS list of Providers that have completed the state-sponsored trauma-informed care training.
- The Network Provider must utilize either the PEARLS tool for children, not more often than once per year per Provider and MCP, or a qualifying ACE questionnaire for adults up to 65 years of age, no more than once per Provider per MCP in the adult’s lifetime.
- The Network Provider must bill using once of the HCPCS codes listed above based on the screening score from the PEARLS tool or ACE questionnaire used.
*Please note the KX modifier denotes screening for autism. Claims with KX modifier are excluded from the supplemental Prop 56 directed payment.
If you have questions, please contact our Customer Service Department at 209-942-6320.