Provider Alerts

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Date:	April 20, 2021
To:	Health Plan of San Joaquin (HPSJ) Oncology Providers
From:	Health Plan of San Joaquin
Subject:	REMINDER and SUPPORT FROM HPSJ – Prior Authorization (PA) | National Drug Codes (NDC) | Other Health Coverage (OHC)
Business:	Medi-Cal Managed Care

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To support you in becoming familiar with regulatory requirements and help your billing team with submission rules, we offer this distillation of three common billing situations. 

Prior Authorization (PA)
Effective June 1, 2021, HPSJ requires prior authorizations for oncology drugs, with the following steps in compliance with CCR Title 28 §1300.67.241.

If you receive a claim denial from HPSJ due to the absence of a Prior Authorization –

• The Notice of Action letter will say “authorization required”.
• Meds administered in office or clinic – Providers must submit a Medical Authorization Form to request a prior authorization for injectable medications that will be administered in the office or infused at the clinic, prior to rendering services. All claims received after June 1, 2021, will be denied if prior authorizations were not approved prior to rendering services. The form can be found at: https://www.hpsj.com/forms–documents/. Or submit electronically through the secure HPSJ provider portal, accessed at   https://www.hpsj.com/providers.  

• Outpatient pharmacy meds – The process has not changed for outpatient pharmacy requests that are picked up at a pharmacy. Please continue to submit the

Medication Prior Authorization Form (Form 61-211) to the HPSJ Pharmacy Department. This form can be found at: https://www.hpsj.com/priorauthorizations/. Or submit electronically through the secure HPSJ provider portal, accessed at https://www.hpsj.com/providers.  

Important Take-away – Providers must obtain a prior authorization before rendering services. All claims received after June 1, 2021 will be denied if prior authorizations were not approved prior to rendering services. 

National Drug Codes (NDC)
The Federal Deficit Reduction Act of 2005 (DRA) requires all state Medicaid agencies to collect rebates from drug manufacturers for physician-administered drugs. Collection of rebates is accomplished with the inclusion of National Drug Codes (NDCs) with each claim submitted to Health Plan of San Joaquin. Source: https://files.medical.ca.gov/pubsdoco/ndc/ndc.aspx.

REMINDER and SUPPORT from Health Plan of San Joaquin (HPSJ) – 

Prior Authorization (PA) | National Drug Codes (NDC) | Other Health Coverage (OHC) April 20, 2021
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Find NDC information required with submitted claims, along with the DHCS Frequently Asked Questions (FAQs), at https://files.medi–cal.ca.gov/pubsdoco/ndc/ndc.aspx.

If you receive a claim denial from HPSJ stating that the claim is incomplete due to missing NDC(s) –

• The letter will say “Resubmit with NDC codes and/or bill valid NDC numbers”.
• Providers can resubmit denied claims with the required National Drug Code(s).
• For recent information on the J Codes requiring Prior Authorization, please see the HPSJ Provider Alert of August 28, 2020 (https:/www.hpsj.com/pharmacy–updateoncology–medicine/).

Other Health Coverage (OHC)
Per All Plan Letter (APL) 21-002 and State law, Medi-Cal is the payer of last resort when the member has OHC. Therefore, HPSJ members with OHC must use their OHC before using their Medi-Cal benefits.

Effective April 1, 2021, HPSJ is required to make sure providers are identifying and billing the OHC carrier as primary. 

Here are some best practices and requirements for providers –

• Providers are advised to check a member’s OHC before beginning treatment.
• Unless the provider presents proof that all payment sources have been exhausted, or the provided service meets the requirement for billing Medi-Cal directly, they must not submit claims for a member whose Medi-Cal Eligibility Record indicates OHC – other than a code of A or N.

For more information on direct bill services, the Medi-Cal website has useful resources, at: 

• https://files.medi–ca.gov/pubsdoco/publications/masters–mtp/part2/medinonhcp.pdf
• https://files.medi–ca.gov/pubsdoco/publications/masters–mtp/part2/medinoncpt.pdf
• https://files.medi–ca.gov/pubsdoco/Publications/masters–MTP/Part1/otherguide.pdf

If you receive a claim denial from HPSJ due to OHC –

• The letter will say “Submit to primary insurance, resubmit with primary EOB”.
• Once the other health provider (OHP) has been billed, and they either make a payment or send a denial determination, HPSJ should be billed as the secondary carrier.

Health Plan of San Joaquin (HPSJ) values your countless contributions to the health of your patients and our community. 

If you have questions, please contact our Customer Service Department at 209-942-6320. Again, we are here to support you and your staff.