partnership healthplan of california …...sep 21, 2016 · internal quality improvement...

PARTNERSHIP HEALTHPLAN OF CALIFORNIA QUALITY/UTILIZATION ADVISORY COMMITTEE MEETING NOTICE

DATE: Friday September 16th, 2016 FROM: Latosha Smith, QI Administrative Assistant (Temp) SUBJECT: Quality/Utilization Advisory Committee (Q/UAC) Meeting

In preparation for the upcoming Q/UAC meeting, please carefully review the agenda topics and corresponding materials.

In addition, please be informed that due to the size of our meeting packets, PHC’s Green Committee has respectfully asked that we reduce our environmental impact, so we encourage you to use your electronic device (ex. iPad, laptop, etc.) during the meeting. However, a few hard copy packets will be available for the external Committee Members only.

PHC Staff: You will be responsible for printing your own copy, if you feel you need it.

If you are calling-in to the meeting, please dial 1 (888) 240-2560. Meeting ID: 870356221 Passcode: 0671

Date: Wednesday, September 21, 2016 Time: 7:30 - 9:00 a.m. Place: Partnership HealthPlan of California

4665 Business Center Drive, Solano/Napa Conference Room – 1st Floor Fairfield, CA 94534

2525 Airpark Drive / Trinity Alps Conference Room Redding, CA 96002 1036 5th St. Suite E. / Grizzly Creek Conference Room

Eureka, CA 95501 Physicians and Consumer Members: Jennifer Wilson, MD Robert Quon, MD Kali Stanger, MD maternity leave Rodrigo Manalo, MD Madhusudan Borde, MD Sara Choudhry, MD Michael Pirruccello, MD Steven Gwiazdowski, MD, FAAP Michael Strain, PHC Consumer Member Steven Namihas, MD Randolph Thomas, MD Thomas Paukert, MD PHC Staff Members: Debra McAllister, RN, Utilization Management Director Michael Vovakes, MD, Northern Region Medical Director James Cotter, MD, Associate Medical Director Nadine Harris, RN, MBA, Quality Compliance Manager Jessica Thacher, MPH, Quality & Performance Improvement Director

Peggy Hoover, RN, Health Services Senior Director

Mark Glickstein, MD, Associate Medical Director Robert Moore, MD, MPH, CMO - Chairman Mark Netherda, MD, Regional Medical Director Scott Endsley, MD, Associate Medical Director Mary Kerlin, Provider Relations Senior Director Heidi Lee, Credentialing Supervisor, Provider Relations

Rachael French, Manager of Quality Improvement Programs Quality and Performance Improvement Department Heather Brandeburg, Assoc. Dir., Provider Relations Kelley Sewell, Northern Region Director of MS & PR

Jennifer Chancellor, Regional Manager Carly Fronefield, Director of Health Services (R) Karen Stephen, PhD, HS Mental Health Director Lynn Scuri, Associate Regional Director

Marshall Kubota, MD, Regional Medical Director Nancy Steffen, Quality, Analysis and Project Management Associate Director (R) Rosemenia Santos, Manager of Quality Assurance and Patient Safety Cc:

Margaret Kisliuk, MPP, JD, Executive Director Richard Fleming, MD, Associate Medical Director Katherine Barresi, Care Coordination Manager

Betsy Campbell, MPH, Senior Health Educator Jeff Ribordy, MD, Northern Regional Medical Director Margarita Garcia-Hernandez, Mgr., Health Analytics

PHC Offices: Please use the “Q/UAC Meeting” directory entry on your video conference unit. If you need assistance please contact IT a minimum of one (1) day prior to the meeting so that they can provide instructions and testing. 1 of 2521 of 252

PARTNERSHIP HEALTHPLAN OF CALIFORNIA QUALITY/UTILIZATION ADVISORY COMMITTEE

MEETING AGENDA

Date: September 21, 2016 Time: 7:30 – 9:00 a.m. Location: Napa/Solano Room (1st Floor)

I. Approval of Minutes Lead Time Page #

1 Quality/Utilization Advisory Committee (QUAC_8.17.2016) (attachment) Internal Quality Improvement (IQI_8.9.2016) (attachment)

Robert Moore, MD 7:30 5-17

II. Standing Agenda Items (Full Committee)

1 Status of open action items (discussion) Robert Moore, MD/

Rachael French 7:33

2 QI Update (attachment) Jessica Thacher 7:35 18-22

3 Health Plan Update (discussion) Robert Moore, MD 7:45

III. Old Business (Committee Members as Applicable) None

IV. New Business (Committee Members as Applicable)

1 Consent Calendar (attachments)

All 7:50 23-87

Utilization Management, no substantive changes

MCCP2005 EPSDT Supplemental Shift Nursing Services

MCUG3022 Incontinence Guidelines

MCUG3038 Long Term Care Facility Review Guidelines

MCUP3027 Members with Limited Benefits

MCUP3034 PCP-To-PCP Transfers & Assignments of New Members to PCP

MP 350 Weight Management Program

MPCP2002 California Children Services

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MPUP3035 Preoperative Day Review

MPCP2006 Coordination of Services for Members with Special Health Care Needs (MSHCNs) and Persons with Developmental Disabilities

Provider Relations, no substantive changes

MPPR201 PCP Availability and Capacity Policy and Procedure

MPPR202 Monitoring of PHC Specialist Physician Network Availability and Accessibility Policy & Procedure

MP PR 205 Monitoring of PCP Accessibility of Services Policy and Procedure

MPPRSA212 Access Standards for Substance Abuse Services

MPPRSA213 Availability of Substance Abuse Clinicians/Outpatient Facilities

Quality and Performance Improvement, no substantive changes

MPQP1018 Preventive Health Guidelines

New Business (Committee Members as Applicable)

MPUP3126 Autism Spectrum Disorder (ASD) Behavioral Health Treatment (BHT)

Review and approve recommended changes

Melissa Rosel 7:55 88-99

MCUG3032 Orthotic and Prosthetic Appliances Guidelines Review and approve recommended changes

Melissa/Dr. Cotter 8:00 100-105

MCUP3113 Telehealth Services


Dr. Moore/Amanda 8:05 106-119

MCUP3131 Genetic Testing- (Attachment A only) Review and approve recommended changes

Dr. Moore 8:10 120-214

MP316 Provider Request to Discharge


Mary Enos 8:15 215-241

Cervical Cancer Screening- Open discussion Dr. Moore 8:20

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Q/UAC Policy Update Rachael French 8:40 242-244

Site Review Bi-Annual Report Laurie Stevenson 8:45 245-251

Tobacco Cessation Report Betsy Campbell 8:50 252

V. Additional Business

VI. Adjournment

This agenda contains a brief description of each item to be considered. Except as provided by law, no action shall be taken on any item not appearing on the agenda.

Government Code §54957.5 requires that public records related to items on the open session agenda for a regular committee meeting be made available for public inspection. Records distributed less than 72 hours prior to the meeting are available for public inspection at the same time they are distributed to all members, or a majority of the members of the committee. The committee has designated the Administrative Assistant to the Quality and Performance Improvement Department as the contact for Partnership HealthPlan of California located at 4665 Business Center Drive, Fairfield, CA 94534, for the purpose of making those public records available for inspection. The Quality Utilization Advisory Committee Agenda and supporting documentation is available for review from 8:00 AM to 5:00 PM, Monday through Friday at all PHC regional offices (see locations above). It can also be found online at www.partnershiphp.org.

In compliance with the Americans with Disabilities Act, PHC meeting rooms are accessible to people with disabilities. Individuals who need special assistance or a disability-related modification or accommodation (including auxiliary aids or services) to participate in this meeting, or who have a disability and wish to request an alternative format for the agenda, meeting notice, agenda packet or other writings that may be distributed at the meeting, should contact the (temp) Administrative Assistant to the Quality Performance Improvement Department at least two (2) working days before the meeting at (707) 863-4622 or by email at [email protected]. Notification in advance of the meeting will enable PHC to make reasonable arrangements to ensure accessibility to this meeting and to materials related to it.

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PARTNERSHIP HEALTHPLAN OF CALIFORNIA MEETING MINUTES

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Committee: Quality and Utilization Advisory Committee (QUAC) Date/Time: August 17, 2016 7:30 – 9:00am

Members Present: Michael Pirruccello, M.D. Steven Namihas. M.D. Michael Strain, PHC Consumer Member Steven Gwiazdowski, M.D., FAAP Randy Thomas, M.D. Sara Choudhry, M.D. Rod Manalo, M.D. Members Absent: Kali Stanger, M.D. – (absent; on maternity leave) Robert Quon, M.D.

Thomas Paukert, M.D. Steven Namihas, M.D.

PHC Members Present: Debra McAllister, RN, Utilization Management Director Rachael French, Manager of Quality Improvement Programs James Cotter, M.D., Associate Medical Director Robert Moore, M.D, MPH, Chief Medical Officer Jessica Thacher, MPH, Director of QI/PI Rose Santos, R.N. Manager of Quality Assurance and Patient Safety Jennifer Chancellor, Regional Manager

Mark Glickstein, M.D. Associate Medical Director Scott Endsley, M.D, Associate Medical Director, Quality

Mark Netherda, M.D, Regional Medical Director Michael Vovakes, M.D, Northern Region Medical Director Nadine Harris, RN, Manager of Quality Compliance Peggy Hoover, RN, Health Services Director

PHC Members Absent:

Mary Kerlin, Director of Provider Relations Steffen, Nancy, NR Associate Director, Analytics, PMO, Quality

Guests: Carly Fronefield, RN, NR Health Services Director

Katherine Barresi, Associate Director of Care Coordination Karen Stephens, Mental Health Clinical Director Ledra Guillory, Senior Provider Relations Rep Manager Lauri Stevenson, RN, Clinical Quality Supervisor

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AGENDA ITEM

DISCUSSION / CONCLUSIONS RECOMMENDATIONS/

ACTION TARGET

DATE DATE

RESOLVED Call to Order and Ap-proval of Minutes

The meeting was called to order at 7:40 am. Minutes from the 6/15/16 QUAC meeting were reviewed. Minutes from the 6/07/2016 IQI meeting were reviewed.

Approved with minor change. Dr. Gwiazdowski did attend the June Meeting

8/17/2016

I. Standing Agenda Items

1. Status of open action items

There were no open action items discussed. 8/17/2016

2. QI Update

Jessica Thacher, MPH, Director of Quality and Performance Improvement, provided an update on key activities occurring in the Quality and Performance Improvement depart-ment, starting on page 18 of the QUAC packet. As part of PHC’s team goal process, an inter-disciplinary HEDIS Measure Improvement workgroup has been established, led by QI. This team will focus on developing a long-range strategic plan to improve HEDIS scores, as well as shorter term strategies to improve performance for measurement years 2016 and 2017. A few things in our report that support this priority: In our pay for perfor-mance arena there are two changes. One big change is we are transitioning from a fiscal reporting year to an annual reporting year which better aligns with the HEDIS rates re-ported to the state. We are also adding a measure that we are consistently performing low across all our regions on to our Family Practice measurement set. The QI team has 2 new staff members. Rose Santos as our Manager of Quality Assurance and Patient Safety. Nadine Harris is retiring the beginning of January and Rose will be taking over many of Nadine’s current duties. Another change is as part of Nadine’s retire-ment planning is that the responsibilities of managing the IQI and QUAC meetings will be taken over by Rachael French. We are also excited to welcome Sarah Molteni-Casper as our new HEDIS Analyst. Sara is assuming Sue Lee’s role in the HEDIS project as she transitions into her new role as Senior NCQA Project Manager. Please refer to the entire update report, provided in your meeting packet.

None. 8/17/2016

3. Health Plan Update

Dr. Moore, Committee Chairman and Chief Medical Officer presented the following update:

• PHC held a leadership retreat yesterday to review the major initiatives. The big ones for this year – Health Homes program which is the replacement for our IOPCM program that will go live sometime in 2017. The key delay is the state is moving slowly on some of the regulatory aspects of it, particularly the rates. We

None. 8/17/2016

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submitted to the state a detailed analysis of what we thought the rates should be and will be meeting with DHCS later today to go over the report and hopefully it might speed things up.

• The Palliative Care benefit. Still awaiting details, from DHCS. They are going to set the parameters and they expect that the savings you achieve from high quality palliative care will offset the cost of the program. This puts the responsibility on the plans to figure out how to pay for it. Of our three pilots, two are still active and one is less active. We did an analysis and feel there are seven to nine entities able to take on this new benefit as it rolls out. We are tweaking our model so it will be ready for the full rollout.

• CCS transition has been pushed back one to two years. This will give us time to see how several of our sister counties do with that program.

• The PPS reform pilot for FQHCs to be paid totally on a capitation basis instead of with a wraparound payment for their prospective payment services is begin-ning to move forward. We are looking at 2017-18 for that one. There are a lot of configuration issues to work through.

Parking lot issues: Transportation – there is a bill floating through the state legislature without much opposition except from health plans to broadly cover transportation for medical. Our one concern is if you don’t put any limits in place members will prefer to use that every time they want to go to the doctor. Currently it is a stop gap for people not having their own transportation. The state thinks it will be about $100,000 and we think it will be much higher.

II. Old Business

There was no old business discussed at this meeting.

III. New Business

1. Consent Calendar Consent Calendar (attachments) Delegation Reports – Credentialing/Re-credentialing MPQP1026 OB/GYN Facility Site Review Requirements and Guidelines MP PR-GR210 Provider Grievance Utilization Management, no substantive changes MCUP3012 Discharge Planning (Non-capitated members) HKCP2015 Continuity of Care (HK Only) HKUP3069 (formerly MPUP) Emergency Services (HK Only) MCCP2014 Continuity of Care (HK Only) MCUG3008 Bathroom Equipment Guidelines MCUG3011 Criteria for Home Health Services MCUP3003 Rehabilitation Guidelines for Acute Skilled Nursing Inpatient Services (pre-viously Acute Inpatient or Long Term Care rehabilitation Institution Services) MCUP3133 Wheelchair Mobility, Seating and Positional Components

Approved without changes

8/17/2016

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MCUP3041-A ATTACHMENT ONLY – TAR Review Process

2. MPQG1011 Non-Physician Medical Practition-ers & Medical As-sistants Practice Guidelines (attachment)

Nadine Harris, Manager of Quality Compliance, discussed the changes to this guidelines. The changes made were in keeping with recent understandings and clarification from DHCS. Page 92-106, the change states it is up to the practice site to determine the timeli-ness of the co-signing by the supervising physician. Under B6, giving more clarification, in terms of a supervising Physician. A physician at any point in time can supervise up to four nurse practitioners that’s only required for NPs with furnishing licenses. Up to four nurse midwives and up to four physician assistants. Deleted unnecessary information.

Approved 8/17/2016

3. MCUG3019 Hear-ing Aid Guidelines (attachment)

Debbie McAllister, Associate Director of UM discussed the changes to this guideline. Page 107-114, we had just revised the policy, however we identified some the numbers were not matching criteria and information was missed. Bringing the policy back with up-dated numbers and information related to the Hearing Aid Guidelines.

Approved 8/17/2016

4. MCUP3014 Emer-gency Services (attachment)

Debbie McAllister, Associate Director of UM, discussed the changes to this guideline. Emergency Services, page 115-128, minor changes made to address language in the pol-icy that was outdated and included information/activity that the UM team currently does not conduct.

Approved

5. MCUP3122 Palliative Care (attachment)

Debbie McAllister, Associate Director of UM, discussed the changes to this guideline. Starting on page 129-134, changes included Hospice service guidelines and provides a de-scription of PHC’s current pilot program. Discussion included bringing the policy back once PHC receive finalized policy guidelines from DHCS.

Approved

8/17/2016

6. MPUP3026 Inter-Rater Reliability Policy (attachment)

Debbie McAllister, Associate Director of UM, discussed the changes to this guideline, pages 135-148. IRR’s are not currently discussed through grand rounds, language was re-moved to reflect. Added incontinence and denied TARs. Annual to Bi-Annual reviews. Sample size for audit changed from ten to five.

Approved with minor changes. Adding back in the review by Medical Director. Section C in the policy.

8/17/2016

7. HEDIS 2016 Summary of Perfor-mance

Rachael French, Manager of Quality Improvement Programs presented our HEDIS 2016 Performance. PHC had 16 measures fall below the Minimum Performance Level; 1 in the Southwest Region, 9 in the Northeast Region and 6 in the Northwest Regions. Plan-wide performance showed a 4% increase from the prior HEDIS reporting year in 2015. Rachael walked through the detailed performance summary that provided Regional and County Level performance in addition to performance compared to HEDIS 2015. An open discus-sion took place focused on the Northern Region Performance. Dr. Bell made a comment to the group that it takes time to improve across a large measurement set. He also shared that years ago our Southern Region Counties sat in a very similar position and the scores today have taken much time and provider commitment to move the needle. Rachael shared performance is publicly reported to our provider network and located on the PHC HEDIS webpage. Rachael shared she will come back in October to present the 2016 DHCS dashboard highlighting PHC’s performance compared to state wide Medicaid re-porting plans.

None

8/17/2016

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8. Cultural & Linguistic Health Education

Susanna Sibilsky, Northern Region Health Educator reviewed that both herself and Betsy Campbell attended a state quarterly meeting in July which was primarily focused on Group Needs Assessment Report, which is a report all plans complete every 5 years. This is the first year the Northern Region is included in the report. One requirement is a mem-ber survey assessing C&L and education needs of our members. We are required to have 400 surveys per reporting region. PHC has met well over 400 completed surveys. A best practice was to start the survey process early and include member incentives through a raffle program. The GNA APL is going under revision and should be effective by 2017. DHCS is still working on revising the language.

None 8/17/2016

9. Tobacco Cessation Monitoring Report

Deferred to September QUAC. Betsy is working on an updated report. Deferred to September QUAC agenda.

8/17/2016

10. Grievance Report w/State Hearing

Dr. Cotter, Associate Medical Director reviewed the grievance report on behalf of the Grievance team. Starting on page 211, the Grievance team has revised the current report to outline the top types of complaints that are coming into the healthplan. Dr. Cotter and Dr. Endsley are working with Dr. Moore on evaluating the appeal review process to in-clude two reviewers to best support getting the member what they need. Current appeal process is improving and we are excited to have a new Director on board focused on im-proving the process moving forward.

8/17/2016

11. PHC Mental Health Oversight

Dr. Karen Stephens highlighted a few slides within her presentation, starting on page 174. Dr. Stephens highlighted a few key areas with in her presentation during the meeting. An update on what our Mental Health Access team has been working on, this team was formed in July of 2015 focused on developing strategies to improve mental health access to outpatient services, now entering its second year of work. The accomplishments for the first year is that there were increase rates in three counties, Humboldt, Solano and Yolo by 10% increase in penetration rate. Increase in the number of counties reaching 6% (bench-mark) went from three of our fourteen counties to six of our fourteen counties. The goal of reaching seven out fourteen was partially met. Fiscal year 16-17 goals include, Increase use rates in three focus counties (Humboldt, Solano and Yolo) an additional 10%. Better understand member barriers to care through surveys and/or focus groups. Improve access to prescriber services in three additional counties. Improve access to care for women with perinatal mood disorder. Dr. Stevens reviewed page 186, representing Penetration rates across all counties compared to prior year and trended penetration rates for priority coun-ties (Humboldt, Solano and Yolo). The data presented represents only those assigned to Beacon. This doesn’t necessarily include members who are receiving mental health ser-vices at Kaiser in five of our fourteen counties. Penetration rate across all fourteen coun-ties are improving. Rates are from 4.8% last year to 5.8% this year. PHC is actively work-ing to improve data accuracy capture from Beacon comparing to PHC claims data. On-go-ing concerns with Beacon reports. PHC will be focused on addressing these type of con-cerns through contracting taking place early 2017.

8/17/2016


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There was no additional business discussed at this meeting.

Respectfully submitted by Rachael French, Manager of Quality Measurement and Improvement Programs Signature of Approval: ____________________________________ Date: ______________________________ Robert Moore, MD, MPH – Chairman

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Committee: INTERNAL QUALITY IMPROVEMENT [IQI] MEETING

Date/Time: August 9, 2016 Tuesday_1:30PM – 3:30PM_Board Room, 3rd Floor

Standing Members Present: Lauck, Cristina, RN, Manager, General Case Management Campbell, Betsy, MPH, Senior Health Educator Chancellor, Jennifer, Regional Manager Cotter, James, MD, MPH, Associate Medical Director Endsley, Scott, MD, Associate Medical Director French, Rachael, Manager of Quality Measurement and Improvement Programs Fronefield, Carly, Director of Health Services, Northern Region Gibboney, Liz, MA, Chief Executive Officer Harris, Nadine, RN, MBA, QI Compliance Manager Hoover, Peggy, RN, Senior Health Services Director Kerlin, Mary, Senior Director, PR

Leung, Stan, Pharm D, Director of Pharmacy Services Netherda, Mark, MD, Regional Medical Director

Scuri, Lynn, Regional Medical Director Sibilsky, Susanna, Northern Region Health Educator

Steffen, Nancy, Northern Region Associate Director of QI, Analytics, and PMO Thacher, Jessica, MPH, Director, Quality and Performance Improvement Vovakes, Michael, MD, Northern Region Medical Director

Standing Members Absent:

Barresi, Katherine, RN, Associate Director of Care Coordination Kubota, Marshall, MD, Regional Medical Director Haynes, Dina, CPHT, Associate Director of Pharmacy Operations (maternity leave) McAllister, Debra, RN, Director of UM Moore, Robert, MD, Chief Medical Officer

Shafer, Debbie, Sr. Director of Member Services Smith, Lyle, Director, Operations Excellence & PMO Layne, Robert, Director, Government and Public Affairs

Guests: Blockman, Tami, QI Project Coordinator II Garcia-Hernandez, Margarita, Manager, Health Analytics Finance Gerdes, Robyn, HEDIS Program Manager Netherda, Mark, MD, Regional Medical Director Rogers, Kendra, Temp QI Administrative Assistant Rosel, Melissa, RN, Utilization Management Team Manager

Turnipseed, Amy, Director of Policy and Program Development Villanueva, Angelica, HS Quality Manager Wilson, Megan, HEDIS Project Manager

Russell, Joan, Manager of Provider Relations Santos, Rose, RN, Manager of Quality Assurance and Patient Safety Stevenson, Laurie, Supervisor of Clinical Quality

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AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION

TARGET DATE

DATE RESOLVED

I. Call to Order and Approval of Minutes

The meeting was called to order by Dr. Cotter chairing the meeting on behalf of Dr. Moore at 1:37 pm. Minutes from the 6/07/2016 IQI meeting were reviewed.

Minutes approved without changes.

8/9/2016

II. Standing Agenda Items (Full Committee)

1. Status of Open Action Items

There was no open action item discussed. No open action items

2. QI Department Update

Jessica Thacher, MPH, Director of Quality and Performance Improvement, provided an update on key activities occurring in the Quality and Performance Improvement department, starting on page 16 of the IQI packet. In preparation for Nadine Harris, RN Manager of Quality Compliance upcoming retirement, the responsibilities for management of both the Internal Quality Improvement and Quality Utilization Management Committees have been transferred over the Rachael French, Manager of Quality Improvement Programs in partnership with our QI department Administrative Assistant. The QI team has 2 new staff members who have started on August, 1st. Rose Santos as our Manager of Quality Assurance and Patient Safety. Rose is assuming most of Nadine’s current duties, including management of the patient safety team, facility site review/medical record review, and the PQ/Peer Review process. Since 2007, Rose has been the Manager of the Survey Readiness Unity within Kaiser’s Health Plan Regulatory Service. We area also excited to welcome Sarah Molteni-Casper as our new HEDIS Analyst. Sara is assuming Sue Lee’s role in the HEDIS project as she transitions into her new role as Senior NCQA Project Manager. Sara comes with a Master’s degree in Healthcare Administration along with five years of experience in project management and data analysis and two years of healthcare experience. Primary Care Quality Improvement Program (PCP QIP) is currently in the measurement year transition period between wrapping up our 15-16 measurement year and the launch of our 16-17 measurement year. Providers have the opportunity to submit supplement data on

None. 8/9/2016

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non-clinical measures until July 31 and on clinical measures (captured in eReports) until August 15th. Measurement year 16-17 is underway and the QIP team hosted two-kick off webinars on July 26th and 27th. Detailed information on the new or changed measures to the upcoming year were introduced in addition to the new Measurement Year transition plan, moving from fiscal year to calendar year measurement and reporting. The QIP program is making a change to the provider level reporting. Reporting will now be required at the site ID level versus the entity level. Dr. Netherda raised a question whether this change would potentially have a financial impact on payment. Jessica Thacher shared it’s possible, as now each site ID is responsible for meeting set targets versus rolling up all scores from the site ID to the entity level. Data will be reported at the individual site ID which provides more values to both the provider and PHC as well as support the work of the Partnership Quality Dashboard. The IT and Finance teams are working closely on module 1 of the Partnership Quality Dashboard project. The current focus is on integrating the PCP QIP non-clinical measures into the dashboard, as well as general design principles for displaying the data effectively. Our next phase is module 2 which will integrate annual HEDIS performance. The goal is to have an internal tool ready by end of fiscal year 16-17 and introduce the tool to the provider network by early 2018. In the QI update portion of the meeting Jess Thacher shared she will not focus much on HEDIS as we have a very detailed presentation on today’s agenda that will address our 2016 HEDIS performance. Jess Thacher shared under Performance Improvement Academy a primary focus has been on our Internal Performance Improvement Training. We are working on developing Performance Improvement skills within the Southern Region QI department. This consists of a didactic instruction on the Model for Improvement based on the Institute for Healthcare Improvement. This training allows hands on application to our three focused improvement projects related to improving HEDIS outcomes in Cervical Cancer Screening, Well Child Visit in the 3rd, 4th, 5th, and 6th years of life and Medication Management for Patients on Persistent Medications. Another training will take place in January. As we refine the training we hope to extend invitations for staff across departments within Health Services. The Southern Region QI team will continue to provide on-going updates on how the internal training is going. HEDIS is a big theme you will start to see for QI and the Organization. We are trying to be more explicit in making HEDIS a strategic priority and emphasis for what we are doing within Quality Improvement, more so than in the past. We are working closely on ways to leverage existing programs and work such as within our ADVANCE program. Steering

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project focus more towards HEDIS. We also have a HEDIS Improvement team focusing on developing a long-range strategic plan to improve HEDIS scores, as well as shorter term strategies to improve performance for measurement years 2016 and 2017. In closing, the Southern Region Quality Improvement team as finalized our 15-16 operational plan. This includes 32 objectives across our major program and project areas. Main priorities for the next fiscal year include improving HEDIS performance among Southern Region providers and strengthening team and operations. Major new work this year includes: NCQA Accreditation, a strategic focus on HEDIS rate improvement and the Partnership Quality Dashboard, the launch of an internal tool to manage facility site review data, and the launch of an internal Performance Improvement training program.

III. Old Business (Committee Members as Applicable)

There was no old business discussed.

IV. New Business (Committee Members as Applicable) 1. Consent

Calendar

The following were on the consent calendar this month: Delegation Reports- Credentialing/Re-credentialing MPCR4 Initial Credentialing Requirements MPCR4A Initial Credentialing Criteria, Application/Attestation, and Monitoring of Sanctions for Behavioral Health Practitioners MPCR5 Review Standards for Credentials, Re-credential Process MPCR7 Re-credentialing Requirements MPCR7A Re-credentialing Criteria, Application/Attestation, and Monitoring of Sanctions for Behavioral Health Practitioners MPCR11A Review of Delegated Credentialing and Re-credentialing Policies MPCR12 Credentialing of Independent Nurses under EPSDT MPCR13B Buphrenorphine Prescriber Credentialing MPCR18 Applied Behavioral Health Provider Credentialing Policy MPCR19 Skilled Nursing Facility Providers (SNFists) Credentialing Policy MPPR200 PHC Provider Contracts MPPR207 PHC Annual Physician Satisfaction Survey MPPR208 PHC Provider Termination or Change in Location Information MPPR-PL-CR201 Credentials Committee Review MPPR-PL-CR701 Re-credentialing Document Collection, Review and Verification and Ongoing Monitoring of Sanctions and Complaints MPPR-PL-CR701 A Re-credentialing Document Collection, Review and Verification and Ongoing Monitoring of Sanctions and Complaints for Behavioral Health Practitioners MPQP1026 OB/GYN Facility Site Review Requirements and Guidelines

Approved Without changes Mary Kerlin notes, PR policies at some point in time will roll over to QI. For now, received approval without changes.

8/9/216

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MP PR-GR210 Provider Grievance Utilization Management , no substantive changes HKCP2015 Continuity of Care (HK Only) HKUP3069 (formerly MPUP) Emergency Services (HK Only) MCCP2014 Continuity of Care (HK Only) MCUG3008 Bathroom Equipment Guidelines MCUG3011 Criteria for Home Health Services MCUP3012 Discharge Planning (Non-capitated Members) MCUP3003 Rehabilitation Guidelines for Acute Skilled Nursing Inpatient Services (previously - Acute Inpatient or Long Term Care Rehabilitation Institution Services) MCUP3133 Wheelchair Mobility, Seating and Positional Components MCUP3041-A ATTACHMENT ONLY - TAR Review Process

2. MPQG1011 Non-Physician Medical Practitioners & Medical Assistants Practice Guidelines

Nadine Harris, Manager of Quality Compliance, discussed the changes to this guidelines. The changes made were in keeping with recent understandings and clarification from DHCS. 7, the change states it is up to the practice site to determine the timeliness of the co-signing by the supervising physician. Under B6, giving more clarification, in terms of a supervising Physician. A physician at any point in time can supervise up to four nurse practitioners that’s only required for NPs with furnishing licenses. Up to four nurse midwives and up to four physician assistants. Deleted unnecessary information.


8/9/2016

3. MCUG3019 Hearing Aid Guidelines

Melissa Rosel, RN Utilization Management Team Manager, discussed the changes to this guideline. Page 164, we had just revised the policy, however we identified some the numbers were not matching criteria and information was missed. Bringing the policy back with updated numbers and information related to the Hearing Aid Guidelines.


8/9/2016

4. MCUP3014 Emergency Services

Melissa Rosel, RN Utilization Management Team Manager, discussed the changes to this guideline. Emergency Services, minor changes made to address language in the policy that was outdated and included information/activity that the UM team currently does not conduct.


8/9/2016

5. MCUP3122 Palliative Care

Melissa Rosel, RN Utilization Management Team Manager, discussed the changes to this guideline. Starting on page 175, changes included Hospice service guidelines and provides a description of PHC’s current pilot program. Page 176, defined PCP and RAF. Discussion included bringing the policy back once PHC receive finalized policy guidelines from DHCS.

Approved with minor grammatical correction

8/9/2016

6. MPUP3026 Inter-Rater Reliability Policy

Melissa Rosel, RN Utilization Management Team Manager, discussed the changes to this guideline. IRR’s are not currently discussed through grand rounds, language was removed to reflect. Added incontinence and denied TARs. Annual to Bi-Annual reviews. Sample size for audit changed from ten to five.


8/9/2016

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7. HEDIS 2016 Summary of Performance

Megan Wilson, HEDIS Project Manager and Robyn Gerdes, HEDIS Program Manager presented our 2016 HEDIS Performance, starting on page 185. PHC had 16 measures fall below the Minimum Performance Level; 1 in the Southwest Region, 9 in the Northeast Region and 6 in the Northwest Regions. The HEDIS team shared plan-wide performance showed a 4% increase from the prior HEDIS reporting year in 2015. Robyn and Megan walked through the detailed performance summary that provided Regional and County Level performance in addition to performance compared to HEDIS 2015. An open discussion took place and the group discussed the location to the detailed summary report which was reported on the PHC HEDIS webpage. Performance is publicly reported to our provider network. Amy brought up that this will be the first year DHCS will include Northeast and Northwest Region in their Quality Aggregate Scoring of all reporting Medicaid plans California. The dashboard will be released by Liz questioned whether the report would be used in the HEDIS Improvement Team workgroup to identify targeted opportunities for improvement. Rachael shared yes, this is one of many sources of data that can be used to support identifying targeted improvement efforts. Liz also shared we should be prepared to share to our Consumers improvement activity conducted by PHC since expanding into the Northeast and Northwest region that has contributed to our improvement from our 2015 reporting year to our 2016 reporting year and what current improvement activity we have in place to support improving reporting year 2017.

None. 8/9/2016

8. Tobacco Cessation Monitoring

Betsy Campbell, Senior Health Educator, reviewed the Tobacco Cessation Report which includes current members with a primary or secondary tobacco/nicotine diagnosis claim or service between, January 31, 2016 and July 31, 2016. Starting on page 210 of the packet, Solano County and Shasta County have the highest rate. Dr. Netherda shared we could educate providers to document tobacco/nicotine use to support gathering more accurate rates.

None. 8/9/2016

9. Cultural & Linguistic Health Education Update

Susanna Sibilsky, Northern Region Health Educator reviewed that both herself and Betsy Campbell attended a state quarterly meeting in July which was primarily focused on Group Needs Assessment Report, Which is a report all plans complete every 5 years. This is the first year the Northern Region is included in the report. One requirement is a member survey assessing C&L and education needs of our members. We are required to have 400 surveys per reporting region. PHC has met well over 400 completed surveys. A best practice was to start the survey process early and include member incentives through a raffle program. The GNA APL is going under revision and should be effective by 2017. DHCS is still working on revising the language.

None. 8/9/2016

10. Grievance

report w/ State Hearing

Dr. Cotter, Associate Medical Director reviewed the grievance report on behalf of the Grievance team. Starting on page 211, the Grievance team has revised the current report to outline the top types of complaints that are coming into the healthplan. Dr. Cotter and Dr. Endsley are working with Dr. Moore on evaluating the appeal review process to include two reviewers to best support getting the member what they need. Current appeal process is improving and we are excited to have a new Director on board focused on improving the process moving forward.

None. 8/9/2016

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11. Site Review Bi-Annual Report

Nadine Harris, RN Manager of Quality Compliance and Lauri Stevenson, RN Northern Region Supervisor of Clinical Quality, reviewed the Facility Site Review compliance report starting on page 213. This report summarized our certified DHCS nurses who go onsite to our primary care provider sites throughout our network and looking at two primary areas; 1) facility component and (2) medical record review. This report represents site visits that have taken place between January 1st and June 30, 2016. Sites must meet DHCS standards which is an 80% score for Facility and 80% for Medical Record. Nadine summarized for Facility Site review, the SE region showed significant improvement seen in Personnel with no significant changes noted in the SE, NE or NW regions. For Medical Record Review, the SE Region saw significant improvement in Pediatric and Adult Preventive Domains, SW Region saw an increase in the Pediatric Preventive domain, NE Region saw a significant decrease in the pediatric and adult preventive screening scores and the NW Region saw improvement noted in Pediatric Preventive, however adult preventive noted a significant decrease.

None.

12. 2015 Delegated audit results for PFMA/SMGR and Bay Children’s

Mary Kerlin, Director of Provider Relations, reviewed the report of Delegation Audit For Credentialing/Re-credentialing Activities for both Sutter Medical Group of the Redwoods (SMRG), Bay Children’s Physician Medical Group and USCF Medical Group. Mary recommended the following:

1. SMRG be approved for continued delegation of Credential/Re-credentialing activities for Physician Foundation Medical Associates/Marin Headlands Medical Group.

2. Physician Foundation Medical Associates (PFMA)/ Marin Headlands Medical Group be approved for continued delegation of Credential/Re-credentialing activities for Physician Foundation Medical Associates/Marin Headlands Medical Group.

3. Bay Children’s Physician Medical Group (BCP) be approved for continued delegation of Credentialing/Re-credentialing activities for BCP

4. UCSF Medical Group be approved for continued delegation of Credentialing/Re-credentialing activities for UCSF Medical Center.

Approved 8/9/2016


There was no additional business discussed.

VI. Adjournment

The meeting was adjourned at 3:30 pm.

Respectfully submitted by Rachael French, Manager Of Quality Measurement and Improvement Programs Signature of Approval: ____________________________________ Date: ______________________________ Robert Moore, MD, MPH, Chairman

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QI Department Update

September 2016

Prepared by Jessica Thacher, Director of Quality and Performance Improvement

Incentive Programs (QIPs)

Primary Care Provider Quality Improvement Program (PCP QIP)

The PCP QIP is transitioning from a fiscal reporting year to a calendar reporting year. o The PCP QIP 2016‐17 will not be impacted and will run between 07/01/2016 to 06/30/2017. o We will then run an abbreviated, six‐month cycle from 07/01/2017 through 12/31/2017.

The abbreviated cycle will use the same measurement set as the 2016‐17 program year with a few minimal changes. We will share the approved measurement set in October.

o In January 2018 PCP QIP will begin running on a calendar year from this point forward. o As part of this transition, all practices will be required to report data at the PCP ID level.

Approximately 30 organization will be impacted by this change. Wrap up 2015‐2016: The grace period for eReports entry for the 2015‐16 measurement year closed

on 8/15. Payment calculations are underway. If applicable, practices will receive site‐specific lists along with detailed instructions on submitting supplemental data on the following two measures: U‐Tox Screens and Follow‐Up Post Discharge.

2016‐2017: We are on target to launch eReports 16‐17 by September 15, 2016. The 2016‐17 eReports Demo Webinar is October 5 from noon‐1:00pm.

MPM Improvement: We will host a plan‐wide webinar on the Annual Monitoring for Patients on Persistent Medications (MPM) measure on October 3rd from noon – 1:00pm. This is a new measure for our Family Practice sites. The webinar is a great opportunity for any practice looking to get a jump start on meeting the 2016‐2017 performance targets for this measure.

Long‐Term Care Quality Improvement Program (LTC QIP)

The measures for the 2017 program year will be brought to the Physician Advisory Committee in September. In the program’s second year, there are no big measurement changes proposed.

Outreach to new LTC QIP participants will begin mid‐September. QI is finalizing the Letter of Agreement. Out of 60 contracted facilities as of March 31, 2016, 50 signed up for the new pay‐for‐performance program. We aim to reach out to the remaining 10, along with facilities that are newly contracted with PHC.

Hospital Quality Improvement Program (HQIP)

Five hospitals have been added to HQIP: Trinity Hospital, Sonoma Valley Hospital, Mayers Memorial, Redwood Memorial, and St. Joseph’s Hospital‐Eureka. In total, we currently have 16 hospitals signed up for the 2016‐17 H‐QIP. We are working with Finance and PR to onboard 5 more hospitals.

The first Hospital QIP Technical workgroup occurred August 31, with representatives from IT, Finance, PR, UM, and Health Services in attendance.

The 2016‐17 Kick‐Off webinar was held on August 17. The team gave an overview of the program and measures.

A CMQCC Maternal Data Center webinar will be held on September 7 to help introduce new hospitals to the submission process for CMQCC.

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HEDIS

Planning is underway for the HEDIS 2017 season. Below is a list of selected vendors: HEDIS Certified Software: Inovalon will serve as our software vendor, returning for a fifth year.

Inovalon is the most widely‐used HEDIS‐certified software in the United States. PHC uses Inovalon’s software to calculate our HEDIS rates and support our Medical Record project.

Medical Record Retrieval: CIOX Health (formerly Enterprise Consulting Solutions, Inc. or ECS), returning for a third HEDIS season, is responsible for medical record retrieval across all 14 counties. CIOX Health has worked with over 18,000 providers nationwide and offers a variety of methods to effectively retrieve HEDIS specific data within our tight HEDIS timeline.

Medical Record Abstraction and Over‐Read: After an extensive RFP process, we are excited to partner with KDJ Consultants for HEDIS 2017 medical record abstraction and over‐read. This is our second year using a medical record abstraction vendor and our first year working with KDJ. KDJ has 20 years of experience with medical record reviews and maintains a large network of highly experienced quality review nurses. KDJ will perform both first and second line abstraction directly into the Inovalon software. PHC will oversee KDJ’s work using a team of returning in‐house temporary nurse reviewers.

Partnership Improvement Academy

ABCs of QI

Our next in‐person ABCs training is Wednesday, October 12th in American Canyon. The event is co‐sponsored by PHC and the California Improvement Network. Advanced Access Collaborative

The first of four Advanced Access Collaborative In‐Person Learning Sessions is September 27 – 28, in Fairfield. In preparation, the 8 participating teams are collecting data on appointment wait time, appointment supply and demand, continuity and patient experience. Team members from two sites (Sutter Lakeside & St. Helena Family Medical Center) were impacted by the recent fire in Lake County. They have done an amazing job handling a difficult situation and getting back to business as usual! Internal Performance Improvement Training/HEDIS Improvement

The SR QI team continues cohort 1 of our internal performance improvement training course. Participating teams are applying the methods they learn to three HEDIS‐related improvement projects in our SR – Annual Monitoring for Patients on Persistent Medications, Cervical Cancer Screening, and Well Child Visits. These are 90‐day projects designed to improve HEDIS 2017 (measurement year 2016) rates. Thus far we’ve covered an introduction to the Model for Improvement, driver diagrams, aim statements, PDSA, and measures. Participants report high satisfaction with the course and are particularly happy with the opportunity to work cross‐functionally with staff from other program areas in the department.

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Improvement Initiatives

Managing Pain Safely (MPS)

On September 22, PHC will partner with the California Healthcare Foundation (CHCF) to host a large multisite conference for CHCF’s Regional Opioid Safety Coalition Network. This all day conference will highlight key issues related to opioid safety, including medication assisted treatment, naloxone, and safe prescribing. This conference will be hosted live in Oakland, with PHC offering five remote locations‐ Fairfield, Santa Rosa, Eureka, Redding, and Dunsmuir. This is a free event, and CMEs and CEs will be available. More information can be found here: https://www.eventbrite.com/e/opioid‐safety‐coalitions‐network‐northern‐california‐fall‐convening‐tickets‐25829068439.

On October 25, from noon‐1pm, the MPS initiative will host “Managing the Monster: Strategies in Managing Opioid and Benzodiazepine Co‐Prescribing”. This webinar will launch the last phase of the MPS initiative, and will discuss key topics related to the co‐prescribing of opioids and benzodiazepines. To register: https://attendee.gotowebinar.com/register/8210921216123819778

In August, MPS hosted a webinar on opioid tapering. Thirty people attended; 63% rated the webinar as “excellent” and 100% rated the webinar as “good” or “excellent”.

The Partnership for Complex Care team is moving into implementation! Earlier this year, the team developed an integrated system to improve care for opioid‐dependent high utilizers under a CHCF planning grant. The team submitted their final plan to CHCF at the end of July and were invited by CHCF to proceed into an implementation grant in August.

Social Determinants of Health

The SDH Implementation and Planning Grantees are busy moving forward on their projects. Below are some updates from select Implementation Grants. The Ukiah Valley Medical Center Street Medicine Program has hosted 9 clinics since April. Total

encounters: 39; unique patient seen: 21. The Petaluma Healthcare District’s Serial Inebriate Program (Sober Circle) has shown great success

thus far. From January‐March 2016 they brought one serial inebriate individual into treatment. During the months of April‐June 2016, they brought 14 serial inebriate individuals into treatment (13 of 14 were PHC members). The number of transports conducted by EMS to Petaluma Valley Hospital ED was reduced from 37 transports in Q1 2016 to 12 transports in Q2 2016, and the number of calls to Petaluma Police Department regarding serial inebriates has reduced from 154 to 28 during the same time period.

North Coast Clinics Network Rx to Wellness Program: NCCN has continued to expand their Rx to Wellness Program (RxWP) over the last quarter. During the months of April‐June they have seen 50 patients by participating providers and care teams to receive RxWP prescriptions. The program also initiated Rx for Famers Market voucher distribution for NCC case management patients and at NCC nutrition sites.

Offering and Honoring Choices

The Partners in Palliative Care (PIPC) pilot evaluation is still underway. The purpose of the evaluation is to develop recommendations to inform DHCS’ implementation of the new palliative care benefit. PHC has contracted with Virginia Commonwealth University to conduct the PIPC Outcome evaluation. A webinar presentation of the preliminary results to key stakeholders will occur on November 10. The final report is due by December 1.

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DHCS anticipates distributing the SB 1004 policy paper on September 9. They anticipate the all‐plan letter will follow 12 weeks after the policy paper is finalized. DHCS will make a small pool of funding available to health plans that want to engage their networks in palliative care training. PHC will continue to fund the Partners in Palliative Care pilot until the benefit is implemented (estimated to begin in January 2017).

As a first step in promoting culture change around Advance Care Planning, PHC is promoting ACP among our own staff. Our 2016‐2017 goal is to increase the percentage of PHC employees who have completed an advance care directive from 18% to 25% by June 30, 2017, as measured by those that respond to the ACP Employee Survey. An internal workgroup is developing specific strategies to support this goal.

PHC kicked off the second End of Life Nursing Education Consortium (ELNEC) cohort in Lake County on August 4‐5. PHC targeted participants from 10 critical access hospitals in Sonoma, Lake, Mendocino, and others from the northeastern region unable to join in May. We were pleased to have 20 people in attendance. Starting in September we will have monthly virtual check‐ins with both cohorts in which the trainers and invited guest speakers will present information on different topics.

Improving Diabetic Retinopathy Screening Rates

EyePACs: Providers participating in the EyePACS project attended a share and learn webinar last month, facilitated by the PHC project team. The topic for the August webinar was screening workflow. Some of the participating clinics are opting to use an ad‐hoc screening model and some are scheduling patients for screening during designated hours when staff can be dedicated to the process.

Screening cost continues to be a challenge for provider sites using PPS. More sustainable solutions are being explored by sites in the Northern Region.

For the Southern Region DHCS Performance Improvement Project (PIP), we have been partnering with Baechtel Creek Medical Clinic to improve the rate of diabetic retinopathy screening. Baechtel Creek is also one of the six clinics to receive a camera as result of our EyePACs program. Through this work, Baechtel has improved their diabetic retinopathy screening rate from 25% (QIP 14‐15) to 80% (QIP 15‐16). The threshold to be in the top 10 percent of Medicaid plans nationally on this measure is 68%. Great work Baechtel Creek Medical Clinic!

Compliance

We are excited to announce that we received zero findings specific to the Quality Improvement Department during our 2015 Annual DHCS audit. In 2014 we received a finding for lack of compliance with DHCS standards for Initial Health Assessment (IHA); PHC is required to ensure the provision of an Initial Health Assessment (IHA) within a 120 days of the member’s enrollment to PHC. Following 2014 audit findings, we worked closely with DHCS to develop a meaningful corrective action plan (CAP) to support improvement in our IHA rates. DHCS recognized the effort PHC has put into addressing the CAP and therefor did not give us any findings for IHA this year. The IHA improvement team continues working closely with our providers to improve IHA rates.

In response to Northern Region HEDIS performance, DHCS and the Northern Region QI leadership had multiple communications in August to define state‐mandated improvement actions for measures with performance below the “minimum performance level” (MPL). The following summary outlines DHCS’ directives to PHC:

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o The NR team is required to partner with our provider network in five new rapid‐cycle improvement efforts (i.e. PDSAs: Plan‐Do‐Study‐Act) to address below MPL performance in the NE and NW regions. A PDSA is required for each of the following measures: Adolescent Immunizations, Cervical Cancer Screening, Childhood Immunization, Timely Prenatal Care, and Timely Postpartum Care. Note, this is one rapid‐cycle improvement project for each measure, not one project for each region with measure performance below MPL.

o PHC is permitted to utilize the on‐going PDSA, led by the FF QI team in the SW region, to demonstrate plan‐wide improvement efforts on the MPM measure. An additional regional PDSA is not required in either the NE or NW.

o PHC is permitted to use the existing PIP (i.e. longer term improvement project mandated last year by DHCS) for Diabetic‐Eye Exam to address performance in this measure plan‐wide. This is being led by the FF QI team out of the SW region. An additional regional PDSA is not required in either the NE or NW for this measure.

o A brief summary of QI activities that have been implemented (Jan. 2016 to Sept. 2016) to improve all measures with below MPL rates in the NE and NW is due to DHCS by 9/15/16.

o PHC is expected to continue the current PIP for Controlling High BP with Open Door‐Eureka (NW), even though both regions saw great improvement in this measure in the 2016 HEDIS season and no regions are below the MPL.

o A PDSA is not require for the Well Child (W34) measure, only a summary of improvement efforts conducted in regions with below MPL performance (i.e. NE and NW).

o The submission frequency for the new PDSAs and W34 improvement summary, cited above, is every 4 months. The first submission requires the Plan with subsequent submissions detailing the Do‐Study‐Act results. Final submissions must include the next test‐of‐change targeted in the project. DHCS prefers the following submission timeline: 9/15/16, 1/15/17, and 5/15/17 but encouraged PHC to propose a staggered submission timeline to ensure we can resource each project effectively and develop meaningful plans to execute with our providers. DHCS warned not to propose any final submission due dates beyond 7/31/17.

o The NR team proposed a staggered timeline to DHCS last week, which was approved last Friday 8/25. The team was able to submit the Plan for Adolescent Immunizations on 8/24, earlier than initially requested, based on improvement efforts we made earlier this year in partnership with Shasta County Public Health. Similarly, we plan to submit the Plan for the Cervical Cancer Screening project early the week of 9/6, based on improvement activities already in process with the northern consortia before the 2016 rates were finalized. DHCS accepted our proposed submission timeline overall with initial submissions spanning from August through November, which still allows PHC to complete final submissions by the end of July 2017.

o The Northern Region team continues to work closely with HANC, NCCN and local collaboratives to engage our providers as partners in improvement opportunities. These opportunities are not only to support state‐mandated projects in the near term but our overall performance improvement strategies. In the past month, we have supported multiple provider‐hosted Well Child ‘Catch‐up’ Days and Immunization Clinics through offering targeted member outreach and guidance in data collection/measurement.

For the month of August QI has a 92% rate of compliance with our QI policies. The two policies currently out of compliance are scheduled for committee review and approval in September, which will move our rate to 100% by September 29th.

The QI team is currently gearing up for the on‐site Kaiser audit taking place on November 8th. We have met with the compliance team and reviewed the audit tool, expectations and timeline of activity.

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PARTNERSHIP HEALTHPLAN OF CALIFORNIA

QUALITY/UTILIZATION ADVISORY COMMITTEE CONSENT CALENDAR

Items on the Consent Calendar have minor or no changes and are recommended by staff for approval.

Page # Utilization Management, no substantive changes MCCP2005 EPSDT Supplemental Shift Nursing Services 24-32 MCUG3022 Incontinence Guidelines 33-39 MCUG3038 Long Term Care Facility Review Guidelines 40-51 MCUP3027 Members with Limited Benefits 52-54 MCUP3034 PCP-To-PCP Transfers & Assignments of New Members to PCP 55-57 MP 350 Weight Management Program 58-60 MPCP2002 California Children Services 61-63 MPUP3035 Preoperative Day Review 64-66 MPCP2006 Coordination of Services for Members with Special Health Care Needs (MSHCNs) and Persons with Developmental Disabilities 67-72 Provider Relations, no substantive changes MPPR201 PCP Availability and Capacity Policy and Procedure 73-74 MPPR202 Monitoring of PHC Specialist Physician Network Availability and Accessibility Policy & Procedure 75-78 MP PR 205 Monitoring of PCP Accessibility of Services Policy and Procedure 79-80 MPPRSA212 Access Standards for Substance Abuse Services 81-82

MPPRSA213 Availability of Substance Abuse Clinicians/Outpatient Facilities 83-85

Quality and Performance Improvement, no substantive changes MPQP1018 Preventive Health Guidelines 86-87

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POLICY / PROCEDURE

Page 1 of 3

Policy/Procedure Number: MCCP2005 (previously CP100205) Lead Department: Health Services

Policy/Procedure Title: EPSDT Supplemental Shift Nursing

Services External Policy

Internal Policy

Original Date: 04/18/2001 Next Review Date: 01/20/201709/21/2017

Last Review Date: 01/20/201609/21/2016

Applies to: Medi-Cal Healthy Kids Employees

Reviewing

Entities:

IQI P & T QUAC

OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT

Approving

Entities:

BOARD COMPLIANCE FINANCE PAC

CEO COO CREDENTIALING DEPT. DIRECTOR/OFFICER

Approval Signature: Robert Moore, MD, MPH Approval Date: 01/20/201609/21/2016

I. RELATED POLICIES: A. MCUP3065 - Early & Periodic Screening, Diagnosis and Treatment (EPSDT) Services

B. CR #12 - Credentialing of Independent Nurses under EPSDT

B.C. MCUP3041 - TAR Review Process

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS: N/A

IV. ATTACHMENTS: A. EPSDT Supplemental Services Review of Request

B. EPSDT Shift Nursing Services – Individual Nurse Agreement

C. EPSDT Shift Nursing Services – Family / Primary Caregiver Agreement

V. PURPOSE: To define Partnership HealthPlan of California’s (PHC’s) responsibility to provide Early and Periodic

Screening, Diagnosis and Treatment (EPSDT) Supplemental Service Benefit for shift nursing to appropriate

members under the age of 21. Under the Federal EPSDT Supplemental Services Program, Federal law

[((Title 42, USC, Section 1396(a)(43) and 1396d(r)] requires that state Medicaid plans provide coverage for

any service that is medically necessary to correct or ameliorate a defect, physical and mental illness, or a

condition for beneficiaries under 21 years of age even if the service or item is not otherwise included in the

state’s Medicaid plan.

VI. POLICY / PROCEDURE:

A. PHC will provide or arrange for health care services under EPSDT Supplemental Services as identified

in Title 22, CCR, Division 3, Subdivision 1, Chapter 3.

1. All requests are subject to current Prior Authorization requirements. The services must be prescribed

by the beneficiary’s primary care physician provider in accordance with EPSDT regulatory requirements for medical necessity, CCR, Title 22, section 51340(e).

B. Requests are authorized through Licensed and Medi-Cal certified home health agencies or individually

enrolled supplemental service providers acting within their scope of practice (registered nurses and/or

vocational/practical nurses). If independent service providers are to be utilized, PHC Health Services

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http://eshare/sites/PoliciesnProcedures/_layouts/15/WopiFrame.aspx?sourcedoc=/sites/PoliciesnProcedures/Care%20Coordination/MCCP2005%20Attachments/MCCP2005-A.docx&action=default

http://eshare/sites/PoliciesnProcedures/_layouts/15/WopiFrame.aspx?sourcedoc=/sites/PoliciesnProcedures/Care%20Coordination/MCCP2005%20Attachments/MCCP2005-B.docx&action=default

http://eshare/sites/PoliciesnProcedures/_layouts/15/WopiFrame.aspx?sourcedoc=/sites/PoliciesnProcedures/Care%20Coordination/MCCP2005%20Attachments/MCCP2005-C.docx&action=default



Services

☒External Policy

☐Internal Policy


Last Review Date: 01/20/201609/21/2016

Applies to: ☒ Medi-Cal ☐ Healthy Kids ☐ Employees

Page 2 of 3

staff must verify that the services are not available through a home health agency. PHC authorizes if,

and only if, services are not available through a licensed agency. The approval is contingent upon the

active participation of the family and/or primary caregiver in the program and appropriate level of an

adequate level, direct patient care to ensure the continued health and safety of the beneficiary.

C. A family member and/or a primary caregiver should be proficient in the tasks necessary to care for the

beneficiary at home to ensure care is not interrupted should an unforeseen event occur. This proficiency

may be satisfied by training as necessary to safely carry out the plan of treatment and by caregiver

providing four or more hours of direct care to the member per week. In keeping with this requirement,

PHC reserves the right to limit skilled care to a maximum of 21 hours/day to enable primary caregiver(s)

to maintain their skills.

D. Beneficiary must have FULL SCOPE Medi-Cal benefits.

E. Respite services are not included in this service.Parent respite is not a benefit of this program.

F. The services must be provided in the home, which has been assessed to be a safe, healthy environment.

G. Treatment Authorization Requests (TARs) and applicable documentation are reviewed by the EPSDT

case manager. PHC Health Services (HS) staff.

H. The total cost of providing services and all other medically necessary Medi-Cal services to the

beneficiary is not greater than the costs incurred in providing medically equivalent services at the

appropriate institutional level of care.

I. The following documentation is required at the time of the request for services is made and/or with

request for a renewal of services:

1. Completed TAR Form

2. Current Nursing Care Plan of Treatment Nursing Plan of Care

3. Home safety assessment

4. Emergency Plan

5. Report(s) of initial assessment

J. Other documentation may be requested to clarify specific issues related to appropriate determination of

care needs, such as:

1. Current History and Physical with full systems review

2. Social Worker Assessment

3. Regional Center Assessment

4. Current Physician Progress Notes

5. A needs assessment completed by an independent nurse consultant

6. Staff timesheets

K. Authorization period for initial requests will be 90 days. Subsequent authorizations will be 180 days, as

appropriate.

L. Independent Services Providers - Additional Requirements:

1. The family/ beneficiary, independent nurses and nurse case manager must read and acknowledge

their understanding of the provision of independent nursing as described in the EPSDT

Supplemental Nursing Services Family/Primary Caregiver Agreement (Attachment B) and the

EPSDT Supplemental Nursing Services Individual Nurse Agreement (Attachment C) prior to PHC’s

approval of services.

2. See credentialing policy if services are requested by an individually enrolled supplemental service

provider not associated with a home health agency. (Policy CR #12 Credentialing of Independent

Nurses under EPSDT)

VII. REFERENCES: A. Title 42 U.S. Code (USC) Sections 1396(a)(43) and 1396d(r)

B. Title 22 California Code of Regulations (CCR) Division 3, Subdivision 1, Chapter 3

C. Title 22 California Code of Regulations (CCR) Section 51340(e)

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Services

☒External Policy

☐Internal Policy


Last Review Date: 01/20/201609/21/2016


Page 3 of 3

VIII. DISTRIBUTION: A. PHC Department Directors

B. PHC Provider Manual

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services

X. REVISION DATES: 04/17/02; 08/20/03; 04/20/05; 01/18/06; 01/16/08; 09/19/12; 01/20/16; 09/21/16

PREVIOUSLY APPLIED TO: N/A

***********************************

In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with

involvement from actively practicing health care providers and meets these provisions:

Consistent with sound clinical principles and processes

Evaluated and updated at least annually

If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be

disclosed to the provider and/or enrollee upon request

The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar

illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered

under PHC.

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ATTACHMENT A

EPSDT SUPPLEMENTAL NURSING SERVICES REVIEW OF REQUEST

Name: CIN #: Diagnosis: Provider: Requested Services: Review: Skilled nursing needs: Subacute: The intensity of medical/skilled nursing care required is such that in the absence of in-home services, the individual would be placed in a pediatric subacute care facility. Pediatric subacute care services are the health care services needed by a person under 21 years of age who uses a medical technology that compensates for the loss of a vital bodily function. Medical necessity for pediatric subacute care services shall be substantiated by any of the following items in (1) through (4) below: 1) A tracheostomy with dependence on mechanical ventilation for a minimum of six hours each day; 2) Dependence on tracheostomy care requiring suctioning at least every six hours, and room air mist or oxygen

as needed, and dependence on one of the four treatment procedures listed in (A) through (E) below: A) Dependence on intermittent suctioning at least every eight hours, and room air mist or oxygen as

needed; B) Dependence on continuous intravenous therapy including administration of therapeutic agents necessary

for hydration or of intravenous pharmaceuticals; or intravenous pharmaceutical administration of more than one agent, via a peripheral or central line, without continuous infusion;

C) Dependence on peritoneal dialysis treatments requiring at least four exchanges every 24 hours; D) Dependence on tube feeding, naso-gastric or gastrostomy tube;

E) Dependence on other medical technologies required continuously, which in the opinion of the attending physician and the Medi-Cal consultant require the services of a professional nurse.

3) Dependence on total parenteral nutrition or other intravenous nutritional support, and dependence on one of the five treatment procedures listed in (2)(A) through (E) above;

4) Dependence on skilled nursing care in the administration of any three of the five treatment procedures listed in (2)(A) through (E) above.

Medical necessity for pediatric subacute skilled nursing care shall be further substantiated by all of the following conditions: 1) The intensity of medical/skilled nursing care required by the patient shall be such that the continuous

availability of a registered nurse in the pediatric subacute unit is medically necessary to meet the patient’s healthcare needs.

2) The patient’s medical condition has stabilized such that the immediate availability of the services of an acute care hospital, including daily physician visits, are not medically necessary.

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of 3

3) The intensity of medical/skilled nursing care required by the patient is such that, in the absence of a facility providing pediatric subacute care services, the only other medically necessary inpatient care appropriate to meet the patient’s health care needs under the Medi-Cal program is in an acute care licensed hospital bed.

Skilled Nursing Facility Services - NF B: The intensity of medical/skilled nursing care required is such that in the absence on in-home services, the individual would be placed in a SNF level B facility. A need for one or more skilled nursing procedures does not necessarily indicate a medical need for skilled shift nursing services. The level of service includes the continuous availability of procedures, which require the presence of a licensed nurse. The following criteria together will assist in determining the NF-B level of care:

1) Dressing or postsurgical wounds, decubiti, leg ulcers, etc. Observation must be needed at frequent intervals throughout the 8-hour shift to warrant in-home shift nursing.

2) Tracheostomy care, nasal catheter maintenance. 3) Indwelling catheter in conjunction with other conditions. 4) Tube feedings. 5) Colostomy care for initial or debilitated patients. The license nurse shall be required to instruct the

family in care. Colostomy care alone should not be a reason for shift skilled nursing. 6) Bladder and bowel training for incontinent patients. 7) The following may require skilled shift nursing services dependent on the severity of the condition:

a) Regular observation of vital signs is indicated by the diagnosis or medication and ordered by the attending physician.

b) Regular observation of skin for abnormal conditions. c) Careful I&O is indicated by diagnosis or medication and ordered by the attending physician.

8) The patient needs medications, which requires skilled nursing for administration. a) Injections. If this is the sole reason for skilled shift nursing, other therapeutic approaches or

teaching of the family should be considered. b) PRN medications dependent on the nature of the drug, the treated condition and frequency of

need as documented. c) Use of restricted or dangerous drugs if required more than during daytime, requiring close

nursing supervision. d) Use of new medication requiring close observation during the initial stabilization dependent

upon the circumstances. Intermediate Care Facility / Developmentally Disabled Nursing – ICF/DDN: The intensity of medical/skilled nursing care required is such that in the absence of in-home services, the individual would be placed in an ICF/DDN facility. In determining this level of skilled shift nursing a regional center must have diagnosed the child as developmentally disabled or has determined that the child demonstrates significant developmental delay that may lead to a developmental disability if not treated. The stability of the member’s medical condition and frequency of skilled nursing services shall be the determining factors in evaluating the appropriateness for this level of care. The following criteria together will be used to determine the appropriate level of care: 1) The child shall have two or more developmental deficits in any one or combination of the following three

domains: a) Self-help domain-eating, toileting, bladder control, dressing b) Motor domain-ambulation, crawling and standing, wheelchair mobility, and rolling and sitting c) Social emotional domain-aggression (has had one or more violent episodes causing minor physical injury

within the past year or has resorted to verbal abuse and threats but has not caused physical injury within the past year), self-injurious behavior which results only in minor injuries requiring first aide, smearing feces once a week or more but less than once a day, destruction of property, running or wandering away, temper tantrums or emotional outbursts, or unacceptable social behavior where positive social participation is impossible without close supervision or redirection.

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of 3

2) In addition to the above, the individual must have need for active treatment and intermittent skilled nursing services such as:

a) Apnea monitoring b) Colostomy care c) Tube feeding d) Tracheostomy care and suctioning e) Oxygen therapy f) Intermittent positive-pressure breathing g) Intermittent Licensed nurse evaluation h) Catheterization i) Wound irrigation and dressing j) Needs special feeding assistance k) Needs repositioning to avoid breakdown leading to decubitus ulcers and contractions Intermediate Care Facility / Developmentally Disabled Habilitative – ICF/DDH: The intensity of medical/skilled nursing care required is such that in the absence of in-home services, the individual would be placed in an ICF/DDH facility. In determining this level of skilled shift nursing a regional center must have diagnosed the child as developmentally disabled or has determined that the child demonstrates significant developmental delay that may lead to a developmental disability if not treated. The stability of the member’s medical condition and frequency of skilled nursing services shall be the determining factors in evaluating the appropriateness for this level of care. The individual must have active treatment and intermittent predictable skilled nursing. Individuals who require skilled nursing procedures on an “as needed basis” are not a candidate for placement in an ICF-DDH. The following criteria together will be used to determine the appropriate level of care: 1) The child shall have two or more developmental deficits in any one or combination of the following two domains:

a) Self-help domain-eating, toileting, bladder control, dressing b) Social emotional domain-aggression (has had one or more violent episodes causing minor physical injury within

the past year of has resorted to verbal abuse and threats but has not caused physical injury within the past year), self injurious behavior which results only in minor injuries requiring first aide, smearing feces once a week or more but less than once a day, destruction of property, running or wandering away, temper tantrums or emotional outburst, or unacceptable social behavior where positive social participation is impossible without close supervision or redirection

***************************************************** Recommendation: Level: Hours approved

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ATTACHMENT B

EPSDT Supplemental Nursing Services

Individual Nurse Agreement

The individual nurse provider(s) has been informed prior to enrolling as an EPSDT Supplemental Service Provider of the following items prior to receiving the packet for enrollment so that he/she may determine whether or not they want to follow through with the process: A. The nurse provider must possess the knowledge and abilities related to the overall care of the beneficiary

including use of specialized equipment such as ventilators, phrenic nerve pacers, CPAP, Bi-PAP, etc. PHC has no jurisdiction in the area of qualifications of the nurse, however an EPSDT nursing supplemental service provider must be licensed and practice accordingly under his/her nurse practice act Currently no other requirements exist in this area (Business and Professional Code, Division 2, Chapter 6, Section 2732.05).

B. The nurse is responsible for the development and periodic updates of the Plan of Treatment (POT). This is a nursing responsibility since the contents serve as the orders for the nursing care to be rendered and should be beneficiary specific. CCR, Title 22, Sections 51337, 74697 and 74701 provides specific information that is to be included on the POT and the receipt of orders for treatments and medications.

C. There should be a home evaluation for safety, which addresses adequate space for beneficiary and equipment; pest infestations, refuse collection, adequacy of utilities and emergency equipment as warranted.

D. The identified nurses for each case have the responsibility for providing the required documentation to PHC for initial and subsequent authorization of services requested (TARs), and to Provider Enrollment to process the EPSDT Supplemental Services provider number. The nurse is responsible for submission of ongoing, periodic submission of TARs as determined by PHC for nursing services rendered and a time lag may be experienced in the reimbursement process.

E. The use of a RN hired by the family to work on the case as a coordinator is a beneficiary’s/family’s choice. The coordinator is not the supervisor since the nurses are not in his/her employ. Because of this, the coordinator does not have the ability to discipline the nurse in question. This identified RN would be similar in nature to a supervising nurse of a HHA and would be paid by Medi-Cal under the same conditions. Any suspicious or negligent activity on behalf of any nurse(s) on the case should be reported to the appropriate nursing board. The identification of a RN coordinator is not a PHC requirement nor is it prohibited by regulation.

F. For RNs acting as a coordinator, their responsibilities primarily involve reviewing the overall case, assessing the beneficiary and his/her response to the POT, identification of problems with a plan for resolution, follow-up and coordinating the care provided. This information is to be provided to the PHC Health Services (HS) staff Special Programs Liaison in a written report for each visit made to the beneficiary.

G. The coordinator with multiple nurses on the case needs to make sure that he/she is not acting like a home health agency, which is against the law, since he/she is not licensed as such.

H. PHC’s Role – PHC staff may make home visits to evaluate the overall home nursing program but issues with staffing or quality of care will be the responsibility of the physician and /or the family. The PHC Health Services (HS) staff staff person assigned to the case will carefully review the POT, with assistance from the Health Services Director or the Chief Medical Officer and request modifications as warranted.

I. I have read, understand and agree to the above: Signature: __________________________________________________________ Individual Nurse Provider __________________________________________________________ Print Name

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Date: __________________________

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ATTACHMENT C

EPSDT Supplemental Nursing Services

Family / Primary Caregiver Agreement

A. Issues related to the care provided by nurses are to be handled by the family/caregiver and/or

the appropriate nursing board depending upon the nature and severity of the issue.

B. There is no requirement or mechanism to enforce or ensure that nurses have proper credentials

related to CPR certification or malpractice insurance and if they are in place or maintained.

C. Issues related to staffing and or quality of care will be the responsibility of the family.

Partnership HealthPlan of California’s (PHC’s) PHC Health Services (HS) staff EPSDT Case

Manager will review the treatment plan in place and may ask for modifications as indicated.

D. The use of a RN hired by the family/primary caregiver to work on the case as the “coordinator”

is the family’s choice. This individual IS NOT the supervisor since nurses are not employees

of this individual. Any suspicious or negligent activity on behalf of any nurse(s) on the case

should be reported to the appropriate nursing board and the physician on the case.

E. For RN(s) acting as “coordinator”, responsibilities primarily involve review of the case,

assessment of beneficiary and response to the Plan of Treatment, identification of problems

with plan for resolution, follow-up and coordination of care provided. This information is to be

documented in a written report for each visit made and forwarded to PHC’s EPSDT

Supplemental Service Case Manager Health Services (HS) staff member.

F. Nurses are to be identified and recruited by the family/primary care giver(s). They may want to

evaluate the nurse’s experience in the care needs of the beneficiary and use of any equipment in

the home.

G. I have read, understand and agree to the above:

Signature: ______________________________________________

Family Primary Care Giver

______________________________________________

Print Name

Date: ______________________

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GUIDELINE / PROCEDURE

Page 1 of 3

Guideline/Procedure Number: MCUG3022 (previously

UG100322) Lead Department: Health Services

Guideline/Procedure Title: Incontinence Guidelines External Policy

Internal Policy


Last Review Date: 01/20/201609/21/2016


Reviewing

Entities:

IQI P & T QUAC


Approving

Entities:




I. RELATED POLICIES: A. MCUP3041 - TAR Review Process

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS: A. N/A

IV. ATTACHMENTS:

A. PHC Maximum/ Average Benefit Guidelines

B. PHC Incontinence Questionnaire

C. Incontinence Supplies Prescription Form

V. PURPOSE:

Incontinence supplies are a Medi-Cal benefit that must be prescribed by the physician who currently is

responsible for the care of the member and has evaluated the member's urinary incontinence within the past

year. All members with a diagnosis of incontinence should be evaluated by the current physician to

determine whether consultation with an urologist is indicated.

VI. GUIDELINE / PROCEDURE: A. TREATMENT AUTHORIZATION REQUEST (TAR) PROCESS

1. The TAR must contain documentation regarding the member's history of incontinence, along with

information regarding the medical necessity for the supplies ordered.

2. A copy of the completed Incontinence Supplies Prescription Form must accompany the TAR, which

includes the following:

a. Medical condition / diagnosis causing bowel and bladder incontinence

b. Type of urinary / bowel incontinence

c. Evaluation and treatments attempted and outcomes (including urologist assessment or reports)

d. Documentation of the reasons why other options (pharmacologic, drugs, behavioral techniques

or surgical interventions) are not appropriate to decrease or eliminate incontinence

e. Prognosis for controlling incontinence

f. Brief summary of the incontinence therapeutic intervention plan

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Guideline/Procedure Title: Incontinence Guidelines ☒External Policy

☐Internal Policy


Last Review Date: 01/20/201609/21/2016


Page 2 of 3

g. Explanation if physician orders supplies in excess of the thresholds listed below and information

regarding medical necessity for the additional use

h. All wash and creams requests need documented history of skin breakdown

i. The requested item must be the lowest cost item to meet the member’s medical needs

The request will be reviewed by the Utilization Management (UM) staff in consultation with the

prescribing physician.

3. The UM staff will contact the member or caregiver either by phone or letter to verify usage of

incontinence supplies and will complete the form UM-59 (PHC Incontinence Supplies

Questionnaire).

4. If the member has chronic non-treatable incontinence as confirmed by the primary care provider or

an urologist, the TAR can be approved up to one (1) year.

5. If the approval is granted for an interval GREATER than 30 days, the provider of service has the

responsibility to verify that the member remains eligible with Partnership HealthPlan of California

(PHC) on a monthly basis and in NO instance will PHC reimburse for supplies in excess of a 60 day

supply dispensed at any one time. (EXAMPLE: PHC approves for the supplies for a ONE YEAR

time frame, then provider will NOT be reimbursed for the entire year at one time. Billings are to

occur on a monthly basis as the member’s eligibility status may change.)

6. The following documentation will be batched and kept on site at PHC for a one year period of time,

after which it will be sent to off-site storage to comply with the record retention policy.

a. PHC Incontinence Supplies Questionnaire

b. Completed Incontinence Supplies Prescription Form

c. Copy of TAR

The information will be reviewed and updated when a new TAR is submitted.

7. Incontinence supplies such as diapers, liners, chux, etc. over $125 per month (including sales tax)

require a TAR. All creams and washes require a TAR regardless of the cost.

8. Incontinence supplies under $125 per month DO NOT require a TAR but a copy of the Prescription

must accompany the claim.

B. Incontinence supplies for members in a skilled nursing facility (SNF) and Intermediate Care Facility

(ICF)/Developmentally Disabled (DD) or ICF are part of the facility per diem rate and are not billable

separately to PHC. Incontinence supplies for members in ICF/DD- Habilitative (H) or ICF/DD- Nursing

(N) are not part of the facility per diem and are separately billable to PHC. Incontinence supplies for

members in ICF/DD-H or ICF/DD-N can be approved for up to one (1) year. The same requirements as

per A5 apply.

C. Incontinence supplies for patients under age five must be requested as Early & Periodic Screening,

Diagnosis and Treatment (EPSDT) Services.

D. The Incontinence Prescription must be dated within 12 months of the date of service on the claim and

must be signed by the member's current physician.

VII. REFERENCES: A. Medi-Cal Guidelines - Incontinence Supplies

B. Kaiser Incontinence Supplies Guidelines

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Guideline/Procedure Title: Incontinence Guidelines ☒External Policy

☐Internal Policy


Last Review Date: 01/20/201609/21/2016


Page 3 of 3

VIII. DISTRIBUTION: A. PHC Departmental Directors



X. REVISION DATES: 01/01/96; 04/28/00; 06/20/01; 04/21/04; 02/16/05; 03/15/06; 08/20/08; 11/18/09;

07/21/10; 06/20/12; 08/20/14; 01/20/16; 09/21/16

***********************************








illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits

covered under PHC.

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MCUG3022 ATTACHMENT A Partnership HealthPlan of California

4665 Business Center Drive Fairfield, California 94534

PHC MAXIMUM/AVERAGE BENEFIT- INCONTINENCE GUIDELINES

Page 1 of 2

DESCRIPTION OF PRODUCTS HCPCS MCL QTY

Disposable Diapers: Youth T4533 200/Month Small T4521 200/Month Medium T4522 192/Month Regular T4522 192/Month Large T4523 216/Month Extra Large and XXL T4524 192/Month Bariatric XXXL T4543 TAR

Children's Diapers / Pull-Ups:

Pediatric Diaper Small/Medium T4529 TAR Pediatric Diaper Large T4530 TAR Pediatric Pull-Up Small/Medium T4531 TAR Pediatric Pull-Up Large T4532 TAR Youth Sized Pull-Up T4534 TAR

Disposable Protective Underwear:

Adult Small T4525 120/Month Adult Medium T4526 120/Month Adult Large T4527 120/Month Adult Extra Large and XXL T4528 120/Month Adult Bariatric XXXL T4544 TAR

Liners/Pads/Undergarments:

Disposable Liners T4535 180/Month Disposable Pads T4535 180/Month Beltless Undergarments T4535 180/Month Belted Undergarments T4535 180/Month

Note: Specific qty. limits apply to each product type. Liners, pads & undergarments may be mixed and matched as long as no single product type exceeds 180 units AND the combined total does not exceed 300 units, without a TAR

Disposable Underpads:

Large Underpad T4541 120/Month Small Underpad T4542 120/Month

Incontinent Reusable Pants: T4536 2/Month Reusable Waterproof Sheeting: T4537 2/Year Cont’d

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MCUG3022 ATTACHMENT A Partnership HealthPlan of California


PHC MAXIMUM/AVERAGE BENEFIT- INCONTINENCE GUIDELINES

Page 2 of 2

Incontinence Skin Care: Skin Cream A6250 540 gm/Month Skin Wash A4335 960 ml/Month

Note: Approved only with documented history of skin breakdown. Enter in the system in cc’s (8 oz. tube = 270 cc)

Gloves:

Non-Sterile Gloves A4927 200/Month Note: These are not routinely approved, and there must be a clear need for the item. Diagnosis of quad/paraplegia, AIDS, hepatitis, etc., is considered appropriate reasons for gloves. We will also consider approval if the caregiver of an adult is not a family member.

Kimberly Products are not a Medi-Cal Benefit

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ATTACHMENT B Partnership HealthPlan of California


Page 1 of 1

Name: Phone No: Address: Date Phoned: Date Mailed: TAR/Batch No:

Dear Member or Caregiver, A request for incontinence supplies was received from: ______________________________. Partnership HealthPlan of California would like to provide you with the best possible service. This letter is to obtain an accurate count of the supplies you use. Please answer the following questions as accurately as possible to enable us to better serve you. Please fill in the blanks and check mark the boxes. Do you use the following items? If so, please give us the amounts. YES NO PRODUCT TYPE FILL IN

AMOUNTS USED CHECK HOW OFTEN

PER….

Diapers, Briefs 24 hours week month Undergarments (Like Kotex) 24 hours week month Liners (used inside diaper or

brief) 24 hours week month

Shields (smaller panty liners) 24 hours week month Pants (rubber pants) 24 hours week month Tuckables, Underpads

(i.e., chux, disposable pad to protect mattress/chair)

24 hours week month

Waterproof Sheets, Mattress Cover

24 hours week month

Gloves 24 hours week month Periwash* 24 hours week month Cream* 24 hours week month Other 24 hours week month

*Creams and washes require documented history of skin breakdown from your physician. YOUR REQUEST FOR SUPPLIES CANNOT BE AUTHORIZED UNTIL THIS QUESTIONNAIRE IS RETURNED TO PARTNERSHIP HEALTHPLAN. Please sign, date and return as soon as possible in the enclosed postage-paid envelope. Thank you

Signature: ___________________________________________ Date: __________________ Please Check: Member / Caregiver

Caregiver’s Relationship to Member: ___________________________________________________ Telephone intake: _________________________________________________________________

Signature & Title of PHC Staff Collecting Information

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ATTACHMENT C Partnership HealthPlan of California


Page 1 of 1

Recipient Name:______________________________________Date of Birth: ______________ Age: ____ Member ID#: _____________

Recipient Residence: ____________________________________________________________________________________

Home B&C ICF/DD-H ICF/DD-N Other _________________________________________________

Provider Contact: _______________________________________________________________ Tel#: __________________

Recipient is incontinence of: Bowel Bladder

*Medical Condition/Diagnosis causing B & B Incontinence:_____________________________________________________

______________________________________________________________________________________________________

*Type of urinary incontinence: overflow stress Urge Mixed Functional *Type of bowel incontinence: Nervous system pathology Functional (i.e., chronic constipation) *Describe any previous evaluation and treatments attempted and outcomes. Document reasons why other treatment options (pharmacologic, drug, behavioral techniques or surgical intervention) are not appropriate to decrease or eliminate incontinence:

______________________________________________________________________________________________________

Prognosis for controlling incontinence: _____________________________________________________________________

*Brief Summary of incontinence therapeutic intervention plan: __________________________________________________

*Document need for and usage of multiple absorbent products and garments. Explain need if multiple types of incontinence supplies: ______________________________________________________________________________________________

Type of bowel incontinence

Product Type Daily Usage Monthly Usage Diapers/Briefs Undergarments (Like Kotex) Liners (used inside diaper or a brief) Shields (smaller panty liners) Pants (rubber pants) Tuckable (i.e., chux) Underpads (i.e., chux) Waterproof sheets Mattress cover Gloves Periwash (require documented history of skin breakdown) Cream (require documented history of skin breakdown)

Prescription valid for : ________ months. Prescribing Physician’s Verification (Physician Use Only)

I have reviewed my patient’s medical records and the items requested above. I verify that I have physically examined the patient within the last 12 month and have established that this patient has a chronic pathologic condition which is causally related to his/her incontinence and that other treatment options are not appropriate to decrease or eliminate incontinence. I have prescribed the items described above which I have determined to be medically necessary for this patient. I will maintain a copy of this prescription in the recipient’s medical record to meet Medi-Cal documentation requirements.

I further authorize the provision of listed and generically equivalent incontinence products for this patient should the requested item not be listed on the incontinence Medical Supply list. YES NO.

Physician’s Name and Address (please print or type) _____________________________________________________

Physician’s Telephone No.: __________________________ Physician’s medical Number: _____________________

Physician’s Signature: _______________________________________________ Date: _________________________

Incontinence Supplies Prescription Form

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Page 1 of 8



Guideline/Procedure Title: Long Term Care Facility Review

Guidelines

☒External Policy

☐ Internal Policy


Last Review Date: 01/20/201609/21/2016


Reviewing

Entities:

☒ IQI ☐ P & T ☒ QUAC

☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving

Entities:

☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ PAC

☐ CEO ☐ COO ☐ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER


I. RELATED POLICIES:

A. MCUP3041 - TAR Review Process

B. MCUP3051 - Long Term Care SSI Regulation

C. MCUG3058 - Utilization Review ICF/DD, ICF/DD-H, ICF/DD-N Facilities

D. MCCP2016 - Transportation Guidelines for Non-Medical (NMT) and Non-Emergency Medical

Transportation (NEMT)

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

N/A

IV. ATTACHMENTS:

A. BedHold / TAR Process After Acute Hospitalization Flowchart

B. Admissions for Short Term Rehabilitation or Short Term Skilled Nursing

C. Skilled Nursing Facility Transition of Care Summary

V. PURPOSE: To delineate the medically necessary criteria for admission and continuing care in Long Term Care facilities

(LTCs) for Partnership HealthPlan of California (PHC) members.

VI. GUIDELINE / PROCEDURE:

A. Overview

1. Skilled level nursing care is a covered level of care for PHC’s members. Usually this level of care

follows hospitalization at an acute care facility during the acute rehabilitation stage of treatment for

an illness or injury. Coverage does not include chronic, custodial care or institutional care not

requiring skilled nursing services.

2. Title 22 Medi-Cal guidelines are used to determine the medical necessity for continued placement in a long term care facility. If care can be delivered at a lower acuity level, an alternative setting will

be approved / recommended.

3. Admission to skilled nursing facilities must be coordinated in a contracted, licensed nursing home

by the discharge planners at the acute care facility, by the attending physician, and/or by the LTC

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Guidelines

☒ External Policy

☐ Internal Policy


Last Review Date: 01/20/1609/21/2016


Page 2 of 8

Nurse Coordinator. If the member is not currently confined, or the hospital discharge planner is

unavailable, the PHC LTC Nurse Coordinator is the appropriate contact for referral to a skilled

nursing level facility. 4. The attending physician should also be aware that a history and physical are needed by the skilled

nursing facility that is accepting the member. Orders are generally accepted over the telephone for

an immediate placement and a written history and physical must then be completed and sent to the

accepting facility.

5. The choice of a nursing home for a patient is a decision that should include consideration of the

following:

a. If the facility is contracted with PHC

b. If the attending physician is on staff at the facility

c. If there are beds available

d. The relative cost of those beds

e. If more than one choice is available, the family’s choice of facility

f. Benefit limitations.

6. NOTE - Long Term Care fFacility (LTC) means a licensed institution (other than a hospital) which

meets all of the following requirements:

a. It must be qualified as a LTC and as a provider of services under Medicare;

b. It must maintain on the premises all facilities necessary for medical care and treatment;

c. It must provide such services under the supervision of physicians;

d. It must provide services given by or supervised by a registered nurse; and

e. It must keep medical records an all patients

B. Classification Categories

1. Subacute Care

a. The member requires subacute care, which is more intense than skilled nursing care but less

intense than acute hospitalization. Members at this level of care either can be short term, where

there is potential for the member eventually being transferred to a lower level of care;, or long

term, when there is no potential for improvement in their medical condition. Treatment

Authorization Requests (TARs) for these members are authorized for time intervals based on the

characteristics of the member's medical condition.

2. Short Term Care

a. The member may need a short term stay for a skilled nursing care need or short term rehab

services and expected to return to his/her previous living arrangement or alternate level of care.

3. Long Term Care

a. The member has been reviewed, assessed and determined that discharge potential is not possible

and placement is assumed to be lifelong. TARs for these members may be authorized for up to

two years.

C. Admission

1. Acute Care to Long Term Care Facility

a. The transfer must be coordinated by the hospital discharge planner or case worker to PHC

inpatient concurrent review nurse prior to admission to the sSkilled facility. The hospital

discharge planner or case worker will notify the PHC inpatient concurrent review nurse when

the member needs to be transferred to a LTC facility.

b. The PHC inpatient concurrent review nurse will discuss the case with the PHC LTC Nurse

Coordinator. If the transfer meets the PHC guidelines, verbal approval is given for admission to

the skilled nursing facility.

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Guidelines

☒ External Policy

☐ Internal Policy


Last Review Date: 01/20/1609/21/2016


Page 3 of 8

c. If a member is capped to a hospital, the discharge planner at the hospital will directly notify the

PHC LTC Nurse Coordinator to initiate a referral to a skilled facility.

2. Admission from Home to Long Term Care Facility

a. A LTC facility is required to notify PHC before any elective admission. Prior authorization is

required for all elective admissions from home.

b. The following information must be submitted with the prior authorization request via TAR:

1) Primary Care Physician’s Provider’s (PCP’s) orders indicating the services needed that

require confinement in a long term care facility and the physician’s certification that

placement in the long term care facility is the appropriate level of care for the member.

2) If placement follows an acute hospital stay within the past 30 days, please submit the

hospital history and physical and discharge summary.

3) If the member has not been confined in an acute care hospital within the past 30 days,

please submit the Primary Care Physician’s Provider’s progress notes for the past six (6)

months.

c. Please Note: If the admission from home occurs without prior approval from PHC and the

member’s condition and services do not meet criteria, PHC will issue a denial to the facility.

3. Routine LTC Admission

a. Routine admissions to a LTC facility must be reported to LTC Nurse Coordinator weekly by

using bed hold and change of status form.

b. For members who are retroactively assigned or have other health care coverage (exception –

Medicare, see Section H of guideline), the provider has 60 days from either the date PHC is

notified that the member is eligible (confirmation available via PHC eEligibility), or if other

insurance, 60 days from the denial determination from the primary carrier.

4. Admissions on Weekends and Outside normal business hours

a. For weekend and outside normal business hours, LTC admission will be reported via weekly

bed hold and change status form report.

b. The PHC LTC Nurse Coordinator reviews the TAR for the medical necessity of the member’s

admission and if appropriate, determines length of stay.

5. Transfer to an Acute Care Facility

a. The transfer of a member to an acute care facility must be reported through bed hold and change

of status report form weekly. When appropriate, the PHC LTC Nurse Coordinator places the

member in a “bed hold” status for up to 7 days.

b. The LTC facility must notify PHC when the member is readmitted to the LTC facility. Claims

will not be paid if the readmission is not appropriately reported to PHC.

6. Discharge or Death

a. All discharges or deaths must be reported on a weekly basis by using bed hold and change of

status report form.

b. Notification of a member's death should include whether the death occurred within the LTC or

in an acute care facility.

7. Kaiser Capitated Members

a. LTC facility fees for member’s capitated to Kaiser are Kaiser’s financial responsibility for the

month of admission and the month immediately following the admission. Services after that

time period are PHC’s responsibility.

b. Disenrollment from Kaiser must be requested prior to the end of the second month of financial

responsibility. At that time, the LTC facility must submit a completed TAR with the required

medical documentation. PHC will review the case to determine if continued authorization is

medically indicated. .

8. Medicare/Medi-Cal Members

a. Members with both Medi-Cal and Medicare coverage become the financial responsibility of

42 of 25242 of 252




Guidelines

☒ External Policy

☐ Internal Policy


Last Review Date: 01/20/1609/21/2016


Page 4 of 8

PHC when the member has exhausted his/her Medicare LTC benefit. b. The LTC facility must submit Medicare denial letter when Medicare benefit or non-coverage of

services to PHC along with completed TAR along with required medical documentation for

review. PHC’s HSC LTC Nurse Coordinator reviews the case to determine the medical

necessity of continued authorization.

c. Note: PHC follows Title 22 criteria for admission and continuing care for LTCs. The

Utilization Management (UM) nurses utilize checklists to determine medical necessity of care in

LTCs. (See Attachment A)

D. Denials

1. Cases determined to not meet LTC guidelines based on Title 22 Medi-Cal Guidelines and the

information available at the time of review, are managed as follows:

a. If the LTC Nurse Coordinator has concerns regarding a case, the case is discussed with the

appropriate facility representative to determine if there is any additional pertinent information

available.

b. The LTC Nurse Coordinator contacts the attending physician to discuss concerns regarding

patient's acuity, treatment plan or length of stay (LOS), or to obtain any additional pertinent

information that might assist with the level of care determination.

c. Denial determinations are made only by the PHC Chief Medical Officer or Physician Designee.

E. Monitoring and Review

1. The LTC Nurse Coordinator reviews each member’s case for quality of care issues according to

PHC's quality improvement guidelines. Any areas of concern are reported to the Quality

Improvement (QI) Coordinator. The LTC Nurse Coordinator also assists the QI Coordinator with

data collection for QI focused studies.

F. TAR Submission Requirement:

The authorization request shall be initiated by the facility with all required attachments

*TAR should be submitted within 15 business days from the date of service

1. Initial TAR

a. Completes new TAR form.

b. MC171 (Medi-Cal Long Term Facility Admission Discharge notification)

c. Medicare or other Insurance denial letter (if applicable).

d. MDS (Minimum Data Set)

2. Re-Auth TAR

a. New completed TAR

b. Current MDS (or most recent quarterly MDS)

c. Social Services notes and evaluation

3. Retro TAR

a. New completed TAR

b. MC171 (Medi-Cal LTC Facility Admission and Discharge Notification form)

c. PASSR (Preadmission Screening and Resident Review Medicaid form)

d. MDS

e. Medicare or other health coverage denial letter (as applicable)

f. Social Services notes and evaluation

*Note: TAR must be submitted within 60 days from the date that the member established eligibility

with PHC

4. Bedhold TAR: (When a member is transferred to acute hospital)

a. Doctor’s order

b. Completed new TAR

*Maximum bed hold is 7 days

*When member returns to facility on the 8th day current TAR is still valid.

43 of 25243 of 252




Guidelines

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☐ Internal Policy


Last Review Date: 01/20/1609/21/2016


Page 5 of 8

*If a PHC member returns to a Long Term Care fFacility after 8 days, a new TAR and all required

attachments must be submitted (see VI.F.1. TAR Submission Requirements, Initial TAR).

5. Short Term TAR:

*Less than 90 days in a LTC

a. Doctor’s order

b. Completed new TAR

c. Medicare or other health coverage denial letter (as applicable)

d. Eligibility: No Other Insurance

6. TAR Renewal

a. Members in Long Term Care and Skilled Nursing Care/Intermediate Care fFacility must submit

TAR renewal within specified timeliness guidelines.

b. Renewal of a TAR for a member with a long term admission must occur at least two weeks prior

to the expiration of the current TAR.

c. For members confined in a LTC, the facility must submit a new completed TAR, a copy of the

current Minimum Data Set, and copy of the old tar.

d. The LTC Nurse Coordinator reviews the case for medical necessity, if appropriate, approves the

TAR for up to 2 years.

*Please note – TAR Renewals are subject to the same timeline requirements as initial TARs.

**NOTE** PHC reserves the right to modify a request – it is the facility’s responsibility to check what

was requested against what PHC has approved.**

G. Criteria for Closing and Cancelling Existing TAR

PHC staff will end a currently existing valid TAR in the system under the following circumstances.

1. Certification date expired

2. Members death

3. Exhausted 7 day bedhold

4. Discharge to Medicare, HMO or other insurance bed

5. Discharge to hospice care

6. Discharged to home or transfer to other LTC facility

H. Other Policies

1. Facility Therapy Services

Federal Law states that “each resident must receive, and the facility must provide, the necessary care

and services to attain or maintain the highest practicable physical, mental and psychological well-

being, in accordance with the comprehensive assessment and plan of care.” In many cases, however,

these therapy services can and should be performed as part of the nursing facility inclusive services

(covered under the facility’s per diem rate) and, therefore, are not separately reimbursable.

a. Therapy services provide to the recipient that are covered by the per diem rate include, but are

not limited to:

1) Keeping recipients active and out of bed for reasonable periods of time, except when

contraindicated by a physician’s order

2) Supportive and restorative nursing and personal care needed to maintain maximum

functioning of the recipient 3) Care to prevent formation and progression of decubiti, contractures and deformities,

including:

a) Changing position of bedfast and chairfast recipients

b) Encouraging and assisting in self-care and activities of daily living

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☐ Internal Policy


Last Review Date: 01/20/1609/21/2016


Page 6 of 8

c) Maintaining proper body alignment and joint movement to prevent contractures and

deformities

2. Short Term Skilled Nursing and Rehab Program

a. Specialized Rehabilitative Services in Skilled Nursing Facilities

Specialized rehabilitative services shall be covered in accordance with the standards of medical

necessity. Such service shall include the medically necessary continuation of treatment services

initiated in the hospital or short term intensive therapy expected to produce recovery of function

leading to either:

1) (1) Aa sustained higher level of self- care and discharge to home or

2) (2) Aa lower level of care.

b. Specialized rehabilitation service shall be covered contingent upon compliance with the

following requirements:

1) The services shall be ordered by the beneficiary’s attending physician..

2) The physician’s signed order, specifying the care to be given, shall be on the beneficiary’s

chart..

1)3) A copy of the order shall be made available for departmental review upon request.;

c. The services require prior authorization by the PHC LTC Nurse Coordinator prior to admission

to a sSkilled nNursing fFacility.

d.c. The authorization request shall be accompanied by a treatment plan, signed by the attending

physician, which shall include the following:

1) Principal and significant diagnoses;

2) Prognosis;

3) Date of onset of illness or injury;

4) Specific type, number, and frequency of services to be performed by each discipline;

5) Therapeutic goals of the service provided by each discipline and anticipated duration of

treatment;

6) Extent of and benefits or improvements demonstrated by any previous provision of physical

therapy, occupational therapy, speech pathology or respiratory services;

e. Authorization for rehabilitative and nursing services to the written treatment plan prescribed by

the physician after necessary consultation with the qualified physical therapist, occupational

therapist, speech pathologist, or respiratory therapist and skilled nursing care.

1) The direct and specific relationship of the services to the written treatment plan prescribed

by the physician after necessary consultation with the qualified physical therapist,

occupational therapist, speech pathologist, or respiratory therapist, and skilled nursing care.

2) Complexity and sophistication of the level of service, or condition of the beneficiary which

requires the judgment, knowledge and skills of a therapist;

3) Provision of the services with the expectation that the beneficiary will improve significantly

in a reasonable, and generally predictable, period of time; or in order to establish an

effective maintenance program for specific disease state;

4) Performance of the services must be performed by a qualified therapist.

5) Consideration of the services, under accepted standards of medical practice, to be specific

and effective treatment for beneficiary’s condition;

6) Reasonableness and necessity of the services for treatment of the beneficiary’s condition.

f.d. Professional therapy necessary to establish maintenance program services under treatment

programs not requiring the skills of a qualified therapist shall not be separately payable or

authorized

3. Non-Emergency Transportation

a. Non-Emergency transportation to Primary Care and dental appointments is not a PHC benefit.

For all other transportation needs please refer to PHC’s policy MCCP2016 Transportation

45 of 25245 of 252




Guidelines

☒ External Policy

☐ Internal Policy


Last Review Date: 01/20/1609/21/2016


Page 7 of 8

Guidelines for Non-Medical (NMT) and Non-Emergency Medical Transportation (NEMT).

4. Discharge Procedures

a. Discharge summary should be sent to the member’s PCP upon discharge.

b. When discharging a PHC member from a LTC facility and responsibility for medical care is

being transitioned to another Primary Care Physician Provider, it is important that pertinent facts

about the patient’s status and care requirements be communicated to the primary care physician

provider who will assume responsibility for the member’s medical care needs. Proper

communication allows for appropriate continuity of care and patient safety. The LTC facility

should do the following the day of discharge or no later than 48 hours after discharge:

1) Identify the Primary Care Physician Provider who will assume responsibility for care of the

member

2) Fax and/or mail a copy of the completed Transition of Care Summary to the new Primary

Care Physician Provider

3) Fax a copy of the completed Transition of Care Summary to PHC using fax # (707) 863-

4118: ATTN: LTC Nurse Coordinator

c. Day of Discharge or Death Same as Day of Admission Reimbursement Policy

1) When a patient receiving skilled nursing or intermediate care expires or is discharged from

a LTC facility, the facility must notify PHC via bedhold and change of status report form

2) If the day of discharge or death is the same day as admission, the day is payable regardless

of the hour of discharge or death. If the day of death/discharge is not the same day as

admission, the day is not payable

5. Durable Medical Equipment (DME)

a. RFor requests on for DME for residents residing in a LTC facility, it is the responsibility of the

facility and its staff to meet the patient’s needs of activities of daily living including assistance

with mobility. Please refer to DHS Policy Letter 88-11 regarding provision of wheel chairs for

patients residing in a skilled nursing facility.

b. LTC facilityies provides wheelchairs that are properly maintained at all times.

VII. REFERENCES: A. Medi-Cal Guidelines

B. Title 22 California Code of Regulations (CCR)

C. DHS Policy Letter 88-11

D. InterQual criteria

VIII. DISTRIBUTION:

A. PHC Directors

B. Provider Manual


X. REVISION DATES: 06/21/00; 04/18/01; 03/20/02; 03/19/03; 04/21/04; 02/16/05; 03/15/06; 08/20/08;

03/21/12; 01/20/16; 09/21/16

PREVIOUSLY APPLIED TO:

***********************************

46 of 25246 of 252




Guidelines

☒ External Policy

☐ Internal Policy


Last Review Date: 01/20/1609/21/2016


Page 8 of 8







The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with

similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the

benefits covered under PHC.

47 of 25247 of 252

LTC Acute Hospital

BedHold

MediCalBed MedicareBed MediCalBed MedicareBed

Return to LTCDay 8 or Less

Return to LTCDay 9 or More

BedHold / TAR ProcessAfter Acute Hospitalization

Close Existing TAR

New TAR Required If Return To MediCal Bed

Close Existing TAR

Close Existing TAR

Continue Existing TAR

MCUG3038 Attachment A

48 of 25248 of 252

Admissions for Short Term Rehabilitation or Short Term Skilled Nursing

MCUG3038 Attachment B

Hospital Discharge Planner

Capitated to Hospital System (Hospital Financial

Responsibility)

Special Case Managed (PHC Financial Responsibility)

PHC Concurrent Review Nurse will review request

PHC Concurrent Review Nurse refer to

PHC LTC Coordinator

LTC Coordinator review request with

Dr’s Orders

Rehab evaluation, tx, notes and care plan

Pre-Auth for Short Term Rehab services for SNF 49 of 25249 of 252

SKILLED NURSING FACILITY

TRANSITION OF CARE SUMMARY

Name:

Phone #:

Fax #:

Partnership HealthPlan Notified: Fax #:

PROCEDURE

THERAPY

Provider:

Patients Name:

DIAGNOSIS DATE

DISCHARGE DIAGNOSIS & PROCEDURES

DIET

Admission Date:

Date of Birth:

(707) 863-4118 Fax Sent:

Attending Physician's Name:

Fax Sent:

Discharge Date:

Facility Name:

Care Transitioned To (Primary Care):

DISCHARGE INFORMATION & INSTRUCTIONS

Frequency:

ADMISSION INFORMATION

Therapy Physical Occupational Other

Diet Additional Information

Regular Diabetic Low Fat Other

Yes No

Yes No

I:\POLICIES\Draft policies for review\Medi-Cal\U MGMT\UM Policies for 09-13-16 IQI\MCUG3038\MCUG3038-C NO CHANGE.xlsx Revision Date: 8/29/2016

MCUG3038 Attachment Cpg. 1 of 2

50 of 25250 of 252

SKILLED NURSING FACILITY

TRANSITION OF CARE SUMMARY

Facility:

Phone No.:

MEDICATION AT DISCHARGEFREQUENCYDOSAGE

Nursing Supervisor's SignatureAttending Physician's Signature

MEDICATION

I:\POLICIES\Draft policies for review\Medi-Cal\U MGMT\UM Policies for 09-13-16 IQI\MCUG3038\MCUG3038-C NO CHANGE.xlsx Revision Date: 8/29/2016

MCUG3038 Attachment Cpg. 2 of 2

51 of 25251 of 252


POLICY / PROCEDURE

Page 1 of 3

Policy/Procedure Number: MCUP3027 (previously UP100327) Lead Department: Health Services

Policy/Procedure Title: Members with Limited Benefits ☒External Policy

☐ Internal Policy


Last Review Date: 01/20/201609/21/2016


Reviewing

Entities:



Approving

Entities:





A. MCUP3014 - Emergency Services

B. MCUG3118 - Prenatal and Perinatal Care

C. MCUP3041 - TAR Review Process

II. IMPACTED DEPTS:

A. Health Services

B. Member Services

C. Claims

III. DEFINITIONS:

Aid Codes developed by the State of California to facilitate the Administration of Medi-Cal.

The list allows the provider to determine which services a recipient qualifies for and what services the

provider may claim under Medi-Cal regulations. The Aid Codes are assigned by county eligibility worker

when the person is determined to be eligible for Medi-Cal.

IV. ATTACHMENTS:

A. N/A

V. PURPOSE:

To define the benefits for members with limited services coverage.


A. Some members of the Partnership HealthPlan of California (PHC) have a limited scope of benefits.

These members have the following AID codes:

LTC 53 - LTC services only (PHC responsible for facility fee only)

IRCA/OBRA D2, D3, D4, D5, D6, D7,

55

Limited LTC, emergency services, and pregnancy

(Excluded from Sonoma, Marin and Mendocino

Counties)(Applies to Solano, Napa, and Yolo counties

only)

IRCA/OBRA C1, C2, C3, C4, C5, C6,

C7, C8, C9, D1, 58, D8,

D9, 5F

Limited pregnancy and emergency services (non-

emergency dental benefits available during pregnancy)

(Excluded from Sonoma, Marin and Mendocino

52 of 25252 of 252

Policy/Procedure Number: MCUP3027 (previously

UP100327) Lead Department: Health Services

Policy/Procedure Title: Members with Limited Benefits ☒ External Policy

☐ Internal Policy


Last Review Date: 01/20/201609/21/2016


Page 2 of 3

CountiesApplies to Solano, Napa, and Yolo counties only)

D8, D9, 5F Limited pregnancy & emergency services (non-emergency

dental benefits available during pregnancy)

(Excluded from Sonoma, Marin and Mendocino Counties)

Limited to

ER only

5G - Emergency services only - (Applies to Solano, Napa, and

Yolo counties only)(Excluded from Sonoma County)

Limited to

Pregnancy

only

5N - Pregnancy services only - (Applies to Solano, Napa, and

Yolo counties only)(Excluded from Sonoma, Marin and

Mendocino Counties)

Breast and

Cervical

Cancer

(BCC)

ØU - Breast / Cervical Cancer treatment AND emergency,

pregnancy, LTC services only – under 65

BCC

Treatment

ØT - Breast / Cervical Cancer treatment only

BCC

Treatment

ØR - Breast / Cervical Cancer treatment only

(these members have other insurance w/ deductible greater

than $750)

B. Emergency medical condition means one that manifests with acute symptoms of sufficient severity,

including severe pain, such that a prudent layperson who possesses an average knowledge of health and

medicine could reasonably expect in which the absence of immediate medical attention could reasonably

be expected to result in any of the following:

1. Placing the health of the member 's(or, if the member is a pregnant woman, the health of the member

and her unborn child) health in serious jeopardy;

2. Serious impairment to bodily functions; or

3. Serious dysfunction to any bodily organ or part

C. Members are eligible for inpatient and outpatient services that are necessary for the treatment of an

emergency medical condition. Emergency services are defined as those required for the alleviation of

severe pain, or immediate diagnosis of unforeseen medical conditions which, if not immediately

diagnosed and treated, would lead to disability or death. Services that fall into this category do not

require prior authorization, but inpatient days do require authorization upon admission.

D. The Medi-Cal coverage for individuals whose eligibility is limited to emergency services begins at the

point when the emergency condition is diagnosed by the attending provider and ends when the

emergency condition is stabilized.

E. Continuation of medically necessary inpatient hospital services and follow-up care after the emergency

is stabilized is not covered. This means that treatment aimed at a cure or long-term solution to the

problem, related to the underlying chronic medical condition is not authorized or reimbursed by PHC.

F. While both inpatient and outpatient services that are necessary to stabilize the emergency medical condition are covered, follow-up care that may be necessary to restore the member to health is not

covered.

G. Emergency services rendered in an emergency room, urgent care facility, or provider's office are paid on

a fee for service basis for conditions on the PHC emergent diagnosis list. (See policy MCUP3014

53 of 25253 of 252



Policy/Procedure Title: Members with Limited Benefits ☒ External Policy

☐ Internal Policy


Last Review Date: 01/20/201609/21/2016


Page 3 of 3

Emergency Services Addendum C) All other care is considered either urgent or routine and payment is

denied.

H. Routine prenatal care, labor and delivery, routine post-partum care, and family planning are considered

pregnancy-related services. In addition, medical conditions which might complicate the pregnancy are

covered. Routine post-partum care including family planning is available for the month of, and the

month following the delivery.

I. Newborns are covered for full scope under the mother’s limited eligibility for treatment of emergency

medical conditions for the month of birth and the following month.

J. Claims for emergency services for limited scope members are reviewed for medical necessity by the

Health Services staff. Services for conditions that do not meet the emergency condition definition are

denied payment by either the Director of Health Services or the Chief Medical Officer or physician

designee.

K. Dialysis and related services are considered emergency services, however, for tracking purposes a

Treatment Authorization Request (TAR) is required.

VII. REFERENCES: A. The Aid Codes Master Chart developed for use in conjunction with the Medi-Cal Eligibility Verification

System

VIII. DISTRIBUTION:

A. PHC Department Directors



X. REVISION DATES: 06/16/95; 10/10/97 (name change only); 06/02/00; 06/20/01, 09/18/02; 10/20/04;

10/19/05; 10/18/06; 10/17/07; 10/15/08; 11/17/10; 11/28/12; 01/20/16; 09/21/16


*********************************









covered under PHC.

54 of 25254 of 252


POLICY / PROCEDURE

Page 1 of 3

Policy/Procedure Number: MCUP3034 (previously UG100334) Lead Department: Health Services

Policy/Procedure Title: PCP-To-PCP Transfers & Assignments of

New Members to PCP

☒External Policy

☐ Internal Policy


Last Review Date: 01/20/201609/21/2016


Reviewing

Entities:



Approving

Entities:





A. MCUP3039 - Special Case Managed Members

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

N/A

IV. ATTACHMENTS:

APPENDIX

A. Guidelines for Determining Medical Stability Prior to PCP Transfer

V. PURPOSE: To clarify when transfers are medically acceptable.


A. Primary Care Physician Provider (PCP) to PCP transfers:

1. At the time a member requests transfer from one PCP to another, the member must be medically

stable in order for the transfer to be processed by the Member Services Department.

2. A member who is “unstable” is not to be transferred from one PCP to another without the approval

of both the current and accepting PCPs. Unstable means that the member possesses one or more

medical conditions such that transfer at that point in time might jeopardize the care of that member.

3. A member with a pre-existing medical condition(s) who is not unstable is eligible for PCP transfer

when requested by the member.

4. Pregnant women are permitted to change PCP assignment through week 32 of pregnancy, but are

considered inappropriate for transfer from the 33rd week of pregnancy until 8 weeks postpartum.

Exceptions for members wishing to transfer after 32 weeks of pregnancy and before 8 weeks

postpartum are permitted with the approval of the potential accepting PCPs.

5. If Partnership HealthPlan of California (PHC) determines that the member is eligible for medical special case management status at the time of the requested PCP transfer, an assignment to the

special member category is made, rather than assignment to a PCP.

6. When a member requests a transfer from one PCP to another, the Member Services Department at

PHC is to screen the request for suitability of transfer. Information regarding the member’s medical

55 of 25255 of 252



Policy/Procedure Title: PCP-To-PCP Transfers & Assignments

of New Members to PCP

☒ External Policy

☐ Internal Policy


Last Review Date: 01/20/201609/21/2016


Page 2 of 3

condition(s) and stability are assessed. When necessary, the HealthPlan’s Chief Medical Officer or

physician designee determines the member’s suitability and timing for transfer.

B. Assignment of new members to a PCP

1. A member not known by PHC, who indicates preference for a particular PCP, is assigned to that

provider if the provider is accepting new members.

2. A member who does not submit a choice of PCP within the specified time frame is randomly auto-

assigned to a PCP from the geographic pool of PCPs who are accepting new members through this

process.

3. If PHC determines that the member is eligible for special case management status during the period

of initial administrative special case management, an assignment to the special category is made.

4. If a member is 28 weeks pregnant when she becomes a PHC member, she will be granted special

member status for continuity of care. The special member status is closed the 1st of the month

following 8 weeks postpartum.

5. In all cases, it is expected that the PCP accepting new PHC members (by member choice or by auto-

assignment) will assume responsibility for the member, even if the member currently is hospitalized,

is in active care, or has a pre-existing medical condition. If PHC determines that a hospitalized new

member will enter a hospital cap on the first of the next month and may still be hospitalized at that

time, PHC will notify the capitated hospital and the PCP of the impending assignment.

VII. REFERENCES: N/A

VIII. DISTRIBUTION:




X. REVISION DATES: 10/13/99; 03/21/01; 04/17/02; 08/20/03; 10/19/05; 10/18/06; 09/19/07; 10/15/08;

01/18/12; 01/20/16; 09/21/16


*********************************









covered under PHC.

56 of 25256 of 252



Policy/Procedure Title: PCP-To-PCP Transfers & Assignments

of New Members to PCP

☒ External Policy

☐ Internal Policy


Last Review Date: 01/20/201609/21/2016


Page 3 of 3

APPENDIX A

Guidelines for Determining Medical Stability Prior to PCP Transfer

The following groups are considered unstable for purposes of transfer to another Primary Care Provider (PCP).

1. Hospitalized members or members discharged from hospital less than 2 weeks prior to request

2. Pregnant members more than 28 weeks gestation or within 8 weeks after delivery

3. Members scheduled for major diagnostic procedures such as CT, MRI scans in the next sixty (60) days

4. Members scheduled for major therapeutic procedures such as surgery within the next sixty (60) days

5. Members with established relationship with PCP and chronic medical conditions (i.e., heart failure, diabetes)

requiring frequent office visits (more than 2 per month) in the past month because of a change in the member’s

condition. Exception can be made if mutually agreeable to both PCPs.

57 of 25257 of 252


POLICY / PROCEDURE

Page 1 of 3

Policy/Procedure Number: MP 350 Lead Department: Member Services

Policy/Procedure Title: Weight Management Program External Policy Internal Policy

Original Date: 07/18/2007 Next Review Date: 08/05/201609/13/2017 Last Review Date: 08/05/201509/13/2016


Reviewing Entities:

IQI P & T QUAC


Approving Entities:



Approval Signature: Kevin Spencer; Kelley SewellDebbie Shafer Approval Date: 08/05/201509/13/2016

I. RELATED POLICIES: N/A II. IMPACTED DEPTS.: N/A III. DEFINITIONS:

A. Take Off Pounds Sensibly (TOPS) - TOPS is a non-profit, non-commercial, non-sectarian weight loss program with participants who meet weekly to share tips on losing weight, to exchange recipes and to lend encouragement and support. Officers of TOPS are all volunteers.

IV. ATTACHMENTS:

A. Website Summary V. PURPOSE:

To define the criteria and outline the enrollment process for the Take Off Pounds Sensibly (TOPS) program. VI. POLICY / PROCEDURE:

A. Eligibility Criteria 1. Available to eligible PHC members who would like to reduce the negative health consequences

associated with obesity and are able to attend meetings.

B. TOPS Enrollment 1. Eligible PHC members and\or member’s representative contact PHC’s Member Services

Department to request enrollment into the TOPS program. 2. The MSR confirms the member’s PHC eligibility and enters a “WL” remark code. 3. A weekly report of all new “WL” remarks is forwarded to TOPS using “SECURE” email. 4. The TOPS Program is available in English and limited Spanish.

VII. REFERENCES: N/A VIII. DISTRIBUTION:

A. SharePoint B. Provider Manual (all programs) C. Website (Member Section - Summary)

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director of Member

Services

58 of 25258 of 252

Policy/Procedure Number: MP 350 Lead Department: Member Services

Policy/Procedure Title: Weight Management Program ☒External Policy ☐Internal Policy


Applies to: ☒ Medi-Cal ☒ Healthy Kids ☐ Employees

I:\QUALITY\QI Assistant\IQI\2016\9.13.2016\Policies on Agenda\Consent\Policies and Procedures\MP350\MP 350 - WeightManagement - REDLINE v 8-5-2015 ToIQI 9-13-2016.docx Page 2 of 3

X. REVISION DATES: Medi-Cal 10/17/07; 05/21/08; 01/2109; 06/25/09; 08/11/09; 02/01/10; 02/09/11; 08/09/11; 01/10/12; 05/05/13; 09/18/13; 03/18/14; 08/05/16 Healthy Kids 10/17/07; 05/21/08; 01/2109; 06/25/09; 08/11/09; 02/01/10; 02/09/11; 08/09/11; 01/10/12; 05/05/13; 09/18/13; 03/18/14; 08/05/16 PREVIOUSLY APPLIED TO: PartnershipAdvantage: MP 350 - 06/2006 to 01/01/2015

59 of 25259 of 252

of 3

Attachment A TOPS (Take off Pounds Sensibly)

TOPS (Take Off Pounds Sensibly), is a common sense approach to managing weight. TOPS also promotes maintaining good health. Enrolled members attend weekly meetings. They share tips on losing weight. They also exchange recipes. They encourage and support each other. The staff is all volunteers. The TOPS weight loss program is non-profit and non-commercial.

This program is offered to all eligible PHC members. Are you ready to stop dieting and start making real life changes?

Partnership HealthPlan of California will pay your membership for one year, if you qualify. Some TOPS locations charge a chapter fee (on average $5.00 per month). PHC does not pay chapter fees.

To join TOPS or get more facts, call the Partnership HealthPlan of California Member Services Department at (800) 863-4155.

60 of 25260 of 252


POLICY / PROCEDURE

Page 1 of 3

Policy/Procedure Number: MPCP2002 (previously CP100202 &

KK CC401) Lead Department: Health Services

Policy/Procedure Title: California Children Services External Policy

Internal Policy

Original Date: 04/25/1995 - Medi-Cal

11/16/2005 - Healthy Kids (KK CC401) Next Review Date: 01/20/201709/21/2017

Last Review Date: 01/20/201609/21/2016


Reviewing

Entities:

IQI P & T QUAC


Approving

Entities:




I. RELATED POLICIES: A. County specific Memoranda of Understanding (MOUs)

B. Pharmacy Service Authorization Request (SAR) requirements

C. MCCP2005 - EPSDT Supplemental Shift Nursing Services

D. MPCP2006 - Coordination of Services for Members with Special Health Care Needs (MSHCNs) and

Persons with Developmental Disabilities

E. MCUP3041 - TAR Review Process

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services


IV. ATTACHMENTS: N/A

V. PURPOSE:

To outline the collaboration between the California Children's Services (CCS) program and the Partnership

HealthPlan of California (PHC) as an adjunct to the county specific MOUs.


A. CCS Program Responsibilities:

1. Provide consultation to PHC regarding CCS regulations, policies and guidelines concerning CCS

procedures, benefits, and criteria for authorizations and medical eligibility.

2. Determine eligibility of a PHC member for the CCS program.

2.3. ,D develop and implement a case management plan based on the CCS guidelines for the condition.

3.4. Authorize services for care related to the CCS condition and make available documentation of such

authorization to PHC.

B. PHC Responsibilities:

1. Provide consultation to CCS regarding PHC benefits and policies and post regular updates to the

online PHC Pprovider Mmanual.

2. Assure that PHC/CCS members are assigned special case managed (SCM) status from date of CCS

61 of 25261 of 252

Policy/Procedure Number: MPCP2002 (previously CP100202

& KK CC401) Lead Department: Health Services

Policy/Procedure Title: California Children Services ☒External Policy

☐Internal Policy

Original Date:

04/25/1995 - Medi-Cal

11/16/2005 - Healthy Kids (KK CC401)

Next Review Date: 01/20/201709/21/2017

Last Review Date: 01/20/201609/21/2016


Page 2 of 3

eligibility determination through the last month of CCS eligibility. CCS medical eligibility cannot

be earlier than PHC’s effective date. (Commercial coverage takes precedence over SCM status).

3. Work collaboratively with CCS and member to establish a medical home based on the complexity of

the member’s condition.

C. Primary Care Physician Provider Responsibility:

1. The physician provider identified as the child’s medical home is responsible for managing the

child’s primary care needs and coordinating the child’s care for both the CCS-eligible condition(s)

and the non-CCS-eligible condition(s).

2. For CCS eligible condition(s), CCS children require a Service Authorization Request (SAR) from

CCS is required. It is the responsibility of the provider of service to obtain the authorization.

3. CCS children, as special case managed members, do not require a Referral Authorization Form

(RAF) to see a specialist, for neither the CCS-eligible condition(s) nor the non-CCS eligible

condition(s).

4. For non-CCS eligible conditions, CCS children require a Treatment Authorization Request (TAR)

for services that are on PHC’s TAR Requirement List. It is the responsibility of the provider of

service to obtain the authorization.

D. Inter-county CCS Authorizations:

1. PHC works in collaboration with respective CCS offices and providers as needed to transition a

child into and out of their county of residence to ensure care is coordinated and that there are no

barriers to accessing care. access to care and care is coordinated, as needed.

2. PHC does not honor CCS authorizations from counties outside the PHC network. TARs must be

submitted directly to PHC.

E. Care Coordination:

1. Representative staff from PHC and CCS meet on a quarterly or as needed basis to collaborate and

discuss coordination of service and benefits between the CCS program and PHC / Medi-Cal and

review case specific issues when necessary. discuss administering the CCS program to CCS/PHC

members and case specific care coordination issues.

VII. REFERENCES: N/A

VIII. DISTRIBUTION: A. PHC Department Directors



X. REVISION DATES: Medi-Cal

10/13/95; 10/10/97 [name change only]; 06/02/00; 11/27/00, 12/20/00, 08/15/01, 04/16/03; 04/20/05;

01/16/08; 09/16/09; 09/19/12; 05/21/14; 01/20/16; 09/21/16

Healthy Kids

01/16/08; 09/16/09; 09/19/12; 05/21/14; 01/20/16; 09/21/16

PREVIOUSLY APPLIED TO: PartnershipAdvantage:

MPCP2002 - 01/16/2008 to 01/01/2015

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Policy/Procedure Number: MPCP2002 (previously CP100202

& KK CC401) Lead Department: Health Services

Policy/Procedure Title: California Children Services ☒External Policy

☐Internal Policy

Original Date:

04/25/1995 - Medi-Cal

11/16/2005 - Healthy Kids (KK CC401)

Next Review Date: 01/20/201709/21/2017

Last Review Date: 01/20/201609/21/2016


Page 3 of 3

*********************************









covered under PHC.

63 of 25263 of 252


POLICY / PROCEDURE

Page 1 of 3

Policy/Procedure Number: MPUP3035 (previously UP100335) Lead Department: Health Services

Policy/Procedure Title: Preoperative Day Review ☒External Policy

☐ Internal Policy


10/18/2006 - Healthy Kids Next Review Date: 01/20/201709/21/2017

Last Review Date: 01/20/201609/21/2016


Reviewing

Entities:



Approving

Entities:





A. MCUP3041 TAR Review Process

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

A. Preoperative Day – The planned admission of a member to the acute hospital one or more days prior to a

scheduled (elective) procedure.

1. As part of the precertification review process, patients are identified for Preoperative Day Review

when the reasons for and the timing of admissions are submitted by the provider of service.

2. Preoperative Day Review is initiated for patients who must be admitted on the day prior to the

planned procedure. If the admitting physician requests that the patient be admitted the day before

surgery, all patient information is compared to InterQual criteria for an elective admission and to the

anesthesia staging criteria. If necessary, the clinical information is referred to the Utilization

Management (UM) Manager, UM Director or to the, Chief Medical Officer, or Physician Designee.

IV. ATTACHMENTS:

APPENDIX

A. Preoperative Day Review/ American Society of Anesthesiologists (ASA) Patient Classification System

V. PURPOSE:

To identify elective surgical cases that may be admitted to the hospital the day prior to surgery rather than the

day of surgery.


A. Objective

1. To determine the appropriateness of a patient’s admission to the hospital prior to the day of surgery.

Whenever possible, early morning admission on the day of a proposed surgical procedure should be

utilized. If the patient's problem precludes such utilization, special certification consideration by the Chief Medical Officer, Physician Designee or UM manager may be given through the prior

authorization process.

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Policy/Procedure Number: MPUP3035 (previously


Policy/Procedure Title: Preoperative Day Review ☒ External Policy

☐ Internal Policy



Last Review Date: 01/20/201609/21/2016


Page 2 of 3

B. Procedure

1. Admissions for elective surgical procedures are identified during the precertification review process.

2. If the admitting physician requests the patient be admitted the day prior to surgery, all pertinent

clinical information is compared to InterQual criteria and to the anesthesia staging criteria. The

authorization request must clearly explain the medical necessity of the requested preoperative day.

3. If any one of the criteria elements for anesthesia staging criteria class IV-V is met, the Health

Services Nurse Coordinator approves the admission for the day prior to the planned procedure.

4. If none of the criteria elements are met, or the medical need for the request is not clear, the case is

referred to the UM Manager, UM Director, or to the Chief Medical Officer or Physician Designee.

5. Chief Medical Officer or Physician Designee is the only individual who can deny a request based on

lack of medical justification.

VII. REFERENCES: A. American Society of Anesthesiologists (ASA) Standards and Guidelines

A.B. InterQual criteria

VIII. DISTRIBUTION:





05/17/00; 09/19/01; 10/16/02, 10/20/04; 10/19/05; 10/18/06; 08/20/08; 11/18/09; 10/01/10; 05/16/12;

08/20/14; 01/20/16; 09/21/16

Healthy Kids

10/18/06; 08/20/08; 11/18/09; 10/01/10; 05/16/12; 08/20/14; 01/20/16; 09/21/16

PREVIOUSLY APPLIED TO: PartnershipAdvantage:

MPUP3035 - 10/18/2006 to 01/01/2015

Healthy Families:

MPUP3035 - 10/01/2010 to 03/01/2013

***********************************









covered under PHC.

65 of 25265 of 252

Policy/Procedure Number: MPUP3035 (previously


Policy/Procedure Title: Preoperative Day Review ☒ External Policy

☐ Internal Policy



Last Review Date: 01/20/201609/21/2016


Page 3 of 3

APPENDIX

Preoperative Day Review

AMERICAN SOCIETY OF ANESTHESIOLOGISTS (ASA)

PATIENT CLASSIFICATION SYSTEM

CLASS I - The patient has no organic, physiologic, biochemical, or psychiatric disturbance. The pathologic

process for which the surgery is to be performed is localized and does not entail a systemic

disturbance.

Examples - A fit patient with an inguinal hernia; fibroid uterus in an otherwise healthy woman.

CLASS II - Mild to moderate systemic disturbance caused either by the condition to be treated surgically or by

other pathophysiologic processes.

Examples - Non- or only slightly limiting organic heart disease, mild diabetes, essential

hypertension, or anemia. Some might choose to list the extremes of age here, either the neonate or

the octogenarian, even though no discernible systemic disease is present. Extreme obesity and

chronic bronchitis may be included in this category.

CLASS III - Severe systemic disturbance or disease from whatever cause even though it may not be possible to

define the degree of disability with finality.

Examples - Severely limiting organic heart disease, severe diabetes with vascular complications,

moderate to severe degrees of pulmonary insufficiency, angina pectoris, or healed myocardial

infarction.

CLASS IV - Indicative of the patient with severe systemic disorders that are already life threatening, not always

correctable by surgery.

Examples - Patients with organic heart disease showing marked signs of cardiac insufficiency,

persistent anginal syndrome, or active myocarditis; advanced degrees of pulmonary, hepatic, renal,

or endocrine insufficiency.

CLASS V - The moribund patient who has little chance of survival but is submitted to surgery in desperation.

Examples - The burst abdominal aneurysm with profound shock, major cerebral trauma with rapidly

increasing intracranial pressure, massive pulmonary embolus. Most of these patients require surgery

as a resuscitative measure with little if any anesthesia.

Emergency Operation (E) - Any patient in one of the classes listed previously who is operated upon as an emergency

is considered to be in poorer physical condition. The letter "E" is placed beside the numerical classification. Thus, the

patient with a hitherto uncomplicated hernia now incarcerated and associated with nausea and vomiting is classified

"I. E".

66 of 25266 of 252


POLICY / PROCEDURE

Page 1 of 5

Policy/Procedure Number: MPCP2006 (previously CP100206) Lead Department: Health Services

Policy/Procedure Title: Coordination of Services for Members with

Special Health Care Needs (MSHCNs) and Persons with Developmental

Disabilities

External Policy

Internal Policy

Original Date:

06/20/2001 Medi-Cal

01/16/2008 Healthy Kids

Next Review Date: 09/21/2017

Last Review Date: 09/21/2016


Reviewing

Entities:

IQI P & T QUAC


Approving

Entities:



Approval Signature: Robert Moore, MD, MPH Approval Date: 09/21/2016

I. RELATED POLICIES: A. Regional Center Memorandums of Understanding

B. MPCP2002 – California Children’s Services

C. MCQG1015 – Pediatric Preventive Health

D. MPUP3126 – Autism Spectrum Disorder (ASD) Behavioral Health Treatment (BHT)

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

D. Provider Relations

III. DEFINITIONS: A. Members with Special Health Care Needs (MSHCNs) are those who have or are at increased risk for

chronic physical, developmental, behavioral, or emotional conditions.

IV. ATTACHMENTS: A. PCP Notification Letter

V. PURPOSE:

To outline a process for the identification, assessment, case management and coordination of care for

Members with Special Health Care Needs and Persons with Developmental Disabilities that encourages

access to specialties, sub specialties, ancillary providers, and community resources.

VI. POLICY / PROCEDURE: Partnership HealthPlan of California (PHC) has a process for the identification, assessment, case

management and coordination of care for Members with Special Health Care Needs and Persons with

Developmental Disabilities. PHC encourages timely access to specialties, sub specialties, ancillary

providers, and community resources. The effectiveness of PHC’s processes in serving MSHCNs is

monitored on an annual basis to ensure best practices and identify opportunities for improvement. This

quality review may be accomplished by utilizing HEDIS measures, member satisfaction surveys, response to

complaints and grievances, input from community agencies, and data-driven measures that analyze clinical

trends, access to care and specific utilization questions. A. Identification

1. PHC identifies MSHCNs in multiple ways including, but not limited to the following:

67 of 25267 of 252

http://eshare/sites/PoliciesnProcedures/_layouts/15/WopiFrame.aspx?sourcedoc=/sites/PoliciesnProcedures/Care%20Coordination/MPCP2006%20Attachments/MPCP2006-A.docx&action=default


Policy/Procedure Title: Coordination of Services for Members

with Special Health Care Needs (MSHCNs) and Persons with

Developmental Disabilities

☒External Policy

☐Internal Policy

Original Date: 06/20/2001 Medi-Cal

01/16/2008 Healthy Kids Next Review Date: 09/21/2017



Page 2 of 5

a. Primary Care Providers (PCP) may identify children with special needs, including California

Children Services (CCS) eligible conditions, and facilitate timely referrals to appropriate

services/agencies.

b. PHC Health Services staff screen Treatment Authorization Requests (TARs) routinely to assess

and identify members with potential special needs/conditions; collaborating when necessary

with providers, PHC Case Managers, CCS, and/or other community agencies to ensure members

are connected and referred appropriately. .

c. UM Nurse Coordinators review all hospitalizations concurrently for early interventional

opportunities.

d. Health Services Care Coordination staff respond to requests from providers, families, and other

agencies for case coordination assistance, and/or other intended departments.

e. PHC downloads the list of Regional Center enrollees from the California Department of Health

Care Services (DHCS) monthly.

2. Assessment

Primary Care Providers (PCPs) are trained by PHC’s Provider Relations Department for the

identification of MSHCN when they contract with PHC. Our review concerns the following

assessment:

a. A History & Physical (H&P) is completed within 120 days of the member’s effective date of

enrollment into the HealthPlan, or documented within the 12 months prior to the plan

enrollment. The H&P will assess and diagnose acute and chronic conditions.

b. Health assessments containing Child Health and Disability Program (CHDP) age-appropriate

content requirements are provided according to the most recent American Academy of

Pediatrics (AAP) periodicity schedule for pediatric preventive health care. Assessments and

identified problems are documented in the progress notes. Follow-up care or referral is provided

for identified physical health problems as appropriate.

3. Direct Access to Specialists

PHC allows certain populations of MSHCNs to be placed in a special member category, which

allows direct access to care without requiring a referral from a primary care provider. These include,

but are not limited to, clients of CCS, youth in Foster Care and Genetically Handicapped Persons

Program (GHPP).

B. Case Management and Care Coordination

PHC coordinates care with other agencies that provide services for MSHCNs:

1. California Children Services (CCS) Birth to age 21 years

a. PHC has established a relationship with the CCS programs in all counties served by PHC.

2. PHC’s Care Coordination Department, upon receiving a referral, contacts the member’s

representative, resulting in either referring the member to appropriate community-based services or

state programs and/or opening a case for PHC Care Coordination members not otherwise eligible but

with other identified special needs.

a. PHC Health Services (HS) staff work closely with the outside agencies and the primary care

provider to encourage all necessary documentation regarding the member’s diagnosis,

treatments, and services are placed in a member’s health record. All interventions are

documented in PHC’s case management record to track the flow of the case.

b. PHC ensures Medi-Cal coverage for medically necessary eligible services for the member’s

potential CCS eligible condition while CCS eligibility is determined. PHC Case Managers

collaborate and coordinate with CCS to ensure adequate coordination of care. c. If CCS program eligibility is established for a member, PHC continues to provide all medically

necessary Medi-Cal covered services that are unrelated to the CCS eligible condition.

d. If the local CCS program does not approve eligibility, PHC remains responsible for the

provision of all medically necessary covered services to the Member.

68 of 25268 of 252





☒External Policy

☐Internal Policy





Page 3 of 5

e. If the local CCS program denies authorization for any services, PHC remains responsible for

obtaining the services, if they were medically necessary, and paying for all the services that

were provided.

3. Early Intervention (EI) Services - Birth to age 3 years

a. The PHC provider network has primary responsibility for the identification of children less than

3 years of age who may be eligible to receive services from the Early Start Program and to make

the referral to the Regional Center which coordinates those services. These include children

where a developmental delay in either cognitive, communication, social, emotional, adaptive,

physical or motor development is suspected, or whose early health history places them at risk

for delay.

b. PHC Health Services (HS) staff assist in identifying and referring children who may qualify for

the Early Start Program..

c. PHC Health Services (HS) staff collaborate with providers, Regional Center(s), and/ or the Early

Start Program in resolving problems, determining medically necessary services including

diagnostic and preventive services and provides input to be considered in the treatment plans for

members participating in the Early Start Program. Children under age 21 with an actual or

provisional diagnosis of Autism Spectrum Disorder (ASD) may be eligible for behavioral health

treatment (BHT) services. Please see PHC policy #MPUP3126 Autism Spectrum Disorder

Behavioral Health Treatment for details.

d. PHC’s Care Coordination Department and primary care providers provide case management and

care coordination to the member to ensure the provision of all medically necessary covered

diagnostic, preventive and treatment services that are identified in the Individual Family Service

Plan developed by the Early Start Program.

4. Services for Persons with Developmental Disabilities and/or ASD - Age 3 years through adulthood

a. PHC provides all screening, preventive, medically necessary, and therapeutic covered Medi-Cal

services to Members with developmental disabilities. Children under 21 with a diagnosis of

Autism Spectrum Disorder (ASD) may be eligible for behavioral health treatment (BHT)

services. Please see PHC policy #MPUP3126 Autism Spectrum Disorder Behavioral Health

Treatment for details.

b. PHC members who are also clients of a Regional Center are advised to contact the Regional

Center for evaluation and access to non-Medi-Cal services provided through the Regional

Centers included but not limited to; respite, day care, out-of-home placement vocational

training, financial management and supportive living.

c. PHC members who are not clients of a Regional Center but who may meet their eligibility

criteria for developmental disability are advised to contact the Regional Center for assessment

and evaluation. PHC is not able to make direct referral to Regional Center without written

consent of the member or legal representative

d. Upon request to PHC by the member, Regional Center staff or other entities, PHC Health

Services (HS)staff will assist with identification and coordination of appropriate services for the

member.

5. Local Education Agency Services (LEA)

a. PHC assures a PCP is available to provide primary care management and care coordination to

the member to ensure the provision of all medically necessary Medi Cal covered diagnostic,

preventive and treatment services. Local Education Agency assessment services are services

specified in Title 22 CCR Section 51360(b) and provided to students who qualify based on Title 22 CCR Section 51190.1. LEA services are provided pursuant to an Individual Educational

Plan as set forth in Education Code, Section 56340 et seq. or Individual Family Service Plan as

set forth in Government Code, Section 95020, are not covered under the contract.

6. School Linked Children’s Health and Disability Prevention (CHDP) Services.

69 of 25269 of 252





☒External Policy

☐Internal Policy





Page 4 of 5

PHC does not currently have a school linked CHDP program in its county service area. If a school

linked CHDP program site establishes within its county service area PHC will do the following:

a. Maintain a “medical home” and ensure the overall coordination of care and case management of

members who obtain CHDP services through the local school districts or school sites.

b. Establish guidelines for the following:

1) Sharing of critical medical information

2) Coordination of services

3) Reporting requirements

4) Quality standards

5) Processes to ensure services are not duplicated

6) Processes for notification to Member/student /parent on where to receive initial and follow-

up services

7) Referral protocols/guidelines for the school sites which conduct CHDP screening only, to

assure those Members who are identified at the school site as being in need of CHDP

services receive those services within the required state and federal time frames

8) Assure processes for appropriate follow-up and documentation of services provided to the

member

9) Provide resources to support the provision of school linked CHDP services

VII. REFERENCES:

A. DHCS Contract 2009 Section A11.7-11.11

VIII. DISTRIBUTION:





08/20/03; 04/20/05; 01/16/08; 05/19/10; 10/01/10; 09/19/12; 10/15/14; 09/16/15; 09/21/16

Healthy Kids

01/16/08; 05/19/10; 10/01/10; 09/19/12; 10/15/14; 09/16/15; 09/21/16


Healthy Families:

MPCP2006 - 10/01/2010 to 03/01/2013

*********************************






70 of 25270 of 252





☒External Policy

☐Internal Policy





Page 5 of 5




covered under PHC.

71 of 25271 of 252

4665 Business Center Drive

Fairfield, CA 94534

Date <Name> <Address> <Address> <Address> Attention: Medical Records Please place into patient file Patient Name: <member name> Dear <PCP>: Partnership HealthPlan would like you to know that < member name > has managed care benefits coordinated through Partnership HealthPlan. We are aware that this person has special needs and receives services through California Children Services and/or Regional Center. The Partnership HealthPlan Care Coordination Department has special program case managers available to assist you in the coordination of medical care for this member. We work together with you well as other agencies including Regional Centers and California Children Services toward ensuring case management medical needs are being met. If you would like to discuss this member’s benefits or the special case management program please call me at 1-800-809-1350 ext XXXX, 8am to 5pm Monday through Friday. We look forward to hearing from you. Sincerely, <Name> Case Manager Special Programs Care Coordination Department Partnership HealthPlan of California 4665 Business Center Drive, Fairfield, CA 94534 Phone (707) 555-5555 | Fax (707) 863-4502 Email: Our Website: www.partnershiphp.org

ATTACHMENT A

72 of 25272 of 252

http://www.partnershiphp.org/


POLICY/ PROCEDURE

Page 1 of 2

Policy/Procedure Number: MP PR 201 Lead Department: Provider Relations Policy/Procedure Title: PCP Availability and Capacity Policy and Procedure

☒External Policy ☐ Internal Policy

Original Date: 08/12/1998 Next Review Date: 09/13/2017 Last Review Date: 09/14/2016


Reviewing Entities:

☐ IQI ☐ P & T ☒ QUAC


Approving Entities:





N/A

II. IMPACTED DEPTS: N/A



V. PURPOSE: To provide and monitor availability to Primary Care Services for Partnership HealthPlan of California (PHC) Members.


A. PHC is responsible for monitoring PCP availability and capacity on an annual basis. Primary Care physicians include General and Family Practitioners, Internists, Gerontologists, Obstetrician-Gynecologists and Pediatricians. The PHC availability standard as defined below: 1. 1 PCP office site located within 30 minutes or 10 miles of member's residence. 2. 1:2000 = 1 Physician to 2000 members 3. 1:1000 = 1 non-physician Medical Practitioner to 1000 members

B. Availability 1. PHC conducts a PCP GeoAccess® analysis on an annual basis to verify PCP office site locations

based on PHC availability standards. The Provider Relations Department will be responsible for working with the PHC IT Department to complete the analysis. Once the report has been completed the results will be reviewed by the Director of Quality and Performance Improvement and Provider Relations Director. The final report will be submitted to the QUAC for recommendations.

C. Capacity

1. PHC conducts a Capacity Survey for each contracted PCP office, Medical Group, or Clinic on an annual basis.

2. The Provider Relations Representative assigned to the specific PCP is responsible for ensuring the survey is completed and assist the provider with questions regarding the Capacity Survey.

73 of 25273 of 252

Policy/Procedure Number: MP PR 201 Lead Department: Provider Relations

Policy/Procedure Title: PCP Availability and Capacity Policy and Procedure

☒ External Policy ☐ Internal Policy



Page 2 of 2

3. The Provider Relations Department will use the Capacity Calculation Software to tabulate the results.

4. If a provider is identified with a practice that exceeds the standard, PHC will communicate it's findings and recommendations to the provider. The provider will be given an opportunity to review the documentation and validate the findings. If capacity has been reached, corrective action steps will be discussed with the practice. PHC will monitor access through member complaints, satisfaction surveys, and QI activities.

5. If access issues are identified PHC or the PCP may request the practice enrollment status to be closed to new patients until additional practitioner(s) have been added to the office or office hours have been extended to allow more capacity.

6. The report is reviewed by PHC staff from Provider Relations, Quality Improvement and Health Services. The final report is submitted to the PHC QUAC for review and recommendations as necessary.

D. Cultural and Linguistics

1. PHC continuously monitors the cultural and linguistic capabilities of the primary care network to ensure members have access to practitioners in threshold languages as defined by DHCS. The report is reviewed by appropriate PHC staff, including representatives from the Health Services, Quality Improvement, Provider Relations, and Member Services Departments. Corrective action plans may be submitted to the QUAC for review and recommendation.

VII. REFERENCES:

A. DHCS B. KNOX-KEENE C. DMHC

VIII. DISTRIBUTION:

A. PHC Provider Manual IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Provider Relations Director

X. REVISION DATES:

Medi-Cal 05/17/01, 06/20/01, 05/15/02, 05/21/03, 06/16/04, 05/18/05, 05/17/06, 06/21/06, 05/16/07, 06/16/08, 03/18/09, 03/17/10, 03/16/11, 03/21/12, 08/15/12, 08/14/13, 09/10/14, 09/09/2015 Healthy Kids 05/17/06, 06/21/06, 05/16/07, 06/16/08, 03/18/09, 03/17/10, 03/16/11, 03/21/12, 08/15/12, 08/14/13, 09/10/14, 09/09/2015 PREVIOUSLY APPLIED TO: PartnershipAdvantage: MP PR #201 – 06/2006 to 01/01/2015

74 of 25274 of 252


POLICY / PROCEDURE

Page 1 of 4

Policy/Procedure Number: MP PR 202 Lead Department: Provider Relations Policy/Procedure Title: Monitoring of PHC Specialist Physician Network Availability and Accessibility Policy & Procedure

External Policy Internal Policy



Reviewing Entities:

IQI P & T QUAC


Approving Entities:





MPQP1023 II. IMPACTED DEPTS:

Provider Relations III. DEFINITIONS:

N/A IV. ATTACHMENTS:

N/A V. PURPOSE:

To provide and monitor adequate availability and accessibility to Contracted Specialist Physicians for Partnership HealthPlan of California (PHC) members.


The HealthPlan is responsible for evaluating the availability and accessibility of Specialist Physicians network. A. The Standard as defined by PHC for Availability:

1. High Volume Key Specialist Physician is available within 50 miles of member's residence.

2. High volume specialty services are identified through PHC claims data. A claim data report is

generated by the PHC Claims Department on an annual basis and evaluated to identify non-hospital based, high volume specialties. The top ten (10) specialties are identified by the highest number of unique member claims.

3. PHC takes into consideration the special cultural and linguistic needs of its members.

4. The HealthPlan will conduct a GeoAccess® analysis of non-hospital based high volume specialties

to monitor the standard of one specialist within 50 miles of member's residence.

5. Per DHCS, the Plan will ensure full time equivalent Physician to member ratio is 1:1200 members per DHCS contract requirements.

75 of 25275 of 252


Policy/Procedure Title: Monitoring of PHC Specialist Physician Network Availability and Accessibility Policy & Procedure

☐External Policy ☐Internal Policy



Page 2 of 4

B. Plan Standards for accessibility of Specialty Services are defined in policy MPQP1023; Access

Standards. 1. PHC commits to contract with specialist providers the meet PHC criteria in geographic areas served

by the Plan.

2. The Plan utilizes a variety of methods to increase access to specialty services which include, but are not limited to: telemedicine, telephone consults, and web-based e-consults.

3. Note:

Specialist Physicians are allowed to freely communicate with patients regarding their health status, medical care and treatment options, alternative treatment, and medication treatment regardless of benefit coverage limitations. Patients must be informed of risks, benefits and consequences of the treatment options. Patients will be allowed to refuse treatment and make decisions about ongoing and future medical treatments. Physicians must provide information regarding treatment options, including the option of no treatment in a culturally competent manner. Health care professionals must ensure that patients with disabilities have effective communication throughout the health system in making decisions regarding treatment options.

4. The Provider Relations Department is responsible for monitoring accessibility to specialty care. Using the high volume claims data, the top 10 specialties identified by the highest number unique member claims, are surveyed by using one or more of the following methods: a. A telephone survey of the physicians' office, asking for specific appointment time to be

scheduled, and/or 3rd next available appointment.

b. A “secret shopper” survey.

c. On-site evaluation of physicians appointment scheduling system.

d. Interviews with office staff.

5. After hours care is monitored by the Provider Relations Department by placing a call to the physicians office after the close of business day and document the findings.

a. Telephone wait times are monitored by calling the practice phone number, findings are

documented.

b. Member appointment wait times are evaluated by telephone and/or site review.

6. Reports and Corrective Action Plans (CAP) will be presented to the Chief Medical Officer and Regional Medical Directors for review, recommendation, and approval. The Provider Relations Department is responsible for implementation and monitoring of the CAP. The goal is to assist providers and remeasure to ensure standard met.

Accessibility to specialty care is continuously monitored through member complaints, member focus groups, QI activities, provider focus groups, and provider input.

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When issues are identified through member complaints, the Provider Relations department takes immediate action and addresses the issues with the specialist office.

C. Reporting and Actions 1. The Provider Relations Department issues a report documenting the findings.

2. The final report is forwarded to the IQI for review, recommendations, and approval.

3. The PHC Provider Relations Department is responsible for implementation, monitoring and

subsequent reporting of the Corrective Action Plan.

4. When a practitioner terminates a contract with PHC, the member is allowed to receive ongoing care with the practitioner for up to 60 days to treat an illness and through the postpartum period for deliveries as long as the provider agrees to the Plan's rate of reimbursement.

D. Ongoing Monitoring of Specialist Network 1. PHC carefully monitors the Specialist provider network. Terminated providers are reviewed

monthly to identify potential deficiencies. Member complaints, appeals and grievances regarding access and availability to provider services are monitored via the member grievance process.

2. PHC conducts periodic member satisfaction surveys that include questions about access to specialty care.

3. The Plan's Specialty Access Workgroup activities are included in the ongoing monitoring of the

PHC network.

4. Feedback from the provider network is another means by which PHC monitors access to services. When issues are identified the Provider Relations department takes immediate action to address deficiencies.

VII. REFERENCES: A. DHCS B. DMHC

VIII. DISTRIBUTION:

- PHC Provider Manual IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Provider Relations Director

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Page 4 of 4

X. REVISION DATES:

Medi-Cal 02/15/00, 03/01/00, 04/19/00, 04/18/01, 08/15/01, 04/17/02, 05/21/03, 06/16/04, 05/18/05, 06/15/05, 06/21/06, 05/16/07, 07/16/08, 03/18/09, 03/17/10, 03/16/11, 03/21/12, 08/15/12, 08/14/13, 09/10/14, 09/09/2015, 09/14/2016 Healthy Kids 06/21/06, 05/16/07, 07/16/08, 03/18/09, 03/17/10, 03/16/11, 03/21/12, 08/15/12, 08/14/13, 09/10/14, 09/09/2015, 09/14/2016 PREVIOUSLY APPLIED TO: PartnershipAdvantage: MP PR #202 - 06/2006 to 01/01/2015

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POLICY / PROCEDURE

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Policy/Procedure Number: MP PR 205 Lead Department: Provider Relations Policy/Procedure Title: Monitoring of PCP Accessibility of Services Policy and Procedure




Reviewing Entities:

IQI P & T QUAC


Approving Entities:





MPQP1023 Access Standards II. IMPACTED DEPTS:

N/A III. DEFINITIONS:

N/A IV. ATTACHMENTS:

N/A V. PURPOSE:

To provide and monitor adequate access to Primary Care and Specialty Services for PHC Members based on access standards per Policy MPQP1023.


The following process is used to evaluate the accessibility to service to Specialty Physicians and to a Primary Care Physician on an annual basis. Primary Care Physicians include General and Family practitioners, Internists, Gerontologists, Obstetrician – Gynecologists and Pediatricians when contracted as Primary Care Physicians. 1. The Provider Relations Department is responsible for verifying that the PCP and Specialty physician

office meets the standards of accessibility as identified in the PHC Access Standards Policy MPQP1023.

2. The Provider Relations Department conducts an annual access survey by using one or more of the following methods: a. a telephone survey is conducted by the Provider Relations staff, asking for specific appointment

times to be scheduled and/or 3rd next available appointment. b. a “secret shopper” survey c. on-site evaluation of the practitioner’s appointment scheduling system d. interviews with office staff

3. The after-hours care evaluation is conducted by telephone. The Provider Relations Representative

calls the practice site after the close of business day and documents the findings.

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Policy/Procedure Title: Monitoring of PCP Accessibility of Services Policy and Procedure




Page 2 of 2

4. Telephone wait times are monitored quarterly. The Provider Relations department staff call all PCP sites to verify telephone wait times. Member appointment wait times are evaluated annually by telephone and/or site review.

5. The report and a proposed Corrective Action Plan (CAP) will be reported to the QUAC for review,

recommendation and approval.

6. The PHC Provider Relations Department is responsible for implementation and monitoring of the Corrective Action Plan. The goal is to assist providers and remeasure to ensure standards are met.

7. Accessibility to services are continually monitored through member complaints, member focus

groups, PHC QI activities, and provider focus groups. When issues are identified the Provider Relations department takes immediate action with the practice site and implements corrective action to ensure compliance.

VII. REFERENCES:

A. MPQP1023 B. DHCS C. DMHC D. CMS

VIII. DISTRIBUTION:

- PHC Provider Manual IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: X. REVISION DATES:

Medi-Cal 02/15/00, 05/17/00, 06/20/01, 05/15/02, 03/16/03, 06/16/04, 01/19/05, 02/15/06, 06/21/06, 05/16/07, 07/16/08, 07/15/09, 07/21/10, 07/20/11, 08/15/12, 08/14/13, 09/10/14, 09/09/2015, 09/14/2016 Healthy Kids 02/15/06, 06/21/06, 05/16/07, 07/16/08, 07/15/09, 07/21/10, 07/20/11, 08/15/12, 08/14/13, 09/10/14, 09/09/2015, 09/14/2016

PREVIOUSLY APPLIED TO: PartnershipAdvantage: MP PR #205 – 06/2006 to 01/01/2015

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POLICY/ PROCEDURE

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Policy/Procedure Number: MP PR SA #212 Lead Department: Provider Relations Policy/Procedure Title: Access Standards for Substance Abuse Services



Applies to: ☐ Medi-Cal ☐ Healthy Kids ☐ Employees

Reviewing Entities:

☒☐ IQI ☐ P & T ☒ QUAC


Approving Entities:





A. N/A

II. IMPACTED DEPTS: A. Provider Relations

III. DEFINITIONS: A. N/A

IV. ATTACHMENTS: A. N/A

V. PURPOSE: To ensure access to substance abuse services for PHC members.


The Partnership HealthPlan of California has developed access standards for substance abuse services. In addition, PHC monitors access to necessary substance abuse services as specified within this policy. STANDARDS

A. Access to Substance Abuse Facilities is available to members and clinicians from 8:00am to 5:00pm, Monday through Friday. Access to substance abuse services is to occur within the following access parameters: 1. Emergency – immediate access. 2. Non-life threatening emergency – access within 6 hours. 3. Urgent – access within 48 hours. 4. Routine – access within ten (10) business days.

B. After Hours

1. Outside of the stated hours, calls made to a substance abuse provider will be routed to appropriate Counselors on a 24 hour, seven days per week basis for assistance with crisis services.

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Policy/Procedure Number: MP PR SA #212 Lead Department: Provider Relations

Policy/Procedure Title: Access Standards for Substance Abuse Services



Applies to: ☐ Medi-Cal ☐ Healthy Kids ☐ Employees

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C. Telephone Access Standards 1. Members have access to substance abuse staff as follows:

a. Emergent calls are answered immediately. b. Callers reach a non-recorded voice within 30 seconds. c. If provider uses an automated telephone system, rates of call abandonment must not exceed 5%.

D. Interpretive Services

1. In the event that interpretive services are necessary or are requested by a member, substance abuse personnel are to use the telephonic interpreter service available with online services on the PHC website.

E. Monitoring, Collecting, and Analyzing Data 1. The PHC Provider Relations department conducts an annual access survey by using one or more of

the following methods: a. Telephonic survey conducted, asking provider for specific next available appointment times b. A “secret shopper” survey c. On-site evaluations d. Interviews with provider staff e. A telephonic survey to monitor call answer time

2. The PHC Provider Relations department reports specific results of the measures to the Quality

Improvement Department for review of the results and recommend intervention as needed.

3. Opportunities for Improvement. Opportunities to improve availability of clinicians, facilities, programs, and services for members are identified based on the annual analysis of results. In addition to the measures described above, member complaints and responses to the Member Satisfaction Survey are considered when identifying opportunities for improvement.

4. Interventions Interventions are developed in response to multiple indicators; effectiveness of the interventions is evaluated through ongoing monitoring.

VII. REFERENCES:

A. - NCQA VIII. DISTRIBUTION:

A. - PHC Provider Manual IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Provider Relations Director

X. REVISION DATES:

04/19/2006, 06/21/2006, 05/16/2007, 07/16/2008, 07/15/2009, 07/21/2010, 07/20/2011, 08/15/2012, 09/11/2013, 09/10/2014, 09/10,2015,09/13/2016 PREVIOUSLY APPLIED TO:

N/A

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POLICY/ PROCEDURE


Policy/Procedure Title: Availability of Substance Abuse Clinicians/Outpatient Facilities

☒External Policy □ Internal Policy


Applies to: □ Medi-Cal □ Healthy Kids □ Employees

Reviewing Entities:

☒ IQI □ P & T ☒ QUAC

□ OPERATIONS □ EXECUTIVE □ COMPLIANCE □ DEPARTMENT

Approving Entities:

□ BOARD □ COMPLIANCE □ FINANCE ☒ PAC

□ CEO □ COO □ CREDENTIALING □ DEPT. DIRECTOR/OFFICER


I. RELATED POLICIES: A. N/A

II. IMPACTED DEPTS:

A. Provider Relations

III. DEFINITIONS: A. For purposes of this policy, “Availability of Substance Abuse Clinicians and Outpatient Facilities” is

defined as the extent to which PHC has contracted clinicians and outpatient facilities of the appropriate type and number distributed geographically to meet the needs of the membership.

B. Substance abuse credentialed clinicians may include licensed psychiatrists, licensed clinical social

workers, master’s-level clinicians, advanced nurse practitioners, child/adolescent clinicians, and marriage family counselors.

C. Substance Abuse Outpatient Care Facilities include chemical dependence treatment outpatient facilities.

D. Geo-Access® Report is the computer-generated report that measures the estimated distance a member

would need to drive from their place of residence to access in-network services.

E. In-Network Services are services provided by clinicians, facilities, programs, or other substance abuse services contracted with PHC to provide treatment to members. Contracted providers are listed in the PHC Provider directory.

IV. ATTACHMENTS:

A. N/A

V. PURPOSE: To establish standards to ensure that members have appropriate availability of substance abuse clinicians and out-patient facilities.


The Partnership HealthPlan of California is committed to ensuring that its members have the availability of substance abuse health care clinicians and outpatient facilities to meet their substance abuse needs. PHC has established standards for the numbers and types of clinicians and outpatient facilities, as well as for their geographic distribution. The standards are monitored and re-evaluated annually.

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☒ External Policy □ Internal Policy



A. Standards: Members with Estimated Desired Drive Distance from their Residence to a Clinician/Facility.

PROVIDER TYPE STANDARD PERFORMANCE GOAL

Outpatient Care ( substance abuse )

Estimated 30 Miles or 60 minutes

90%

Facility-to-Member Ratio – Number per 1,000 Members.

PROVIDER TYPE STANDARD

Intensive Outpatient Care ( substance abuse )

1.0 per 20 Thousand Members

B. Measurement 1. Members with Estimated Desired Drive Distance: On an annual basis, PHC runs a GeoAccess™

Report, using GeoAccess® software, to calculate estimated drive distance, based on zip codes of unique members and facilities. Performance against standards is determined by calculating the percentage of unique members who have availability of the facility within the established standard.

2. Facility-to-Member Ratio: On an annual basis, PHC calculates the ratio of facilities to members.

Performance against standards is determined by comparing the ratio of facilities to unique members in the service area.

C. Linguistic Specialty/Cultural Competency of Clinician Network

1. Annually, a review is done on clinician linguistic and cultural specialties. The data, along with any related member complaints, is reviewed and action taken as warranted to add diversity to the clinician network.

D. Monitoring, Collecting and Analyzing Data

1. PHC Provider Relations Department monitors compliance of its network adequacy against availability standards as stated in Section B.

2. PHC Provider Relations Department reports specific results of the measures to the Quality

Improvement Department to review these results and recommend interventions, as needed.

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☒ External Policy □ Internal Policy



E. Opportunities for Improvement 1. Opportunities to improve availability of clinicians, facilities, programs, and services for members

are identified based on the annual analysis of results. In addition to the measures described above, member complaints and responses to the Member Satisfaction Survey are considered when identifying opportunities for improvement.

F. Interventions

1. Interventions are developed in response to multiple indicators; effectiveness of the interventions is evaluated through ongoing monitoring.

VII. REFERENCES:

A. - NCQA

VIII. DISTRIBUTION: A. - PHC Provider Manual

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Provider Relations Director

X. REVISION DATES:

04/19/2006, 06/21/2006, 05/16/2007, 07/16/2008, 07/15/2009, 07/21/2010, 07/20/2011, 08/15/2012, 08/14/2013, 09/10/2014, 09/10/2015, 09/13/2016


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POLICY / PROCEDURE

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Policy/Procedure Number: MPQP1018 (previously QP100118) Lead Department: Health Services

Policy/Procedure Title: Preventive Health Guidelines External Policy Internal Policy

Original Date: 05/17/2000 – Medi-Cal 03/21/2007 – Healthy Kids

Next Review Date: 08/19/2016 9/12/2017 Last Review Date: 08/19/2015 09/13/2016


Reviewing Entities:

IQI P & T QUAC


Approving Entities:



Approval Signature: Robert Moore, MD, MPH Approval Date: 08/19/2015 09/13/2016


A. MPQG1005 – Adult Preventive Health Guidelines B. MPQG1015 – Pediatric Preventive Health

II. IMPACTED DEPTS.:

A. -- III. DEFINITIONS:

A. N/A IV. ATTACHMENTS:

A. N/A V. PURPOSE:

Preventive Health Guidelines assist the practitioner to remove or reduce disease risk factors and promote early detection of disease or precursor states.


Preventive Health Guidelines consist of standards for pediatric, adult, and perinatal care. These standards are to serve as a guideline and are not necessarily recommended at every periodic visit. The services may be performed during visits for other reasons, like illness visits or chronic disease checkups, when indicated. Medically necessary services and supplies required for preventive health care are covered when ordered and performed by the Primary Care Practitioner or Obstetrician/Gynecologist. A. The Preventive Health Guidelines are developed by the Health Services Department using input from

like-specialty providers and evidence-based recommendations including but not limited to: 1. Pediatrics:

a. American Academy of Preventive Adolescent/ Pediatric Health Care b. Centers for Disease Control and Prevention – U.S. Preventative Services Task Force

2. Obstetrics: a. American College of Obstetricians and Gynecologists b. U.S. Preventative Services Task Force

3. Adult: a. U.S. Preventative Services Task Force b. American Academy of Family Physicians (AAFP)

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Policy/Procedure Number: MPQP1018 (previously QP100118) Lead Department: Health Services

Policy/Procedure Title: Preventive Health Guidelines ☒External Policy ☐Internal Policy

Original Date: 05/17/2000 – Medi-Cal 03/21/2007 – Healthy Kids

Next Review Date: 08/19/2016 Last Review Date: 08/19/2015


Page 2 of 2

c. American College of Obstetricians and Gynecologists (ACOG) d. American College of Physicians (ACP)

B. The Preventive Health Guidelines are presented to the Quality/Utilization Advisory Committee and to

the Physicians Advisory Committee for review, revision if needed, and approval at least biannually, and more frequently if major changes occur.

C. The Preventive Health Guidelines are included in the facility site review tool.

D. The Preventive Health Guidelines are included in the Practitioner Manual and are available on the PHC website. The Guidelines are distributed to new practitioners upon entering the plan and annually thereafter. The Provider Relations Department is responsible for the distribution of Preventive Health Guidelines.

E. The practitioner manual is updated as changes occur. At the discretion of PHC Internal Quality

Improvement Committee, a broadcast bulletin may also be done by Provider Relations.

F. Members receive an updated copy of the Preventive Health Guideline grid annually in the member newsletter

VII. REFERENCES:

A. N/A VIII. DISTRIBUTION:

A. PHC Department Directors, B. PHC Provider and Practitioner Manuals

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: X. REVISION DATES:

Medi-Cal 05/16/01; 07/17/02; 10/20/04; 03/15/06; 03/21/07; 03/19/08; 04/16/08; 03/18/09; 03/17/10; 05/18/11; 08/15/12; 08/21/13; 08/20/14; 08/19/15 Healthy Kids 03/21/07; 03/19/08; 04/16/08; 03/18/09; 03/17/10; 05/18/11; 08/15/12; 08/21/13; 08/20/14; 8/19/15 PREVIOUSLY APPLIED TO: PartnershipAdvantage: MPQP1018 - 03/21/07 to 01/01/2015 Healthy Families: MPQP1018 - 08/15/2012 to 03/01/2013

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POLICY/ PROCEDURE

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Policy/Procedure Number: MPUP3126 Lead Department: Health Services

Policy/Procedure Title: Autism Spectrum Disorder (ASD) Behavioral Health Treatment (BHT)


Original Date: 08/19/2015 Effective Date: 09/15/2014 vs. DHCS

Next Review Date: 11/18/201609/21/2017 Last Review Date: 11/18/201509/21/2016


Reviewing Entities:



Approving Entities:





A. MCUP3065 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services B. MPCP2006 - Coordination of Services for Members with Special Health Care Needs

(MSHCNS) and Persons with Developmental Disabilities C. MCUP3041 - TARar Review Process D. MCCP2014 - Continuity of Care

II. IMPACTED DEPTS:

A. Health Services B. Claims C. Member Services D. Provider Relations

III. DEFINITIONS: A. Autism Spectrum Disorder (ASD) is characterized by varying degrees of difficulty in social

interaction, verbal and non-verbal communication, and manifestation of repetitive behavior and restricted interests. According to Diagnostic and Statistical Manual (DSM) V, a diagnosis of ASD includes several conditions including Autistic Disorder, Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) and Asperger Syndrome.

B. Applied Behavioral Analysis (ABA) is the design, implementation, and evaluation of environmental modifications to produce socially significant improvement in human behavior. ABA includes the use of direct observation, measurement, and functional analysis of the relations between environment and behavior. (BACB Certification Board Guidelines 2012)

C. Behavioral Health Treatment (BHT) means professional services and treatment programs, including but not limited to Applied Behavior Analysis (ABA) and other evidence-based behavior intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual with ASD. BHT is the design, implementation and evaluation of environmental modification using behavioral stimuli and consequences to produce significant improvement in human behavior, including direct observation, measurement, and functional analysis of the relations between environment and behavior. BHT services teach skills through the use of behavioral observation and reinforcement, or through prompting to teach each step of targeted behavior. BHT services are services based on reliable evidence and are not experimental. (Department of Health Care Services [DHCS] All Plan Letter 14-011)

D. Behavior Analyst Certification Board (BACB) is a corporation established to meet professional credentialing needs identified by behavior analysts and government agencies. They have defined requirements for behavior provider certification. They are accredited by the National Commission for Certifying Agencies. Their 2012 document presents features of ABA, credentialing process and

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Page 2 of 6

consensus of standards for acceptable practices by experts in the delivery of ABA services. E. California Association for Behavioral Analysis (CalABA) is the state association for professional

behavior analysts in California. The association publishes guidelines and offers support and resources for behavior analysts. It has provided guidelines and recommendations to the Department of Developmental Services (DDS) and other entities toward ensuring appropriate, cost-effective behavior services, and utilization of qualified experts in the delivery of services.

F. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Supplemental Services is a federally mandated Medicaid/ Medi-Cal benefit for Medi-Cal beneficiaries under age 21 for medically necessary treatment services needed to correct or ameliorate a defect, physical illness, mental illness or a condition, even if the service or item is not otherwise included in the State’s Medicaid Plan. (Source: Title 22, California Code of Regulations (CCR), Sections 51184; 51242; 51340; 51532)

G. Parent Training - Service Type refers to instruction, observation and/or modeling behavior techniques under the direct guidance/ supervision of the behavior therapy agency staff who developed the behavior treatment plan.

G.H. Release of Information (ROI) Consent Form is a form valid one calendar year from the date of signature of the member to allow the Regional Center and/or Regional Center Behavioral Health Treatment (BHT) provider to share the treatment information with the managed care plan.

H.I. Skills Training - Service Type refers to treatment toward development of improvement of adaptive functioning. Domains of adaptive function may include communication (receptive/ expressive and pragmatic language); socialization; fine and gross motor development; self-help/ daily living skills- eating, toileting, dressing, hygiene; and social emotional functioning. (Source: Autism Spectrum Disorders- Best Practice Guidelines Screening, Diagnosis and Assessment, California Department of Developmental Services, pg 51-52.)

I.J. Therapeutic Behavior Service - Service Type refers to treatment that seeks to identify the stimulus of challenging behaviors and then developing a plan that promotes the development of new skills while reducing the adverse behavior. Challenging behaviors may include tantrums, aggression, self-injury. (Source: Autism Spectrum Disorders- Best Practice Guidelines Screening, Diagnosis and Assessment, California Department of Developmental Services, pg 64-65.)

IV. ATTACHMENTS:

N/A

V. PURPOSE: To define Partnership HealthPlan of California’s (PHC’s) financial responsibility to provide for Behavioral Health Treatment (BHT) services to PHC Medi-Cal eligible beneficiaries under age 21 diagnosed with Autism Spectrum Disorder (ASD) under the Early and Periodic Screening Diagnosis and Treatment (EPSDT) Supplemental Services benefit. To provide an overview of best practices per California Association for Behavior Analysis (CalABA March 2011) and Behavior Analyst Certification Board (BACB report 2012) that meet the expectations of Department of Health Care Services (DHCS) and Partnership HealthPlan for delivery of quality behavioral services.

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A. General Criteria for BHT Services In order to be eligible for BHT services, a PHC Medi-Cal beneficiary must meet all of the following coverage criteria. The recipient must: 1. Be under 21 years of age and have a completed diagnostic evaluation confirming ASD or a provisional diagnosis of ASD if under the age of 3 2. Exhibit the presence of excesses and/or deficits of behaviors that significantly interfere with home or community activities (including, but not limited to, aggression, self-injury, elopement, and/or social interaction, independent living, play and/or communication skills) requiring behavioral assessment and treatment 3. Be medically stable and without a need for 24-hour medical/nursing monitoring or procedures provided in a hospital or intermediate care facility for persons with intellectual disabilities (ICF/ID) B. Diagnostic Evaluation 1. Member must have undergone a comprehensive diagnostic evaluation by an appropriately licensed and/or certified behavior professional that indicates evidence-based BHT services are medically necessary and recognized as therapeutically appropriate. The diagnostic evaluation should include clinical history, direct observation, review of available records and standardized measures including but not limited to ASD features, cognitive abilities and adaptive functioning using published instruments such as Autism Diagnostic Observation Schedule (ADOS). If a copy of the diagnostic evaluation is not available and other reports are provided, such as school reports, those reports will be reviewed. If those reports are not determined to be sufficient, PHC may obtain/authorize a comprehensive diagnostic evaluation. 2. If member does not have a diagnostic evaluation PHC will authorize up to 8 hours for the diagnostic evaluation, which is to include the written report. If, due to special circumstances, it is anticipated that additional time will be needed, the Provider must request the additional time and it must be pre-approved by PHC. Diagnostic evaluation will include: a. Clinical history with informed parent/guardian, inclusive of developmental and psychosocial history b. Direct observation c. Review of available records d. Standardized measures including ASD core features, general psychopathology, cognitive abilities, and adaptive functioning using published instruments administered by qualified members of a diagnostic team C. Covered Services for Behavior Assessment and Behavioral Health Treatment (BHT) 1. TARS will be required for all BHT services and should be faxed or electronically submitted from the Provider to the Health Services Department for review based upon medical necessity criteria and procedures otherwise in compliance with PCHHC Policy MCUP3041 TAR Review Process. . 2. A signed and dated ROI consent form must be submitted with any BHT related clinical documentation or TAR. The ROI is valid for one calendar year from the date of signature and may be cancelled by the member at any time. A copy of the ROI must be submitted with any BHT related clinical documentation. Failure to do so may result in a delay of service. 3. EPSDT covered BHT services must be: a. Prescribed by a licensed physician or surgeon or developed by a licensed psychologist b. Determined as medically necessary as defined by Welfare & Institutions Code Section 14132(v) c. Authorized prior to provision of service in accordance with PHC Policy MCUP3065 Section III A-E: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services; and d. Delivered in accordance with the member’s approved treatment plan

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D. Providers of Services BHT services must be provided and supervised under an approved treatment plan developed by a “qualified autism service provider” as defined by Health & Safety Code Section 1374.73(c). In accordance with DHCS, treatment services may be administered by one of the following: 1. A qualified autism service provider as defined by H&S Code section 1374.73(c)(3) 2. A qualified autism service professional as defined by H&S Code section 1374.73(c)(4) who is supervised and employed by the qualified autism services provider 3. A qualified autism service paraprofessional as defined by H&S Code section 1374.73(c)(5) who is supervised and employed by a qualified autism service provider E. Treatment Plan Criteria 1. BHT services in compliance with Health and Safety Code 1374.73 and Welfare and Institution Code 4686.2 shall be rendered in accordance with the beneficiary’s treatment plan. The treatment plan shall have measureable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific member being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following: a. Describes the patient’s behavioral health impairments or developmental challenges that are to be treated b. Designs an intervention plan that includes the service type, number of hours and parent participation needed to achieve the plan’s goal and objectives, and the frequency at which the member’s progress is evaluated and reported c. Provider’s intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism d. Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate 2. In compliance with DHCS All Plan Letter 14-011, the treatment plan shall: a. Be person-centered and based upon individualized goals over a specific timeline b. Be developed by a qualified autism service provider for the specific beneficiary being treated c. Delineate both the frequency of baseline behaviors and the treatment planned to address the behaviors d. Identify long, intermediate, and short-term goals and objectives that are specific, behaviorally defined, measurable, and based upon clinical observation e. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives f. Utilize evidence-based practices with demonstrated clinical efficacy in treating ASD, and are tailored to the beneficiary g. Ensure that interventions are consistent with evidenced-based BHT techniques. h. Clearly identify the service type, number of hours of direct service and supervision, and parent or guardian participation needed to achieve the plan’s goals and objectives, the frequency at which the beneficiary’s progress is reported, and identifies the individual providers responsible for delivering the services i. Include care coordination involving the parents or caregiver(s), school, state disability programs, and others as applicable; and j. Include parent/caregiver training, support, and participation F. BHT Service Limitations 1. Services must give consideration to the child’s age, school attendance requirements, and other daily activities as documented in the treatment plan. 2. Services must be delivered in a home or community-based settings, including clinics.

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Page 5 of 6

3. Services will be discontinued when the treatment goals and objectives are achieved or are no longer medically necessary. 4. PHC will comply with requirements related to coordination with Local Education Agencies. 5. PHC may cease to authorize continued services that do not meet medical necessity criteria, nor qualify for covered BHT services for reimbursement, including: a. Therapy services rendered when continued clinical benefit is not expected b. Services that are primarily respite, daycare or educational in nature and are used to reimburse a parent for participating in the treatment program c. Treatment whose purpose is vocationally or recreationally-based d. Custodial care defined as provided primarily to assist in the activities of daily living (ADLs), such as bathing, dressing, eating, and maintaining personal hygiene and safety; care that is provided primarily for maintaining the recipient’s or anyone else’s safety; and care that could be provided by persons without professional skills or training. e. Services, supplies, or procedures performed in a non-conventional setting including but not limited to resorts spas or camp f. Services rendered by a parent, legal guardian, or legally responsible person G. Transition of Members Receiving Services from Regional Centers 1. Effective on or after the transition date and phased in approach (to be determined by DHCS), PHC will assume financial responsibility for BHT service for children under the age of 21 who had previously received BHT under a Regional Center. All Regional Center services, other than BHT services for children diagnosed on the Autism Spectrum disorder, will remain the responsibility of the Regional Center. 2. PHC and the member’s local Regional Center will work together to ensure that the needs of the member are met. A Memorandum of Understanding (MOU) that clearly defines roles and responsibilities will be executed between the Regional Centers and PHC. 3. The member and responsible party (parent, guardian) will receive notice of the transition at 60 and 30 days prior to transition implementation. PHC’s Special Program Case Managers and Member Services staff will also attempt outreach to each member’s parent/guardian via telephone to discuss the transition, answer any questions, and to assure them that the transition should not interrupt treatment. 4. Continuity of Care a. If the member is receiving services from an out of network provider, PHC will enter into a continuity of care agreement for up to 12 months when: 1) The beneficiary has a pre-existing relationship with the provider as defined by DHCS 2) The plan and the provider can agree to a minimum of the Medi-Cal FFS rate 3) The provider meets professional standards and has no identified quality of care issues 4) The provider is a State Plan approved provider as defined in the Health & Safety Code 1374.73 and 5) Documents (ie. assessment and treatment plan) are provided to PHC by the provider to facilitate continuity of care b. If PHC and the existing member’s provider are unable to reach a continuity of care agreement, PHC will reach out to the member to transition through a warm handoff to an in-network BHT provider to ensure no gaps in services will apply.

92 of 25292 of 252







Page 6 of 6

VII. REFERENCES:

A. Behavior Analyst Certification Board, Inc (BCBA): Guidelines—Health Plan Coverage of Applied Behavior Analysis Treatment for Autism Spectrum Disorder (2012)

B. California Association for Behavior Analysis (CalABA): Report of the Task Force of California Association for Behavior Analysis—Guidelines for Applied Behavior Analysis (ABA) Services and Recommendations for Best Practices for Regional Center Consumers (March 2011)

C. California Department of Developmental Services, Autism Spectrum Disorders- Best Practice Guidelines Screening, Diagnosis and Assessment, (2002)

D. Department of Health Care Services All Plan Letter 14-011: Interim Policy for the Provision of Behavioral Health Treatment Coverage for Children Diagnosed with Autism Spectrum Disorder (9/15/14)

E. Diagnostic and Statistical Manual (DSM) V F. Health & Safety Code Section 1374.73(c) G. Title 22, California Code of Regulations (CCR), Sections 51184; 51242; 51340; 51532 H. Welfare & Institutions Code Section 14132(v) and 4686.2 I. Department of Health Care Services All Plan Letter 15-019: Continuity of Care for Medi-Cal

Beneficiaries Who Transition Into Medi-Cal Managed Care VIII. DISTRIBUTION:

A. Department Directors B. Provider Manual


X. REVISION DATES: 08/19/15 effective 09/15/14 per DHCS; 11/18/15; 09/21/16


N/A

*********************************

In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with involvement from actively practicing health care providers and meets these provisions:



If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be disclosed to the provider and/or enrollee upon request

The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under PHC.

93 of 25293 of 252


POLICY/ PROCEDURE

Page 1 of 6


Policy/Procedure Title: Autism Spectrum Disorder (ASD)

Behavioral Health Treatment (BHT)

☒External Policy

☐ Internal Policy

Original Date: 08/19/2015

Effective Date: 09/15/2014 vs. DHCS Next Review Date: 09/21/2017



Reviewing

Entities:



Approving

Entities:





A. MCUP3065 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

B. MPCP2006 - Coordination of Services for Members with Special Health Care Needs

(MSHCNS) and Persons with Developmental Disabilities

C. MCUP3041 - TAR Review Process

D. MCCP2014 - Continuity of Care

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

D. Provider Relations

III. DEFINITIONS:

A. Autism Spectrum Disorder (ASD) is characterized by varying degrees of difficulty in social

interaction, verbal and non-verbal communication, and manifestation of repetitive behavior and

restricted interests. According to Diagnostic and Statistical Manual (DSM) V, a diagnosis of ASD

includes several conditions including Autistic Disorder, Pervasive Developmental Disorder Not

Otherwise Specified (PDD-NOS) and Asperger Syndrome.

B. Applied Behavioral Analysis (ABA) is the design, implementation, and evaluation of environmental

modifications to produce socially significant improvement in human behavior. ABA includes the use of

direct observation, measurement, and functional analysis of the relations between environment and

behavior. (BACB Certification Board Guidelines 2012)

C. Behavioral Health Treatment (BHT) means professional services and treatment programs, including

but not limited to Applied Behavior Analysis (ABA) and other evidence-based behavior intervention

programs that develop or restore, to the maximum extent practicable, the functioning of an individual

with ASD. BHT is the design, implementation and evaluation of environmental modification using

behavioral stimuli and consequences to produce significant improvement in human behavior, including

direct observation, measurement, and functional analysis of the relations between environment and

behavior. BHT services teach skills through the use of behavioral observation and reinforcement, or

through prompting to teach each step of targeted behavior. BHT services are services based on reliable

evidence and are not experimental. (Department of Health Care Services [DHCS] All Plan Letter 14-011)

D. Behavior Analyst Certification Board (BACB) is a corporation established to meet professional

credentialing needs identified by behavior analysts and government agencies. They have defined

requirements for behavior provider certification. They are accredited by the National Commission for

Certifying Agencies. Their 2012 document presents features of ABA, credentialing process and

94 of 25294 of 252




☒ External Policy

☐ Internal Policy





Page 2 of 6

consensus of standards for acceptable practices by experts in the delivery of ABA services.

E. California Association for Behavioral Analysis (CalABA) is the state association for professional

behavior analysts in California. The association publishes guidelines and offers support and resources

for behavior analysts. It has provided guidelines and recommendations to the Department of

Developmental Services (DDS) and other entities toward ensuring appropriate, cost-effective behavior

services, and utilization of qualified experts in the delivery of services.

F. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Supplemental Services is a

federally mandated Medicaid/ Medi-Cal benefit for Medi-Cal beneficiaries under age 21 for medically

necessary treatment services needed to correct or ameliorate a defect, physical illness, mental illness or a

condition, even if the service or item is not otherwise included in the State’s Medicaid Plan. (Source:

Title 22, California Code of Regulations (CCR), Sections 51184; 51242; 51340; 51532)

G. Parent Training - Service Type refers to instruction, observation and/or modeling behavior techniques

under the direct guidance/ supervision of the behavior therapy agency staff who developed the behavior

treatment plan.

H. Release of Information (ROI) Consent Form is a form valid one calendar year from the date of

signature of the member to allow the Regional Center and/or Regional Center Behavioral Health

Treatment (BHT) provider to share the treatment information with the managed care plan.

I. Skills Training - Service Type refers to treatment toward development of improvement of adaptive

functioning. Domains of adaptive function may include communication (receptive/ expressive and

pragmatic language); socialization; fine and gross motor development; self-help/ daily living skills-

eating, toileting, dressing, hygiene; and social emotional functioning. (Source: Autism Spectrum

Disorders- Best Practice Guidelines Screening, Diagnosis and Assessment, California Department of

Developmental Services, pg 51-52.)

J. Therapeutic Behavior Service - Service Type refers to treatment that seeks to identify the stimulus of

challenging behaviors and then developing a plan that promotes the development of new skills while

reducing the adverse behavior. Challenging behaviors may include tantrums, aggression, self-injury.

(Source: Autism Spectrum Disorders- Best Practice Guidelines Screening, Diagnosis and Assessment,

California Department of Developmental Services, pg 64-65.)

IV. ATTACHMENTS:

N/A

V. PURPOSE: To define Partnership HealthPlan of California’s (PHC’s) financial responsibility to provide for Behavioral

Health Treatment (BHT) services to PHC Medi-Cal eligible beneficiaries under age 21 diagnosed with

Autism Spectrum Disorder (ASD) under the Early and Periodic Screening Diagnosis and Treatment

(EPSDT) Supplemental Services benefit. To provide an overview of best practices per California

Association for Behavior Analysis (CalABA March 2011) and Behavior Analyst Certification Board

(BACB report 2012) that meet the expectations of Department of Health Care Services (DHCS) and

Partnership HealthPlan for delivery of quality behavioral services.


A. General Criteria for BHT Services

In order to be eligible for BHT services, a PHC Medi-Cal beneficiary must meet all of the

following coverage criteria. The recipient must:

1. Be under 21 years of age and have a completed diagnostic evaluation confirming ASD or a

provisional diagnosis of ASD if under the age of 3

2. Exhibit the presence of excesses and/or deficits of behaviors that significantly interfere with

home or community activities (including, but not limited to, aggression, self-injury,

elopement, and/or social interaction, independent living, play and/or communication skills)

95 of 25295 of 252




☒ External Policy

☐ Internal Policy





Page 3 of 6

requiring behavioral assessment and treatment

3. Be medically stable and without a need for 24-hour medical/nursing monitoring or

procedures provided in a hospital or intermediate care facility for persons with intellectual

disabilities (ICF/ID)

B. Diagnostic Evaluation

1. Member must have undergone a comprehensive diagnostic evaluation by an appropriately

licensed and/or certified behavior professional that indicates evidence-based BHT services are

medically necessary and recognized as therapeutically appropriate. The diagnostic evaluation

should include clinical history, direct observation, review of available records and standardized

measures including but not limited to ASD features, cognitive abilities and adaptive functioning

using published instruments such as Autism Diagnostic Observation Schedule (ADOS). If a

copy of the diagnostic evaluation is not available and other reports are provided, such as school

reports, those reports will be reviewed. If those reports are not determined to be sufficient, PHC

may obtain/authorize a comprehensive diagnostic evaluation.

2. If member does not have a diagnostic evaluation PHC will authorize up to 8 hours for the

diagnostic evaluation, which is to include the written report. If, due to special circumstances, it

is anticipated that additional time will be needed, the Provider must request the additional time

and it must be pre-approved by PHC. Diagnostic evaluation will include:

a. Clinical history with informed parent/guardian, inclusive of developmental and

psychosocial history

b. Direct observation

c. Review of available records

d. Standardized measures including ASD core features, general psychopathology, cognitive

abilities, and adaptive functioning using published instruments administered by qualified

members of a diagnostic team

C. Covered Services for Behavior Assessment and Behavioral Health Treatment (BHT)

1. TARS will be required for all BHT services and should be faxed or electronically submitted from the

Provider to the Health Services Department for review based upon medical necessity criteria and

procedures otherwise in compliance with PHC Policy MCUP3041 TAR Review Process.

2. A signed and dated ROI consent form must be submitted with any BHT related clinical

documentation or TAR. The ROI is valid for one calendar year from the date of signature and may

be cancelled by the member at any time. A copy of the ROI must be submitted with any BHT

related clinical documentation. Failure to do so may result in a delay of service.

3. EPSDT covered BHT services must be:

a. Prescribed by a licensed physician or surgeon or developed by a licensed psychologist

b. Determined as medically necessary as defined by Welfare & Institutions Code Section 14132(v)

c. Authorized prior to provision of service in accordance with PHC Policy MCUP3065

Section III A-E: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services;

and

d. Delivered in accordance with the member’s approved treatment plan

D. Providers of Services

BHT services must be provided and supervised under an approved treatment plan developed by a

“qualified autism service provider” as defined by Health & Safety Code Section 1374.73(c). In

accordance with DHCS, treatment services may be administered by one of the following:

1. A qualified autism service provider as defined by H&S Code section 1374.73(c)(3)

2. A qualified autism service professional as defined by H&S Code section 1374.73(c)(4) who is

supervised and employed by the qualified autism services provider

3. A qualified autism service paraprofessional as defined by H&S Code section 1374.73(c)(5) who is

supervised and employed by a qualified autism service provider

96 of 25296 of 252




☒ External Policy

☐ Internal Policy





Page 4 of 6

E. Treatment Plan Criteria

1. BHT services in compliance with Health and Safety Code 1374.73 and Welfare and Institution Code

4686.2 shall be rendered in accordance with the beneficiary’s treatment plan. The treatment plan

shall have measureable goals over a specific timeline that is developed and approved by the

qualified autism service provider for the specific member being treated. The treatment plan shall be

reviewed no less than once every six months by the qualified autism provider and modified

whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions

Code pursuant to which the qualified autism service provider does all of the following:

a. Describes the patient’s behavioral health impairments or developmental challenges that are to be

treated

b. Designs an intervention plan that includes the service type, number of hours and parent

participation needed to achieve the plan’s goal and objectives, and the frequency at which the

member’s progress is evaluated and reported

c. Provider’s intervention plans that utilize evidence-based practices, with demonstrated clinical

efficacy in treating pervasive developmental disorder or autism

d. Discontinues intensive behavioral intervention services when the treatment goals and objectives

are achieved or no longer appropriate

2. In compliance with DHCS All Plan Letter 14-011, the treatment plan shall:

a. Be person-centered and based upon individualized goals over a specific timeline

b. Be developed by a qualified autism service provider for the specific beneficiary being treated

c. Delineate both the frequency of baseline behaviors and the treatment planned to address the

behaviors

d. Identify long, intermediate, and short-term goals and objectives that are specific, behaviorally

defined, measurable, and based upon clinical observation

e. Include outcome measurement assessment criteria that will be used to measure achievement of

behavior objectives

f. Utilize evidence-based practices with demonstrated clinical efficacy in treating ASD, and are

tailored to the beneficiary

g. Ensure that interventions are consistent with evidenced-based BHT techniques.

h. Clearly identify the service type, number of hours of direct service and supervision, and parent

or guardian participation needed to achieve the plan’s goals and objectives, the frequency at

which the beneficiary’s progress is reported, and identifies the individual providers responsible

for delivering the services

i. Include care coordination involving the parents or caregiver(s), school, state disability programs,

and others as applicable; and

j. Include parent/caregiver training, support, and participation

F. BHT Service Limitations

1. Services must give consideration to the child’s age, school attendance requirements, and other daily

activities as documented in the treatment plan.

2. Services must be delivered in a home or community-based settings, including clinics.

3. Services will be discontinued when the treatment goals and objectives are achieved or are no longer

medically necessary.

4. PHC will comply with requirements related to coordination with Local Education Agencies.

5. PHC may cease to authorize continued services that do not meet medical necessity criteria, nor

qualify for covered BHT services for reimbursement, including:

a. Therapy services rendered when continued clinical benefit is not expected

b. Services that are primarily respite, daycare or educational in nature and are used to reimburse a

parent for participating in the treatment program

c. Treatment whose purpose is vocationally or recreationally-based

d. Custodial care defined as provided primarily to assist in the activities of daily living (ADLs),

97 of 25297 of 252




☒ External Policy

☐ Internal Policy





Page 5 of 6

such as bathing, dressing, eating, and maintaining personal hygiene and safety; care that is

provided primarily for maintaining the recipient’s or anyone else’s safety; and care that could be

provided by persons without professional skills or training.

e. Services, supplies, or procedures performed in a non-conventional setting including but not

limited to resorts spas or camp

f. Services rendered by a parent, legal guardian, or legally responsible person

G. Transition of Members Receiving Services from Regional Centers

1. Effective on or after the transition date and phased in approach (to be determined by DHCS), PHC

will assume financial responsibility for BHT service for children under the age of 21 who had

previously received BHT under a Regional Center. All Regional Center services, other than BHT

services for children diagnosed on the Autism Spectrum disorder, will remain the responsibility of

the Regional Center.

2. PHC and the member’s local Regional Center will work together to ensure that the needs of the

member are met. A Memorandum of Understanding (MOU) that clearly defines roles and

responsibilities will be executed between the Regional Centers and PHC.

3. The member and responsible party (parent, guardian) will receive notice of the transition at 60 and

30 days prior to transition implementation. PHC’s Special Program Case Managers and Member

Services staff will also attempt outreach to each member’s parent/guardian via telephone to discuss

the transition, answer any questions, and to assure them that the transition should not interrupt

treatment.

4. Continuity of Care

a. If the member is receiving services from an out of network provider, PHC will enter into a

continuity of care agreement for up to 12 months when:

1) The beneficiary has a pre-existing relationship with the provider as defined by DHCS

2) The plan and the provider can agree to a minimum of the Medi-Cal FFS rate

3) The provider meets professional standards and has no identified quality of care issues

4) The provider is a State Plan approved provider as defined in the Health & Safety Code

1374.73 and

5) Documents (ie. assessment and treatment plan) are provided to PHC by the provider to

facilitate continuity of care

b. If PHC and the existing member’s provider are unable to reach a continuity of care agreement,

PHC will reach out to the member to transition through a warm handoff to an in-network BHT

provider to ensure no gaps in services will apply.

98 of 25298 of 252




☒ External Policy

☐ Internal Policy





Page 6 of 6

VII. REFERENCES: A. Behavior Analyst Certification Board, Inc (BCBA): Guidelines—Health Plan Coverage of Applied

Behavior Analysis Treatment for Autism Spectrum Disorder (2012)

B. California Association for Behavior Analysis (CalABA): Report of the Task Force of California Association for Behavior Analysis—Guidelines for Applied Behavior Analysis (ABA) Services and

Recommendations for Best Practices for Regional Center Consumers (March 2011)

C. California Department of Developmental Services, Autism Spectrum Disorders- Best Practice

Guidelines Screening, Diagnosis and Assessment, (2002)

D. Department of Health Care Services All Plan Letter 14-011: Interim Policy for the Provision of

Behavioral Health Treatment Coverage for Children Diagnosed with Autism Spectrum Disorder

(9/15/14)

E. Diagnostic and Statistical Manual (DSM) V

F. Health & Safety Code Section 1374.73(c)

G. Title 22, California Code of Regulations (CCR), Sections 51184; 51242; 51340; 51532

H. Welfare & Institutions Code Section 14132(v) and 4686.2

I. Department of Health Care Services All Plan Letter 15-019: Continuity of Care for Medi-Cal

Beneficiaries Who Transition Into Medi-Cal Managed Care

VIII. DISTRIBUTION:

A. Department Directors

B. Provider Manual


X. REVISION DATES: 08/19/15 effective 09/15/14 per DHCS; 11/18/15; 09/21/16


*********************************









covered under PHC.

99 of 25299 of 252



Page 1 of 3



Guideline/Procedure Title: Orthotic and Prosthetic Appliances

Guidelines

☒External Policy

☐ Internal Policy


Last Review Date: 01/20/201609/21/2016


Reviewing

Entities:



Approving

Entities:






II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

N/A

IV. ATTACHMENTS:

N/A

V. PURPOSE:

To describe the criteria for approval of orthotic and prosthetic appliances


A. Partnership HealthPlan of California (PHC) covers orthotic and prosthetic appliances when such

appliances are necessary for the restoration of function or replacement of body parts, as prescribed in

writing by a physician or podiatrist. PHC utilizes Medi-Cal criteria for authorization of orthotic and

prosthetic devices as guidelines to determine medical necessity. Exceptions to these guidelines may be

made based on the individual needs of the member or the unique characteristics of the delivery system.

B. The definition of medical necessity is health care services that are necessary to prevent significant illness

or significant disability, or to alleviate severe pain. Therefore, prescribed appliances will be covered

only as medically necessary to restore bodily functions essential to activities of daily living, to prevent

significant disability or serious deterioration of health, or to alleviate severe pain. The prescribing

physician or podiatrist must supply the vendor with information required to document the medical

necessity for the item.

C. A Treatment Authorization Request (TAR) is required when the cost for repair/maintenance, purchase or

rental exceeds $250 for orthotics or $500 for prosthetics. D. TAR requests for orthotic or prosthetic appliances must include the diagnosis related to the functional

disability, a copy of prescribing physician prescription, a statement concerning the member’s functional

disability that would benefit from the appliance, and a statement explaining the reason more cost

effective options would not meet the member’s needs.

100 of 252100 of 252


UG100332 Lead Department: Health Services


Guidelines

☒ External Policy

☐ Internal Policy


Last Review Date: 01/20/201609/21/2016


Page 2 of 3

E. A repair of an appliance will not be authorized when the repair cost is equal to or exceeds the purchase

cost of a new appliance.

F. For appliance claims submitted by report, the vendor must list the item description, manufacturer name,

model number, catalog page, suggested retail price, cost of part(s) used, cost of labor per hour and total

cost/hours, description of and medical justification for any special features (custom modification or

special accessories) and medical condition necessitating the appliance.

G. Orthopedic Shoes

1. Stock orthopedic and stock conventional shoes are covered when provided on the prescription of a

physician or podiatrist when at least one of the shoes is an integral part of a leg brace and is

medically necessary for the proper functioning of the brace.will be attached to a prosthesis or brace.

Attached to the prosthesis or brace means the prosthesis or brace is permanently affixed to the shoe

as an integral part.

2. Modification of stock conventional shoes or stock orthopedic shoes is covered when the patient's

medical need can be satisfied with such modification.

3. Custom-made orthopedic shoes are reimbursable if the recipient’s medical need cannot be met by

modifications to stock orthopedic or stock conventional shoes. Clinical conditions that might

require custom-made shoes include but are not limited to Charcot or rheumatoid foot deformities,

some partial foot amputations, or when a patient requires a muscle flap to cover a large or unusual

soft tissue foot defect that then is too bulky to be accommodated by an in-depth shoe.

4. The prescribing physician must document the nature, cause and severity of the foot problem leading

to the conclusion that a custom-made orthopedic shoe is the only alternative (CCR, Title 22, Section

51315). A custom-made shoe has the following characteristics:

a. Made and molded to patient model for a specific patient

b. Constructed over a positive model of the patient’s foot

c. Made from leather or other suitable material of equal quality

d. Has removable inserts as an integral part of the shoe that can be altered or replaced as the

patient’s condition warrants

e. Has some form of shoe closure

H. Orthotics

1. Orthotics are covered when medically necessary for the following acute or chronic foot condition:

a. Rehabilitative foot orthotics following foot surgery or trauma

b. Plantar fasciitis

c. Inflammatory conditions such as bursitis, tenosynovitis, plantar fascial fibromatosis

d. Chronic ankle instability

e. Neurologically impaired feet

f. Vascular conditions including poor circulation or peripheral vascular disease

g. Musculoskeletal deformities such as bunions, hallux valgus, talipes deformities, toe deformities

2. Foot orthotics are not medically necessary and are not covered for the following conditions:

a. Back pain

b. Knee pain other than lateral wedges for medial osteoarthritis of the knee

c. Pes planus (flat feet)

d. Pronation

e. Corns or calluses

f. Hip osteoarthritis

e.g. Lower leg injuries

VII. REFERENCES: A. Medi-Cal Allied Health Manual

B. Title 22 California Code of Regulations (CCR) 51515

101 of 252101 of 252




Guidelines

☒ External Policy

☐ Internal Policy


Last Review Date: 01/20/201609/21/2016


Page 3 of 3

C. Title 22 California Code of Regulations (CCR) 51315

VIII. DISTRIBUTION:

A. PHC Departmental Directors



X. REVISION DATES: 06/1/00; 09/20/00; 12/19/01; 11/20/02; 09/15/04; 10/19/05; 08/20/08; 11/18/09;

05/18/11; 02/20/13; 01/20/16; 09/21/16


***********************************









covered under PHC.

102 of 252102 of 252



Page 1 of 3




Guidelines

☒External Policy

☐ Internal Policy

Original Date: 02/21/1995 Next Review Date: 09/21/2017



Reviewing

Entities:



Approving

Entities:






II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

N/A

IV. ATTACHMENTS:

N/A

V. PURPOSE:

To describe the criteria for approval of orthotic and prosthetic appliances


A. Partnership HealthPlan of California (PHC) covers orthotic and prosthetic appliances when such

appliances are necessary for the restoration of function or replacement of body parts, as prescribed in

writing by a physician or podiatrist. PHC utilizes Medi-Cal criteria for authorization of orthotic and

prosthetic devices as guidelines to determine medical necessity. Exceptions to these guidelines may be

made based on the individual needs of the member or the unique characteristics of the delivery system.

B. The definition of medical necessity is health care services that are necessary to prevent significant illness

or significant disability, or to alleviate severe pain. Therefore, prescribed appliances will be covered

only as medically necessary to restore bodily functions essential to activities of daily living, to prevent

significant disability or serious deterioration of health, or to alleviate severe pain. The prescribing

physician or podiatrist must supply the vendor with information required to document the medical

necessity for the item.

C. A Treatment Authorization Request (TAR) is required when the cost for repair/maintenance, purchase or

rental exceeds $250 for orthotics or $500 for prosthetics. D. TAR requests for orthotic or prosthetic appliances must include the diagnosis related to the functional

disability, a copy of prescribing physician prescription, a statement concerning the member’s functional

disability that would benefit from the appliance, and a statement explaining the reason more cost

effective options would not meet the member’s needs.

103 of 252103 of 252




Guidelines

☒ External Policy

☐ Internal Policy




Page 2 of 3

E. A repair of an appliance will not be authorized when the repair cost is equal to or exceeds the purchase

cost of a new appliance.

F. For appliance claims submitted by report, the vendor must list the item description, manufacturer name,

model number, catalog page, suggested retail price, cost of part(s) used, cost of labor per hour and total

cost/hours, description of and medical justification for any special features (custom modification or

special accessories) and medical condition necessitating the appliance.

G. Orthopedic Shoes

1. Stock orthopedic and stock conventional shoes are covered when provided on the prescription of a

physician or podiatrist when at least one of the shoes is an integral part of a leg brace and is

medically necessary for the proper functioning of the brace.

2. Modification of stock conventional shoes or stock orthopedic shoes is covered when the patient's

medical need can be satisfied with such modification.

3. Custom-made orthopedic shoes are reimbursable if the recipient’s medical need cannot be met by

modifications to stock orthopedic or stock conventional shoes. Clinical conditions that might

require custom-made shoes include but are not limited to Charcot or rheumatoid foot deformities,

some partial foot amputations, or when a patient requires a muscle flap to cover a large or unusual

soft tissue foot defect that then is too bulky to be accommodated by an in-depth shoe.

4. The prescribing physician must document the nature, cause and severity of the foot problem leading

to the conclusion that a custom-made orthopedic shoe is the only alternative (CCR, Title 22, Section

51315). A custom-made shoe has the following characteristics:

a. Made and molded to patient model for a specific patient

b. Constructed over a positive model of the patient’s foot

c. Made from leather or other suitable material of equal quality

d. Has removable inserts as an integral part of the shoe that can be altered or replaced as the

patient’s condition warrants

e. Has some form of shoe closure

H. Orthotics

1. Orthotics are covered when medically necessary for the following acute or chronic foot condition:

a. Rehabilitative foot orthotics following foot surgery or trauma

b. Plantar fasciitis

c. Inflammatory conditions such as bursitis, tenosynovitis, plantar fascial fibromatosis

d. Chronic ankle instability

e. Neurologically impaired feet

f. Vascular conditions including poor circulation or peripheral vascular disease

g. Musculoskeletal deformities such as bunions, hallux valgus, talipes deformities, toe deformities

2. Foot orthotics are not medically necessary and are not covered for the following conditions:

a. Back pain

b. Knee pain other than lateral wedges for medial osteoarthritis of the knee

c. Pes planus (flat feet)

d. Pronation

e. Corns or calluses

f. Hip osteoarthritis

g. Lower leg injuries

VII. REFERENCES: A. Medi-Cal Allied Health Manual

B. Title 22 California Code of Regulations (CCR) 51515

C. Title 22 California Code of Regulations (CCR) 51315

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Guidelines

☒ External Policy

☐ Internal Policy




Page 3 of 3

VIII. DISTRIBUTION:

A. PHC Departmental Directors



X. REVISION DATES: 06/1/00; 09/20/00; 12/19/01; 11/20/02; 09/15/04; 10/19/05; 08/20/08; 11/18/09;

05/18/11; 02/20/13; 01/20/16; 09/21/16


***********************************









covered under PHC.

105 of 252105 of 252


POLICY/ PROCEDURE

Page 1 of 7

Policy/Procedure Number: MCUP3113 Lead Department: Health Services

Policy/Procedure Title: Telehealth Services ☒External Policy ☐ Internal Policy



Reviewing Entities:



Approving Entities:





A. MCUP3124 - Referral to Specialists (RAF) Policy B. MCUP3052 - Medical Nutrition Services C. MCUP3028 - Mental Health Services

II. IMPACTED DEPTS:

A. Health Services B. Provider Relations C. Claims

III. DEFINITIONS: A. Telehealth means the mode of delivering health care and public health services utilizing information and

communication technologies to enable the diagnosis, consultation, treatment, education, care management and self-management of patient at a distance from health care providers.

B. Health care provider means a person who is licensed by the State of California Department of Health Care Services and a Medi-Cal certified provider.

C. Originating site means the site where a patient is located at the time health services are provided via a telecommunications system or where the asynchronous store and forward services originates.

D. Distant site means a site where a health care provider who provides health services is located while providing these services via telecommunications system.

E. Synchronous interaction means a real-time interaction between a patient and health care provider located at a distant site.

F. Asynchronous store and forward means the transmission of a patient’s medical information from an originating site to the health care provider at a distance without the presence of the patient

G. Medical Necessity means reasonable and necessary services to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury.


V. PURPOSE:

The goal of telehealth is to improve both access and quality health services provided in rural and other medically underserved areas through the use information and telecommunications technologies. The purpose of this policy is to define telehealth services available to Partnership HealthPlan of California (PHC) members and their general reimbursement policies.

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Policy/Procedure Title: Telehealth Services ☒ External Policy ☐ Internal Policy



Page 2 of 7

In 1996, Medicare initially approved limited coverage for telemedicine services. In the same year, the State of California passed the Telemedicine Development Act of 1996 governing the delivery of health care services through Telemedicine and authorizing terms and conditions of reimbursement of Telemedicine services under Medi-Cal. In 2005, California broadened the definition of telemedicine services to include store and forward telemedicine consults for teleopthalmology and teledermatology. Most recently, the State approved AB 415 the Telehealth Advancement Act of 2011 that allows for: • The provision of a broader range of telehealth services • The expansion of telehealth providers to include all licensed healthcare professionals • The expansion of telehealth settings to include physician offices, hospitals, clinics and home settings and other sites • The ability of California hospitals to establish medical credentials for telehealth providers more easily The Telehealth Advancement Act of 2011 does not limit the type of settings where telehealth services are provided to patients. Telehealth services may be provided at a physician office, clinic setting, hospital, skilled nursing facility, residential care setting or patient home or other setting and must be in compliance with all laws regarding the confidentiality of health care information and a patient’s rights to his or her medical information. There is no longer a need to document a justification for use of telehealth services instead of in-person services. Aside from this, services provided by telehealth must still meet state and federal guidelines for “medical necessity” and the documentation should support this.


This policy defines key telemedicine/telehealth terms, PHC telehealth covered benefits and, reimbursement policies. PHC fully supports the advancement of telehealth services in our region as a means of improving access and quality of care to members as well as providing expert advice and specialty consultation to primary care providers (PCPs) in the PHC network. The effective date of this policy is for dates of service on or after March 1st, 2012. Current PHC referral and authorization requirements apply to telehealth services per policy MCUP3124 Referral to Specialists (RAF) Policy. Telemedicine services may be used to provide mild-moderate severity Mental Health Services to PHC members. Such services are provided through PHC’s contracted Behavioral Health Managed Services organization. See policy MCUP3028 Mental Health Services for additional information. A. Synchronous Telehealth Services and Settings

1. Synchronous telehealth services can be provided to PHC members by any PHC credentialed health care provider with the member’s verbal consent, as documented in the patient’s medical record.

B. Asynchronous Telehealth Services & Settings 1. Asynchronous store and forward telehealth services provides for the review of medical information

at a later time by a physician or optometrist at a distant site without the patient being present in real time. The following Medi-Cal certified health care providers may provide store and forward services: a. Ophthalmologists b. Dermatologists c. Optometrists (licensed pursuant to Chapter 7 (commencing with Section 3000) of Division 2 of

the Business and Professions Code) c.d. Specialists participating in PHC’s eConsult Program

2. Patients receiving teledermatology or teleophthalmology services by store and forward must be notified of the right to interactive communication with the distant specialist if requested. If requested, the communication may occur at the time of the consultation or within 30 days of the patient’s notification of the results of the consultation.

C. Consent

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Page 3 of 7

1. Prior to the delivery of health care services via telehealth, the health care provider at the originating site must verbally inform the patient that telehealth may be used and obtain verbal consent from the patient for this use. The verbal consent must be documented in the patient’s medical record.

D. Confidentiality 1. All federal and state laws regarding the confidentiality of health care information and a patient’s

rights to his or her medical information apply to telehealth services. E. Credentialing of Providers of Telehealth Services to PHC Members in a Hospital Setting

1. Licensed health care providers providing telehealth services to Partnership HealthPlan members, outside a hospital setting, need to be a Medi-Cal certified provider in the State of California and a qualified provider credentialed through Partnership HealthPlan, or an organization with delegated authority for credentialing, as approved by the Partnership HealthPlan Credentials Committee.

2. The governing body of the hospital whose patients are receiving telehealth services may grant privileges to, and verify and approve credentials for, providers of telehealth services based on its medical staff recommendations that rely on information provided by the distant site hospital or telehealth entity, as described in Sections 482.12, 482.22 and 485.616 of Title 42 of the Code of Federal Regulations.

F. Required Equipment 1. The audio-video telemedicine system used, must, at a minimum, have the capability of meeting the

procedural definition of the code provided through telehealth. The telecommunication equipment must be of a quality to adequately complete all necessary components to document the level of service for the CPT code billed.

G. Reimbursement for Telehealth Services 1. There are three main models of telehealth services available to PHC members.

a. The first, called “Traditional Synchronous Telehealth Services” connects the patient with a distant provider of health services through audio-video equipment on a real-time basis. This model is commonly used between specialty centers such as UCSF or UCD with outlying physician offices or community health centers.

b. The second model, called “Asynchronous Telehealth Services” or the “Store and Forward” model connects a patient with a distant provider of ophthalmology, dermatology or certain optometry services using audio-video equipment, but not on a real-time basis. Generally an image or picture is taken and forwarded to the specialty provider to review at a later time. This also includes specialty services provided via eConsults, or electronic consultations, which consist of an electronic exchange of information through the eConsult platform and may include images or photos, labs, and other relevant patient information.

c. The third model called “Synchronous Patient to Provider Telehealth Services” connects a single provider (primary care or specialty provider) to a patient using audio-visual equipment on a real-time basis. The patient can be in a health facility, residential group home or private residence or other setting, provided the appropriate equipment is used. The reimbursement terms for each of the three models are summarized below:

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Page 4 of 7

H. Reimbursement for Traditional Synchronous Telehealth Services

Billing guidelines for Originating Site Providers:

Originating Site Service Code Site facility fee (billable only when no CPT/E&M code is billed)

Q3014

Transmission Cost T1014 (per minute for maximum of 90 min. per patient) Licensed provider fee (if present) E&M codes 99201 - 99215 and other CPT codes for services

distinct and in addition to those rendered by the Distant Site Provider.

If a Licensed provider also is present at the telehealth Originating Site with the patient present and a progress note is generated by the originating provider, the visit is reimbursable. The scope of the interaction with the originating provider should be documented in the progress note that are distinct from those provided by the Distant Site and will be the basis of the E&M and other CPT code(s) billed. If an E&M code is included, the transmission cost fees may be billed. No modifier is needed at the Originating Site.

Billing guidelines for Distant Site Providers:

Distant Site

Service Code Transmission Cost T1014 (per minute for maximum of 90 min. per

patient) Initial hospital care or subsequent hospital care, critical care (new or established patient)

99221 – 99233,

Extended Inpatient Care 99356 - 99357 Consultations: Office or other outpatient ( initial or follow-up) Inpatient, and confirmatory

99241 – 99275

Genetic Counseling 96040, S0265 Nutrition Counseling per PHC Guidelines (See Policy MCUP3052)

97802, 97803, 97804 – use GT modifier

Required Modifier GT modifier required for all CPT-Codes except Transmission Cost codes

Note: An FQHC/RHC/Tribal health site may choose to sub-contract with a specialist and pay them directly. Under these circumstances, the FQHC/RHC would bill for the originating site and the specialty service on two separate claims. The PHC system would need to be set up for the specific specialty and if not, the Provider Relations Department should be contacted.

Originating Site • Patient present • Provider

optional

Distant Site • Provider of

service

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Page 5 of 7

I. Reimbursement for Asynchronous Telehealth Services (Store and Forward) for Teleophthamology, Teleoptometry, and Teledermatology, and eConsult Program Services

If a Licensed provider also is present at the telehealth Originating Site, with the patient present and a progress note generated by the originating provider, the visit is reimbursable as a visit. The scope of the interaction with the originating provider should be documented in the progress note, and will be the basis of the CPT code(s) used. If a CPT code is included, the originating site fee and the transmission cost fees may still be billed. No modifier is needed. Special Billing Guidelines for Asynchronous Retinal Photography - Originating Site Providers: If a provider uses asynchronous telehealth for diabetic eye exam screenings, through the use of a retinal camera located at the originating site, special billing guidelines apply, when the originating site is paying the specialist directly for reading the results of the retinal photographs. A licensed provider does not need to be present for retinal photography service to be reimbursable. If no provider is present at visit, bill using the following CPT codes:

Originating Store and Forward Site Service CPT Codes Retinal photography with interpretation for services provided by optometrists or ophthalmologists 92250 (Do not use modifier)

Site facility fee (billable with or without provider present) Q3014

Transmission Cost T1014 (per minute for maximum of 90 min. per patient)

If provider is present at visit, E&M codes can also be billed as usual. The scope of the interaction with the originating provider should be documented in the progress note. The originating site fee and the transmission cost fees may still be billed. No modifier is needed. Billing guidelines for Distant Store and Forward Site Providers:

Distant Store and Forward Site Service CPT Codes Office consultation, new or established patient 99241 - 99243 Retinal photography with interpretation for services provided by optometrists or ophthalmologists (should not be used if originating site is submitting claims with this code).

92250

Required Modifier: All asynchronous, store-and-forward services are billed with a “GQ” modifier

Special Billing Guidelines for Asynchronous eConsult service - Distant Site Providers: If a provider uses asynchronous telehealth for eConsult services, special billing guidelines apply, as eConsult is not an approved Medi-Cal benefit and is reimbursed solely by PHC. Only approved specialists

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Page 6 of 7

participating in PHC’s eConsult Program can bill using the following CPT code:

Distant Store and Forward Site Service CPT Codes eConsult, electronic consultation 99444

I. Reimbursement for Synchronous: Provider to Patient Telehealth Services

Telehealth Advancement Act of 2011 allows for telehealth services to be provided between a qualified provider and patient at a distant location. The location may be a health facility, residential home, patient’s home or other location.

Billing Guidelines for the Provider Site:

Provider Site Service Code Transmission Cost T1014 (per minute for maximum of

90 min. per patient) Licensed provider fee (if present) E&M codes 99201 – 99215 Nutrition Counseling per PHC Guidelines (See Policy MCUP3052)

97802, 97803, 97804, 99539 – use GT modifier

Required Modifier GT modifier required for all CPT-Codes except Transmission Cost codes

A licensed provider who provides E&M services for a patient utilizing telehealth technology to access the provider’s office may submit claims for this service using the E&M code, without the modifier. The contracted arrangements for primary care providers and specialty providers continue to apply. T1014 Transmission Cost fee may also be billed.

J. Exclusions

Telehealth does not include email, telephone (voice only), text, inadequate resolution video, written communication between the providers (outside of the eConsult Program described above), or between patients and providers.

VII. REFERENCES:

A. Medi-Cal Provider Manual: Medicine: Telehealth (medne tele) Last updated December 2013 B. Title 42 of the Code of Federal Regulations Sections 482.12, 482.22 and 485.616

VIII. DISTRIBUTION:

Originating Site - Patient Location

• Health facility • Residential

home • Patient home • Other location

Provider Site • Provider Site • Patient NOT

present

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Page 7 of 7

A. Provider Manual B. PHC Directors

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Chief Medical Officer

X. REVISION DATES:

3/14/2012, 2/18/2015; 01/20/16; 04/20/16; 09/21/16 PREVIOUSLY APPLIED TO: N/A

*********************************** In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with involvement from actively practicing health care providers and meets these provisions:

• Consistent with sound clinical principles and processes

• Evaluated and updated at least annually

• If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be disclosed to the provider and/or enrollee upon request

The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under PHC.

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POLICY/ PROCEDURE

Page 1 of 7


Policy/Procedure Title: Telehealth Services ☒External Policy

☐ Internal Policy




Reviewing

Entities:



Approving

Entities:





A. MCUP3124 - Referral to Specialists (RAF) Policy

B. MCUP3052 - Medical Nutrition Services

C. MCUP3028 - Mental Health Services

II. IMPACTED DEPTS:

A. Health Services

B. Provider Relations

C. Claims

III. DEFINITIONS:

A. Telehealth means the mode of delivering health care and public health services utilizing information and

communication technologies to enable the diagnosis, consultation, treatment, education, care

management and self-management of patient at a distance from health care providers.

B. Health care provider means a person who is licensed by the State of California Department of Health

Care Services and a Medi-Cal certified provider.

C. Originating site means the site where a patient is located at the time health services are provided via a

telecommunications system or where the asynchronous store and forward services originates.

D. Distant site means a site where a health care provider who provides health services is located while

providing these services via telecommunications system.

E. Synchronous interaction means a real-time interaction between a patient and health care provider located

at a distant site.

F. Asynchronous store and forward means the transmission of a patient’s medical information from an

originating site to the health care provider at a distance without the presence of the patient

G. Medical Necessity means reasonable and necessary services to protect life, to prevent significant illness

or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness

or injury.

IV. ATTACHMENTS:

N/A

V. PURPOSE:

The goal of telehealth is to improve both access and quality health services provided in rural and other

medically underserved areas through the use information and telecommunications technologies. The purpose

of this policy is to define telehealth services available to Partnership HealthPlan of California (PHC)

members and their general reimbursement policies.

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Policy/Procedure Title: Telehealth Services ☒ External Policy

☐ Internal Policy




Page 2 of 7

In 1996, Medicare initially approved limited coverage for telemedicine services. In the same year, the State

of California passed the Telemedicine Development Act of 1996 governing the delivery of health care

services through Telemedicine and authorizing terms and conditions of reimbursement of Telemedicine

services under Medi-Cal. In 2005, California broadened the definition of telemedicine services to include

store and forward telemedicine consults for teleopthalmology and teledermatology. Most recently, the State

approved AB 415 the Telehealth Advancement Act of 2011 that allows for:

• The provision of a broader range of telehealth services

• The expansion of telehealth providers to include all licensed healthcare professionals

• The expansion of telehealth settings to include physician offices, hospitals, clinics and home settings and

other sites

• The ability of California hospitals to establish medical credentials for telehealth providers more easily

The Telehealth Advancement Act of 2011 does not limit the type of settings where telehealth services are

provided to patients. Telehealth services may be provided at a physician office, clinic setting, hospital,

skilled nursing facility, residential care setting or patient home or other setting and must be in compliance

with all laws regarding the confidentiality of health care information and a patient’s rights to his or her

medical information. There is no longer a need to document a justification for use of telehealth services

instead of in-person services. Aside from this, services provided by telehealth must still meet state and

federal guidelines for “medical necessity” and the documentation should support this.


This policy defines key telemedicine/telehealth terms, PHC telehealth covered benefits and, reimbursement

policies. PHC fully supports the advancement of telehealth services in our region as a means of improving

access and quality of care to members as well as providing expert advice and specialty consultation to

primary care providers (PCPs) in the PHC network. The effective date of this policy is for dates of service

on or after March 1st, 2012. Current PHC referral and authorization requirements apply to telehealth

services per policy MCUP3124 Referral to Specialists (RAF) Policy.

Telemedicine services may be used to provide mild-moderate severity Mental Health Services to PHC

members. Such services are provided through PHC’s contracted Behavioral Health Managed Services

organization. See policy MCUP3028 Mental Health Services for additional information.

A. Synchronous Telehealth Services and Settings

1. Synchronous telehealth services can be provided to PHC members by any PHC credentialed health

care provider with the member’s verbal consent, as documented in the patient’s medical record.

B. Asynchronous Telehealth Services & Settings

1. Asynchronous store and forward telehealth services provides for the review of medical information

at a later time by a physician or optometrist at a distant site without the patient being present in real

time. The following Medi-Cal certified health care providers may provide store and forward

services:

a. Ophthalmologists

b. Dermatologists

c. Optometrists (licensed pursuant to Chapter 7 (commencing with Section 3000) of Division 2 of

the Business and Professions Code)

d. Specialists participating in PHC’s eConsult Program

2. Patients receiving teledermatology or teleophthalmology services by store and forward must be

notified of the right to interactive communication with the distant specialist if requested. If

requested, the communication may occur at the time of the consultation or within 30 days of the

patient’s notification of the results of the consultation.

C. Consent

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☐ Internal Policy




Page 3 of 7

1. Prior to the delivery of health care services via telehealth, the health care provider at the originating

site must verbally inform the patient that telehealth may be used and obtain verbal consent from the

patient for this use. The verbal consent must be documented in the patient’s medical record.

D. Confidentiality

1. All federal and state laws regarding the confidentiality of health care information and a patient’s

rights to his or her medical information apply to telehealth services.

E. Credentialing of Providers of Telehealth Services to PHC Members in a Hospital Setting

1. Licensed health care providers providing telehealth services to Partnership HealthPlan members,

outside a hospital setting, need to be a Medi-Cal certified provider in the State of California and a

qualified provider credentialed through Partnership HealthPlan, or an organization with delegated

authority for credentialing, as approved by the Partnership HealthPlan Credentials Committee.

2. The governing body of the hospital whose patients are receiving telehealth services may grant

privileges to, and verify and approve credentials for, providers of telehealth services based on its

medical staff recommendations that rely on information provided by the distant site hospital or

telehealth entity, as described in Sections 482.12, 482.22 and 485.616 of Title 42 of the Code of

Federal Regulations.

F. Required Equipment

1. The audio-video telemedicine system used, must, at a minimum, have the capability of meeting the

procedural definition of the code provided through telehealth. The telecommunication equipment

must be of a quality to adequately complete all necessary components to document the level of

service for the CPT code billed.

G. Reimbursement for Telehealth Services

1. There are three main models of telehealth services available to PHC members.

a. The first, called “Traditional Synchronous Telehealth Services” connects the patient with a

distant provider of health services through audio-video equipment on a real-time basis. This

model is commonly used between specialty centers such as UCSF or UCD with outlying

physician offices or community health centers.

b. The second model, called “Asynchronous Telehealth Services” or the “Store and Forward”

model connects a patient with a distant provider of ophthalmology, dermatology or certain

optometry services using audio-video equipment, but not on a real-time basis. Generally an

image or picture is taken and forwarded to the specialty provider to review at a later time. This

also includes specialty services provided via eConsults, or electronic consultations, which

consist of an electronic exchange of information through the eConsult platform and may include

images or photos, labs, and other relevant patient information.

c. The third model called “Synchronous Patient to Provider Telehealth Services” connects a single

provider (primary care or specialty provider) to a patient using audio-visual equipment on a real-

time basis. The patient can be in a health facility, residential group home or private residence or

other setting, provided the appropriate equipment is used. The reimbursement terms for each of

the three models are summarized below:

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☐ Internal Policy




Page 4 of 7

H. Reimbursement for Traditional Synchronous Telehealth Services


Originating Site

Service Code

Site facility fee (billable only when

no CPT/E&M code is billed)

Q3014

Transmission Cost T1014 (per minute for maximum of 90 min. per patient)

Licensed provider fee (if present) E&M codes 99201 - 99215 and other CPT codes for services

distinct and in addition to those rendered by the Distant Site

Provider.

If a Licensed provider also is present at the telehealth Originating Site with the patient present and a progress

note is generated by the originating provider, the visit is reimbursable. The scope of the interaction with the

originating provider should be documented in the progress note that are distinct from those provided by the

Distant Site and will be the basis of the E&M and other CPT code(s) billed. If an E&M code is included, the

transmission cost fees may be billed. No modifier is needed at the Originating Site.

Billing guidelines for Distant Site Providers:

Distant Site

Service Code

Transmission Cost T1014 (per minute for maximum of 90 min. per

patient)

Initial hospital care or subsequent hospital care,

critical care (new or established patient)

99221 – 99233, 99291, 99292

Extended Inpatient Care 99356 - 99357

Consultations: Office or other outpatient ( initial

or follow-up) Inpatient, and confirmatory

99241 – 99275

Genetic Counseling 96040, S0265

Physical Therapy 97001, 97002

Nutrition Counseling per PHC Guidelines (See

Policy MCUP3052)

97802, 97803, 97804 – use GT modifier

Required Modifier GT modifier required for all CPT-Codes except

Transmission Cost codes

Note: An FQHC/RHC/Tribal health site may choose to sub-contract with a specialist and pay them directly.

Under these circumstances, the FQHC/RHC would bill for the originating site and the specialty service on

two separate claims. The PHC system would need to be set up for the specific specialty and if not, the

Provider Relations Department should be contacted.

Originating Site Patient present

Provider

optional

Distant Site Provider of

service

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☐ Internal Policy




Page 5 of 7

I. Reimbursement for Asynchronous Telehealth Services (Store and Forward) for

Teleophthamology, Teleoptometry, Teledermatology, and eConsult Program Services


Originating Site

Service Code

Site facility fee (billable only when no provider at visit) Q3014

Transmission Cost T1014 (per minute for maximum of 90 min.

per patient)

Licensed provider fee (if present) E&M codes 99201 - 99215 and other CPT

codes for services distinct and in addition to

those rendered by the Distant Site Provider.

If a Licensed provider also is present at the telehealth Originating Site, with the patient present and a

progress note generated by the originating provider, the visit is reimbursable as a visit. The scope of the

interaction with the originating provider should be documented in the progress note, and will be the basis of

the CPT code(s) used. If a CPT code is included, the originating site fee and the transmission cost fees may

still be billed. No modifier is needed.

Special Billing Guidelines for Asynchronous Retinal Photography - Originating Site Providers:

If a provider uses asynchronous telehealth for diabetic eye exam screenings, through the use of a retinal

camera located at the originating site, special billing guidelines apply, when the originating site is paying the

specialist directly for reading the results of the retinal photographs. A licensed provider does not need to be

present for retinal photography service to be reimbursable. If no provider is present at visit, bill using the

following CPT codes:

Originating Store and Forward Site Service CPT Codes

Retinal photography with interpretation for

services provided by optometrists or

ophthalmologists 92250 (Do not use modifier)

Site facility fee (billable with or without provider present) Q3014

Transmission Cost

T1014 (per minute for maximum of 90

min. per patient)

If provider is present at visit, E&M codes can also be billed as usual. The scope of the interaction with the

originating provider should be documented in the progress note. The originating site fee and the transmission

cost fees may still be billed. No modifier is needed.

Originating Site Patient present

Provider

optional

Distant Site Provider of

service Information stored and

forwarded to Distant Site

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☐ Internal Policy




Page 6 of 7

Billing guidelines for Distant Store and Forward Site Providers:

Distant Store and Forward Site

Service CPT Codes

Office consultation, new or established patient 99241 - 99243

Retinal photography with interpretation for services provided by

optometrists or ophthalmologists (should not be used if originating

site is submitting claims with this code).

92250

Required Modifier: All asynchronous, store-and-

forward services are billed with a

“GQ” modifier

Special Billing Guidelines for Asynchronous eConsult service - Distant Site Providers:

If a provider uses asynchronous telehealth for eConsult services, special billing guidelines apply, as eConsult

is not an approved Medi-Cal benefit and is reimbursed solely by PHC. Only approved specialists

participating in PHC’s eConsult Program can bill using the following CPT code:

Distant Store and Forward Site

Service CPT Codes

eConsult, electronic consultation 99444

J. Reimbursement for Synchronous: Provider to Patient Telehealth Services

Telehealth Advancement Act of 2011 allows for telehealth services to be provided between a qualified

provider and patient at a distant location. The location may be a health facility, residential home,

patient’s home or other location.

Billing Guidelines for the Provider Site:

Provider Site

Service Code

Transmission Cost T1014 (per minute for maximum of

90 min. per patient)

Licensed provider fee (if present) E&M codes 99201 – 99215

Nutrition Counseling per PHC Guidelines (See Policy MCUP3052)

97802, 97803, 97804, 99539 – use GT modifier

Required Modifier GT modifier required for all CPT-

Codes except Transmission Cost

codes

Originating Site - Patient Location

Health facility

Residential

home

Patient home

Other location

Provider Site Provider Site

Patient NOT

present

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☐ Internal Policy




Page 7 of 7

A licensed provider who provides E&M services for a patient utilizing telehealth technology to access the

provider’s office may submit claims for this service using the E&M code, without the modifier. The

contracted arrangements for primary care providers and specialty providers continue to apply. T1014

Transmission Cost fee may also be billed.

K. Exclusions Telehealth does not include email, telephone (voice only), text, inadequate resolution video, written

communication between the providers (outside of the eConsult Program described above), or between

patients and providers.

VII. REFERENCES: A. Medi-Cal Provider Manual: Medicine: Telehealth (medne tele) Last updated December 2013

B. Title 42 of the Code of Federal Regulations Sections 482.12, 482.22 and 485.616

VIII. DISTRIBUTION:

A. Provider Manual

B. PHC Directors

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Chief Medical Officer

X. REVISION DATES: 3/14/2012, 2/18/2015; 01/20/16; 04/20/16; 09/21/16


***********************************









covered under PHC.

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MCUP3131- A Genetic Testing Requirements: Providers should refer to the CPT-4 or HCPCS Level II code book, as appropriate, for full descriptions of codes. CPT-4 Code

Description

PHC TAR

Required TAR and/or Billing Requirements

Frequency

Limit BENEFIT COMMENTS

MCUP 3131 Attachment A 09/21/2016 Page 1 of 47

81161

DMD (dystrophin)

deletion analysis, and

duplication analysis, if

performed

No ICD-10-CM diagnosis code G71.0 (muscular dystrophy) is required on the claim.

Once-in-a-lifetime

81201

APC

gene analysis; full gene

sequence

No One of the following ICD-10-CM codes is required on the claim: C18.0 – C18.9, D12.0 – D12.6, K63.5, Z86.010

Once-in-a-lifetime

81202

APC

gene analysis; known

familial variants

Yes Requires documentation on the Treatment Authorization Request (TAR) of a family history of familial adenomatous polyposis that includes a relative with a known deleterious APC mutation

Once-in-a-lifetime

81203

APC

gene analysis;

duplication/deletion

variants


Once-in-a-lifetime

81206

BCR/ABL1 translocation

analysis; major

breakpoint

No One of the following ICD-10-CM codes is required on the claim: C91.00 – C91.02 or C92.10 – C92.12

1 per month

81207


analysis; minor

breakpoint


1 per month

81208


analysis; other

breakpoint


1 per month

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Description

PHC TAR


Frequency



81210

BRAF (v-raf murine

sarcoma viral oncogene

homolog B1) gene

analysis, V600E variant

No One of the following ICD-10-CM codes is required on the claim: C18.0 – C18.9, C19, C20, C43.0 – C43.9, C79.2 or D03.0 – D03.9

Once-in-a-lifetime

81211

BRCA1, BRCA2 gene

analysis; full sequence

analysis

Continued below

Yes A TAR for code 81211 requires documentation of one or more of the following numbered criteria: 1. An individual with a family member with a

known deleterious BRCA mutation; OR 2. Personal history of breast cancer plus one or

more of the following: Diagnosed at ≤ 45 years of age; OR Diagnosed at ≤ 50 years of age with:

– An additional breast cancer primary – One or more close blood relatives with breast cancer at any age – One or more close blood relatives with pancreatic cancer – One or more close blood relatives with prostate cancer (Gleason score ≥ 7) – An unknown or limited family history

Diagnosed at ≤ 60 years of age with a triple negative breast cancer

Diagnosed at any age with: – One or more close blood relatives with breast cancer diagnosed at ≤ 50 years of age – Two or more close blood relatives with breast cancer at any age – One or more close blood relatives with invasive ovarian cancer – Two or more close blood relatives with pancreatic cancer and/or prostate cancer (Gleason score ≥ 7) at any age

Continued

Once-in-a-lifetime

See Attachment B - Quest Diagnostics BRCAvantage ® Patient and Family Clinical History Form which is suggested for use prior to ordering BRCA testing Note that for the purpose of this policy, a “close blood relative” is defined as a first-degree or second-degree blood relative. First degree relatives are biological parents, siblings, and children. Second-degree relatives are biological grandparents, aunts, uncles, nephews, nieces, grandchildren and half-siblings. Where third degree blood relatives are mentioned, they include great-grandparents, great-aunts, great-uncles, great-grandchildren, and first cousins.

124 of 252124 of 252


Description

PHC TAR


Frequency



Continued from above

81211

BRCA1, BRCA2 gene

analysis

Yes – A close male blood relative with breast cancer – For an individual of ethnicity associated with higher mutation frequency (for example, Ashkenazi Jewish), no additional family history may be required

3. Personal history of invasive ovarian cancer 4. Personal history of male breast cancer 5. Personal history of prostate cancer

(Gleason score ≥ 7) at any age with one or more close blood relatives with breast cancer (≤ 50 years of age) and/or invasive ovarian and/or pancreatic or prostate cancer (Gleason score ≥ 7) at any age

6. Personal history of pancreatic cancer at any age with one or more close blood relative with breast cancer (≤ 50 years of age) and/or invasive ovarian and/or pancreatic cancer at any age

7. Personal history of pancreatic cancer and Ashkenazi Jewish ancestry.

8. For an individual without history of breast or ovarian cancer: First or second degree blood relative

meeting any of the above criteria Third degree blood relative (who has

breast cancer and/or invasive ovarian cancer and who has two or more close blood relatives with breast cancer (at least one with breast cancer ≤ 50 years of age) and/or invasive ovarian cancer

Once-in-a-lifetime


81211

(Reflex BRCA1, BRCA2

gene analysis billed with

modifier QP)

Yes A TAR for code 81211 billed with modifier QP requires documentation of the following: A negative result in the single mutation

(codes 81215 or 81217) or three-mutation (code 81212) analysis, and

One or more criteria listed under code 81211

Once-in-a-lifetime

See Attachment B - Quest Diagnostics BRCAvantage ® Patient and Family Clinical History Form which is suggested for use prior to ordering BRCA testing

125 of 252125 of 252


Description

PHC TAR


Frequency



81212

BRCA1, BRCA2 gene

analysis; variants

Yes Requires documentation on the TAR of the following: An individual is of an ethnicity associated

with the Ashkenazi Jewish population No additional family history may be

required

Once-in-a-lifetime


81213

BRCA1, BRCA2 gene

analysis; uncommon


variants

Yes Requires documentation on the TAR of one or more criteria listed under CPT-4 code 81211

Once-in-a-lifetime


81215

BRCA1 (breast cancer 1)


familial variant

Yes Requires documentation on the TAR of family history of breast or ovarian cancer that includes a relative with a known deleterious BRCA mutation

Once-in-a-lifetime


81217



familial variant


Once-in-a-lifetime


81220

CFTR (cystic fibrosis

transmembrane

conductance regulator)

gene analysis; common

variants

No When used to bill for cystic-fibrosis screening requires ICD-10-CM code Z31.430 or Z31.440 Not reimbursable with code 81224 for same date of service, recipient and provider May be billed separately with an appropriate National Correct Coding Initiative (NCCI) associated modifier Refer to the Genetic Counseling and Screening section in the Medi-Cal Manual for additional information

Once-in-a-lifetime

81221

Cystic Fibrosis known

family variants

Yes Not a Medi-Cal covered benefit Testing family members of those previously diagnosed with Cystic Fibrosis (CF)

Once-in-a-lifetime

TAR must be ordered by a medical geneticist with appropriate supporting documentation attached to be considered for authorization.

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Description

PHC TAR


Frequency



81222

Cystic Fibrosis

Deletion/Duplication

Yes Not a Medi-Cal covered benefit Used to identify causal mutations when only a single common mutation or rare variant of CF are detected. (Previous tests with a screening assay for common mutations and variants followed by CFTR full gene sequence analysis revealed only heterozygosity –a single mutation)

Once-in-a-lifetime


81223

Cystic Fibrosis Full

Gene Sequencing

Yes Not a Medi-Cal covered benefit Used to identify rare mutations in individuals suspected of having CF but where only a single common mutation or variant has been identified

Once-in-a-lifetime


81225

CYP2C19 Gene common

variants

Yes Not a Medi-Cal covered benefit The cytochrome P450 (CYP450) enzymes catalyze the oxidation of many drugs and chemicals. Individual differences of cytochrome P450 activity can result in total absence of metabolism of certain drugs to ultrafast metabolism of drugs. This can lead to adverse drug reactions or a lack of therapeutic effect under standard therapy conditions. CYP2C19 is a gene within the family of the CYP450 superfamily. It metabolizes 15% of all prescribed drugs, such as clopidogrel (Plavix).

Once-in-a-lifetime


127 of 252127 of 252


Description

PHC TAR


Frequency



81226

CYP2D6 Gene common

variants

Yes Not a Medi-Cal covered benefit The cytochrome P450 (CYP450) enzymes catalyze the oxidation of many drugs and chemicals. Individual differences of cytochrome P450 activity can result in total absence of metabolism of certain drugs to ultrafast metabolism of drugs. This can lead to adverse drug reactions or a lack of therapeutic effect under standard therapy conditions. CYP2D6 is a gene within the family of the CYP450 superfamily. It metabolizes 25% of all prescribed drugs, such as codeine, tricyclic antidepressants, classical antipsychotics, and β-blockers. Specific variants in this gene also influence the metabolism of the breast cancer drug, tamoxifen, in postmenopausal women. Genetic variants of CYP2D6 can be used to predict the altered enzyme activity and address the potential effects of metabolized drugs.

Once-in-a-lifetime


81227

CYP2C9 Gene common

variants

Yes Not a Medi-Cal covered benefit The presence of certain variants in the CYP2C9 gene can result in poor metabolizer phenotypes that are associated with lack of enzyme activity and drugs may be metabolized slowly or not at all. This results in increased concentrations of the drug with a reduced or absent therapeutic response and the potential for serious side effects. Warfarin metabolism is reduced by 30% to 50% by the *2 variant and 90% by the *3 variant. Individuals with at least one copy of *2 or *3 have an increased risk of bleeding compared to individuals without *2 or *3. A lower maintenance dose may be required.

Once-in-a-lifetime


128 of 252128 of 252


Description

PHC TAR


Frequency



81228, 81229

Molecular Cytogenomic

Testing

Continued below

Yes Not a Medi-Cal covered benefit. Microarray-based Comparative Genomic Hybridization (aCGH) is medically necessary for the following indications:

Evaluating fetuses with structural abnormalities detected on fetal ultrasound or fetal magnetic resonance imaging; or

For evaluating histologically equivocal Spitzoid melanocytic neoplasms (Spitz nevus and atypical Spitz tumors); or

Analyses of stillbirths with congenital anomalies or in stillbirths in which karyotype results cannot be obtained.

Microarray-based Comparative Genomic Hybridization (aCGH) is medically necessary for diagnosing genetic abnormalities in children with developmental delay/intellectual disability (DD/ID) or autism spectrum disorder (ASD) according to accepted Diagnostic and Statistical Manual of Medical Disorders 5 (DSM 5) when all of the following criteria are met:

If warranted by the clinical situation, biochemical testing for metabolic diseases has been performed and is negative; and

Targeted genetic testing, (for example: FMR1 gene analysis for Fragile X), if or when indicated by the clinical and family history, is negative; and

The member's clinical presentation is not specific to a well-delineated genetic syndrome*; and

Continued

If for fetal evaluation, Once per pregnancy

If for child or adult

evaluation, Once-in-a-

lifetime

Although not a Medi-Cal covered benefit, PHC will consider TARs for these codes with appropriate supporting documentation attached. Claims without documentation showing the specified criteria have been met will be denied.

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Description

PHC TAR


Frequency




81228, 81229


Testing

Continued below

Yes In addition to a diagnosis of DD/ID or ASD, the child has one or more of the following: - Two or more major malformations, or - A single major malformation or multiple

minor malformations, in an infant or child who is also small-for-dates, or

- A single malformation and multiple minor malformations, and

- The results for the testing have the potential to impact the clinical management of the member.

* aCGH is considered not medically necessary when a diagnosis of a disorder or syndrome is readily apparent based on clinical evaluation alone.

Continued




lifetime


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Description

PHC TAR


Frequency




81228, 81229

Yes Chromosomal Microarray-based Comparative Genomic Hybridization (aCGH) is considered experimental and investigational in all other cases of suspected genetic abnormality in children with developmental delay/intellectual disability or autism spectrum disorder. aCGH is considered experimental and investigational for any other indications including the following (not an all-inclusive list) because of insufficient evidence of its effectiveness:

Detection of balanced rearrangements

Evaluation of autoimmune lymphoproliferative syndrome

Evaluation of unexplained epilepsies

Screening for prenatal gene mutations in fetuses without structural abnormalities, such as in advanced maternal age, positive maternal serum screen, previous trisomy, or the presence of "soft markers" on fetal ultrasound

Testing products of conception

Diagnosis of melanoma

Additional criteria for Microarray-based Comparative Genomic Hybridization (aCGH): If not meeting above criteria and a medical geneticist believes it is necessary, he or she may submit specific justification to PHC for review. Notes: The Oligo HD Scan is a type of aCGH. The CombiMatrix DNArray is an aCGH test for developmental delay.




lifetime


131 of 252131 of 252


Description

PHC TAR


Frequency



81235

EGFR (epidermal growth

factor receptor) gene

analysis, common

variants

No One of the following ICD-10-CM codes is required on the claim: C33, C34.00 – C34.92

Once-in-a-lifetime

81243

FMR1 (fragile X mental

retardation 1) gene

analysis; evaluation to

detect abnormal alleles

No One of the following ICD-10-CM codes is required on the claim: F70, F71 – F73, F78, F80.0 – F89, H93.25, R48.0

Once-in-a-lifetime

81244


retardation 1) gene

analysis;

characterization of

alleles


Once-in-a-lifetime

81250

G6PC (glucose-6-

phosphatase, catalytic

subunit) gene analysis,

common variants

Yes The patient has clinical features suspicious for, or requires the laboratory service as a diagnostic test for glycogen storage disease, type 1a

Once-in-a-lifetime

81256

HFE (hemochromatosis)

gene analysis, common

variants

No One of the following ICD-10-CM codes is required on the claim: E83.10, E83.110 or E83.118 – E83.119

Once-in-a-lifetime

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Description

PHC TAR


Frequency



81260

IKBKAP (inhibitor of

kappa light polypeptide

gene enhancer in B-

cells, kinas complex-

associated protein) gene

analysis, common

variants

No Indicated for: Hypotonia in infancy Decreased or absent deep tendon reflexes Decreased taste and absence of fungiform

papillae of the tongue Absence of overflow tears with emotional

crying (alacrima) Absence of axon flare response after

intradermal histamine injection Pupillary hypersensitivity to

parasympathomimetic agents

Once-in-a-lifetime

While DHCS requires a TAR for this test, PHC has chosen to have no TAR requirement.

81265

Comparative analysis

using Short Tandem

Repeat markers

No One of the following ICD-10-CM codes is required on the claim: C81.00 – C96.9, D45, T86.00 – T86.09 or T86.5

Once-in-a-lifetime

81266


using Short Tandem

Repeat markers; each

additional specimen


Once-in-a-lifetime

81267

Chimerism

(engraftment) analysis,

post transplantation

specimen; without cell

selection

No One of the following ICD-10-CM codes is required on the claim: T86.01, T86.02, T86.09 or T86.5

1 per month

81268

Chimerism



specimen; with cell

selection


1 per month

133 of 252133 of 252


Description

PHC TAR


Frequency



81270

JAK2 (Janus kinase 2)

gene analysis, p.

Val617Phe (V617F)

variant

No One of the following ICD-10-CM codes is required on the claim: D45, D47.1 or D47.3

Once-in-a-lifetime

81275

KRAS (v-Ki-ras2 Kirsten

rat sarcoma viral

oncogene) gene

analysis, variants in

codons 12 and 13

No One of the following ICD-10-CM codes is required on the claim: C18.0, C18.2 – C20, D01.1, D01.2, D01.40, D01.49, D37.4 or D37.5

Once-in-a-lifetime

81280

Long QT syndrome gene

analyses; full sequence

analysis

Yes Not split-billable and must not be billed with modifier 26, 99 or TC Document on the TAR a copy of the report of the physician-interpreted 12-lead electrocardiogram (ECG) with pattern consistent with or suspicious for prolonged QT interval, and clinical documentation of one or more of the following: Torsade de pointes in the absence of

drugs known to prolong QT interval T-wave alternans Notched T-wave in three leads Syncope Family members with LQTS Sudden death in family members less than

30 years of age without defined cause

Once-in-a-lifetime

81281


analyses; known familial

sequence variant

Yes Not split-billable and must not be billed with modifier 26, 99 or TC Document on the TAR: The family member being tested is a

Medi-Cal recipient, and There is clinical documentation of at least

one first-degree relative (parent, sibling or offspring) with a laboratory-confirmed LQTS genetic mutation

Once-in-a-lifetime

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Description

PHC TAR


Frequency



81287

MGMT (0-6

methylguanin-DNA

methyltransferase)

methylation analysis

No Indicated for:

The patient has the diagnosis of glioblastoma multiforme, and

Treatment strategy will be contingent on the test results

Reimburseable when billed with ICD-10 : C71.9.

Once-in-a-lifetime,

any provider

While DHCS requires a TAR for this test, PHC has chosen to have no TAR requirement when billed with ICD-10 code C71.9

81288

MLH1 gene analysis;

promoter methylation

analysis

Yes Document the following criteria on the TAR: Patient with colon cancer, and The tumor demonstrates microsatellite

instability or immunohistochemistry results indicating loss of MLH1 protein expression

Once-in-a-lifetime

81291

MTHFR

Methylenetetrahydrofola

te Reductase, DNA

Mutation Analysis

Yes Not a Medi-Cal covered benefit Once-in-a-lifetime


81292

MLH1 (mutL homolog 1,

colon cancer,

nonpolyposis type 2)

gene analysis; full

sequence analysis

No One of the following ICD-10-CM codes is required on the claim: C18.0 – C20, C54.0 – C54.9, Z80.0, Z80.49, Z85.030, Z85.038, Z85.040, Z85.048, Z85.42C18.0, C18.2 – C18.9

Once-in-a-lifetime

PHC will also reimburse for these ICD-10 codes : C54.1, C56.1 – C56.9, Z80.0

81293


colon cancer,



familial variants

Yes Document on the TAR family history of Lynch Syndrome that includes a relative with a known deleterious MLH1 mutation

Once-in-a-lifetime

Prediction model calculator suggested for use prior to ordering Lynch syndrome testing: http://premm.dfci.harvard.edu/

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http://premm.dfci.harvard.edu/


Description

PHC TAR


Frequency



81294


colon cancer,


gene analysis;


variants

YesNo One of the following ICD-10-CM codes is required on the claim: C18.0 – C20, C54.0 – C54.9, Z80.0, Z80.49, Z85.030, Z85.038, Z85.040, Z85.048, Z85.42Document on the TAR patient history of colon cancer and a negative result for MLH1 full sequence analysis

Once-in-a-lifetime

81295

MSH2 (mutS homolog 2,

colon cancer,


gene analysis; full

sequence analysis

No One of the following ICD-10-CM codes is required on the claim: C18.0 – C20, C54.0 – C54.9, Z80.0, Z80.49, Z85.030, Z85.038, Z85.040, Z85.048, Z85.42C18.0 or C18.2 – C18.9

Once-in-a-lifetime


81296


colon cancer,



familial variants

Yes Document on the TAR family history of Lynch Syndrome that includes a relative with a known deleterious MSH2 mutation

Once-in-a-lifetime


81297


colon cancer,


gene analysis;


variants

YesNo One of the following ICD-10-CM codes is required on the claim: C18.0 – C20, C54.0 – C54.9, Z80.0, Z80.49. Z85.030, Z85.038, Z85.040, Z85.048, Z85.42Document on the TAR patient history of colon cancer and a negative result for MSH2 full sequence analysis

Once-in-a-lifetime

81298

MSH6 (mutS homolog 6

[E. coli]) gene analysis;

full sequence analysis


Once-in-a-lifetime


81299



known familial variants


Once-in-a-lifetime


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Description

PHC TAR


Frequency



81300




variants

YesNo One of the following ICD-10-CM codes is required on the claim: C18.0 – C20, C54.0 – C54.9, Z80.0, Z80.49. Z85.030, Z85.038, Z85.040, Z85.048, Z85.42Document on the TAR patient history of colon cancer and a negative result for MSH6 full sequence analysis

Once-in-a-lifetime

81301

Microsatellite instability

analysis of markers for

mismatch repair

deficiency

No One of the following ICD-10-CM codes is required on the claim: C18.0 or C18.2 – C18.9

Once-in-a-lifetime

81315

PML/RAR-alpha

(promyelocytic

leukemia/retinoic acid

receptor alpha)

translocation analysis;

common breakpoints

No One of the following ICD-10-CM codes is required on the claim: C92.40 – C92.42

1 per month

81316

PML/RAR-alpha

(promyelocytic


receptor alpha)


single breakpoint


1 per month

81317

PMS2 (postmeiotic

segregation increased 2

[S. cerevisiae]) gene


analysis


Once-in-a-lifetime

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Description

PHC TAR


Frequency



81318

PMS2 (postmeiotic



analysis; known familial

variants

Yes Document on the TAR family history of Lynch Syndrome that includes a relative with a known deleterious PMS2 mutation

Once-in-a-lifetime


81319

PMS2 (postmeiotic



analysis;


variants

YesNo One of the following ICD-10-CM codes is required on the claim: C18.0 – C20, C54.0 – C54.9, Z80.0, Z80.49. Z85.030, Z85.038, Z85.040, Z85.048, Z85.42Document on the TAR patient history of colon cancer and a negative result for PMS2 full sequence analysis

Once-in-a-lifetime

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Description

PHC TAR


Frequency



81321

PTEN (phosphatase and

tensin homolog) gene


analysis

Continued below

Yes A TAR for CPT-4 code 81321 requires documentation of one or more of the following numbered criteria: 1. Individual with a personal history of: Bannayan-Riley-Ruvalcaba syndrome, or Adult Lhermitte-Duclos disease, or Autism spectrum disorder AND

macrocephaly, or Two or more biopsy-proven

trichilemmomas, or Two or more major criteria (one

macrocephaly), or Three major criteria without macrocephaly,

or One major and three or more minor criteria,

or Four or more minor criteria (please see list

below) 2. At-risk individual:

With a relative who has a clinical diagnosis of Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome for whom testing has not been performed AND who has any one major criterion or two minor criteria

(continued on next page)

Once-in-a-lifetime

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Description

PHC TAR


Frequency




81321

PTEN gene analysis; full

sequence analysis

Yes Major Criteria Breast cancer Mucocutaneous lesions One biopsy-proven trichilemmoma Multiple palmoplantar keratosis Multifocal or extensive oral mucosal

papillomatosis Multiple cutaneous facial papules (often

verrucous) Macular pigmentation of glans penis Macroencephaly (megalocephaly, ie, ≥97th

percentile) Endometrial cancer Non-medullary thyroid cancer Multiple GI tract hamartomas or

ganglioneuromas Minor Criteria

Other thyroid lesions (adenoma, nodule, goiter)

Mental retardation (IQ ≤75) Autism spectrum disorder Single GI tract hamartoma or

ganglioneuroma Fibrocystic disease of the breast Lipomas Fibromas Renal cell carcinoma Uterine fibroids

Once-in-a-lifetime

81322

PTEN gene analysis;

known familial variant

Yes Requires documentation on the TAR that patient is from a family with a known PTEN mutation

Once-in-a-lifetime

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Description

PHC TAR


Frequency



81323

PTEN gene analysis;


variant

Yes Requires documentation on the TAR of a negative result in the full sequence analysis in PTEN (CPT-4 code 81321), and that patient meets one or more criteria listed under code 81321

Once-in-a-lifetime

81331

SNRPN/UBE3A


Yes Document the following age-specific criteria on the TAR Birth to 2 years: Hypotonia with poor suck 2 – 6 years: Hypotonia with history of poor

suck and global development delay 6 – 13 years: History of hypotonia with poor

suck (hypotonia often persists); global development delay; and excessive eating (hyperphagia; obsession with food) with central obesity if uncontrolled

13 years – adult: Cognitive impairment – usually mild mental retardation; excessive eating (hyperphagia; obsession with food) with central obesity if uncontrolled; and hypothalamic hypogonadism and/or typical behavior problems (including temper tantrums and obsessive-compulsive features)

Once-in-a-lifetime

Human Leukocyte

Antigen Typing

81370 - 81383

No TAR required

when CPT

codes listed are

billed

CPT-4 codes 81370 – 81380, 81382 and 81383 (human leukocyte antigen typing) are reimbursable only with an ICD-10-CM diagnosis in the range of Z01.812, Z01.89, Z48.21 – Z48.298, Z94.0 – Z94.9. CPT-4 code 81381 (HLA Class I typing, high resolution, one allele or allele group) is only reimbursable with an ICD-10-CM diagnosis of B20, F31.0 – F31.9, G40.001 – G40.919, G50.0, R75, Z21, Z48.21 – Z48.298, Z94.0 – Z94.9

Once-in-a-lifetime

No payment will be made without diagnosis codes listed.

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MCUP3131- A Genetic Testing Requirements: Providers should refer to the CPT-4 or HCPCS Level II code book, as appropriate, for full descriptions of codes.

CPT-4 Code

Description

PHC TAR


Frequency



81400

(Molecular Pathology

Procedure, Level 1)

Continued below

Yes Providers are required to document one of the following on the TAR:

Human Platelet Antigen genotyping: - The patient has clinical features

suspicious for, or requires the service as a confirmatory test for neonatal alloimmune thrombocytopenia, or,

- The patient has clinical features suspicious for, or requires services as a confirmatory test for post transfusion purpura

CCR5 (chemokine C-C motif receptor 5): - Initial test: The use of a CCR5 inhibitor is being

considered, or The patient exhibits virologic failure on

a CCR5 inhibitor - Subsequent tests: A previous Trofile test was performed

including the test date and the results showing that the recipient has a CCR5 virus, and,

The recipient’s previous Trofile test was not less than 90 days from subsequent request, and,

The recipient has clinical scenario such as, but not limited to the following: The treatment with CCR5

antagonist drug therapy was interrupted and the clinician wishes to reinstitute CCR5 antagonist drug therapy, or,

Continued

Once-in-a-lifetime

142 of 252142 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81400


Procedure, Level 1)

Yes The recipient had a Trofile test performed previously that showed that the recipient had the CCR5 virus, but the CCR5 antagonist drug therapy was never initiated.

SMN1 (spinal muscular atrophy) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinal muscular atrophy

IL28B - The patient has genotype 1 hepatitis C

virus infection, and, - Treatment will be contingent on the test

results. Claims without documentation showing the preceding criteria have been met will be denied.

Once-in-a-lifetime

81401


Procedure, Level 2)

Continued below

Yes Coverage for CPT-4 code 81401 (molecular pathology procedure, Level 2) is limited to the listed services. Reimbursement for code 81401 requires an approved TAR and requires providers to document one of the following on the TAR:

ABCC8 (familial hyperinsulinism): - The patient has persistent

hyperinsulinemic hypoglycemia of infancy (PHHI), failed medical therapy, and

- The patient is under evaluation for surgical intervention

Continued

Once-in-a-lifetime

143 of 252143 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81401


Procedure, Level 2)

Continued below

Yes ABL (c-abl oncogene 1, receptor tyrosine kinase) – The patient has chronic myeloid leukemia (CML) and failed tyrosine kinase inhibitor (TKI) therapy

AR (spinal & bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinal and bulbar muscular atrophy or Kennedy disease

ATN1 (dentatorubral-pallidoluysian atrophy) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for dentatorubral pallidoluysian atrophy

ATXN1 (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia


ATXN3 (spinocerebellar ataxia, Machado-Joseph disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia


Continued

Once-in-a-lifetime

144 of 252144 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81401


Procedure, Level 2)

Continued below

Yes ATXN10 (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

ATXN80S (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

CACNA1A (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

CNBP (myotonic dystrophy, type 2) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for myotonic dystrophy, type 2

CSTB (Unverricht-Lundborg disease): The patient has clinical features

suspicious for, or requires the service as a confirmatory test for myoclonic epilepsy type 1, and

Treatment will be contingent on test results

DMPK (dystrophia myotonica-protein kinase) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for myotonic dystrophy type 1

Continued

Once-in-a-lifetime

145 of 252145 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81401

(molecular pathology

procedure, Level 2)

Continued below

Yes E2A/PBX1 (acute lymphocytic leukemia): - The patient has the diagnosis of acute

lymphocytic/lymphoblastic leukemia, and - Treatment or monitoring strategy will be

contingent on the test results

ETV6/RUNX1 (acute lymphocytic leukemia) –The patient has the diagnosis of acute lymphocytic or lymphoblastic leukemia, and requires the test for assessment of cancer prognosis

FXN (Friedreich ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Friedreich ataxia

H19 (Beckwith-Wiedemann syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Beckwith-Wiedemann syndrome

KCNQ1OT1 (Beckwith-Wiedemann syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Beckwith-Wiedemann syndrome

MLL/AFF1 (acute lymphoblastic leukemia): - The patient has the diagnosis of acute lymphoblastic leukemia, and Treatment or monitoring strategy will be contingent on the test results

Continued

Once-in-a-lifetime

146 of 252146 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81401


Procedure, Level 2)

Continued below

Yes MLL/MLLT3 (acute myeloid leukemia): - The patient has the diagnosis of acute myeloid leukemia, and - Treatment or monitoring strategy will be contingent on the test results

MUTYH (MYH-associated polyposis) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for MUTYH- associated polyposis

MT-ATP6 (neuropathy with ataxia and retinitis pigmentosa [NARP], Leigh syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for NARP or Leigh syndrome

PPP2R2B (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

PRSS1 (hereditary pancreatitis):

An unexplained documented episode of acute pancreatitis in childhood, or

Recurrent acute attacks of pancreatitis of unknown cause, or

Chronic pancreatitis of unknown cause, particularly with onset younger than 25 years of age, or

A family history of recurrent acute pancreatitis, chronic pancreatitis of unknown cause, and/or childhood pancreatitis of unknown cause consistent with autosomal dominant inheritance

Continued

Once-in-a-lifetime

147 of 252147 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81401


Procedure, Level 2)

Yes PYGM (glycogen storage disease type V, McArdle disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glycogen storage disease type V

RUNX1/RUNX1T1 (t[8;21]) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for acute myeloid leukemia

TBP (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

Claims without documentation showing the preceding criteria have been met will be denied.

Once-in-a-lifetime

81402


Procedure, Level 3)


KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) – The patient has clinical features suspicious for, or requires the service as a diagnostic test for mastocytosis

Chromosome 1p-/19q- (e.g. glial tumors), deletion analysis – Patient with diagnosis of grade II, III or IV glioma


Once-in-a-lifetime

148 of 252148 of 252


CPT-4 Code

Description

PHC TAR


Frequency



81403


Procedure, Level 4)

Continued below


DNMT3A (acute myeloid leukemia): The patient has diagnosis of acute myeloid leukemia, and The treatment strategy will be contingent on test results

EPCAM (Lynch syndrome) – The patient has colorectal cancer and/or Lynch syndromeone of the following: o Colon cancer o Uterine cancer o Lynch syndrome o Family history of colorectal cancer,

uterine cancer or Lynch syndrome IDH1 – Patient with diagnosis of grade II, III

or IV glioma IDH2 – Patient with diagnosis of grade II, III

or IV glioma JAK 2 (Janus kinase 2) – The patient has

clinical features suspicious for, or requires the service as a diagnostic test for myeloproliferative disorder

KCNC3 (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

KCNJ11 (familial hyperinsulinism): - The patient has persistent hyperinsulinemic hypoglycemia of infancy (PHHI) and failed medical therapy, and - The patient is under evaluation for surgical intervention

Typically once-in-a-

lifetime unless there is a special

circumstance


149 of 252149 of 252



CPT-4 Code

Description

PHC TAR


Frequency



Continued

150 of 252150 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81403


Procedure, Level 4)

Continued below

Yes KIR (killer cell immunoglobulin-like receptor for hematopoietic stem cell transplantation):

The patient has diagnosis of acute myeloid leukemia, and

The test is used for donor search process for patients considering hematopoietic stem cell transplantation

KRAS (Carcinoma), exon 3, codon 61:

The patient has colorectal cancer, and

The intention to treat or not to treat with anti-EGFR antibodies (cetuximab or panitumumab) will be contingent on the test results

MICA (solid organ transplantation):

The patient is undergoing evaluation for kidney transplantation, or

The patient is post kidney transplantation

MPL (myeloproliferative leukemia virus oncogene, thrombopoietin receptor, TPOR) – The patient has clinical features suspicious for, or requires the service as a diagnostic test for myeloproliferative disorder

NDP (Norrie disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Norrie disease

Continued



circumstance

151 of 252151 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81403


Procedure, Level 4)

Yes SH2D1A (X-linked lymphoproliferative syndrome) – The patient is a male with the diagnosis of: Common variable immune deficiency,

or Hypogammaglobulinemia, or Hemophagocytic lymphohistiocytosis,

or Severe infectious mononucleosis, or Lymphoma, or Family history of X-linked

lymphoproliferative syndrome

VHL (von Hippel-Lindau tumor suppressor), deletion/duplication analysis – The patient has clinical features suspicious for, or requires the service as a diagnostic test for von Hippel-Lindau syndrome




circumstance

152 of 252152 of 252


CPT-4 Code

Description

PHC TAR


Frequency



81404


Procedure, Level 5)

Continued below

Yes Coverage for CPT-4 code 81404 (molecular pathology procedure Level 5) is limited to the listed services. Reimbursement for code 81404 requires an approved Treatment Authorization Request (TAR) and requires providers to document one of the following on the TAR: ACADS (acyl-CoA dehydrogenase, C-2 to

C-3 short chain), targeted sequence analysis: The patient has elevated C4-C on newborn screening test, and Confirmation (urine acylglycines or urine organic acids) that C4 (butyrylcarnitine) and/or ethylmalonic acid (EMA) are elevated

CD40LG (X-linked hyper IgM syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for hyperimmunoglobulin M syndromes

CSTB (Unverricht-Lundborg disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Unverricht-Lundborg disease

DMPK (dystrophia myotonica-protein kinase) – The patient has clinical features suspicious for, or requires the service as a diagnostic test for myotonic dystrophy

EMD (Emery-Dreifuss muscular dystrophy) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Emery-Dreifuss muscular dystrophy

Continued



circumstance

153 of 252153 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81404


Procedure, Level 5)

Continued below

Yes EPM2A (progressive myoclonus epilepsy) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for progressive myoclonus epilepsy

FHL1 (Emery-Dreifuss muscular dystrophy) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Emery-Dreifuss muscular dystrophy



PDX1 (pancreatic and duodenal homeobox 1)

- The patient requires the service as a diagnostic test for (maturity onset diabetes of the young) MODY, and

- Is younger than 25 years of age, and - Has a family history of diabetes, and - Has negative islet of autoantibodies

PRNP (genetic prion disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for genetic prion disease

PRSS1 (hereditary pancreatitis): An unexplained documented episode of acute pancreatitis in childhood, or Recurrent acute attacks of pancreatitis of unknown cause, or Chronic pancreatitis of unknown cause,

particularly with onset younger than 25 years of age, or Continued



circumstance

154 of 252154 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81404


Procedure, Level 5)

Yes - A family history of recurrent acute pancreatitis, chronic pancreatitis of unknown cause, and/or childhood pancreatitis of unknown cause consistent with autosomal dominant inheritance

RET (ret proto-oncogene), common variants The patient has a personal history of primary C cell hyperplasia, Medullary Thyroid Carcinoma (MTC), or Multiple Endocrine Neoplasia (MEN), type 2B, or The patient has a family history consistent with MEN, type 2B or MTC, and at risk for autosomal dominant inheritance of the syndrome

SH2D1A (X-linked lymphoproliferative syndrome) – The patient is a male with the diagnosis of: Common variable immune deficiency, or Hypogammaglobulinemia, or Hemophagocytic lymphohistiocytosis, or Severe infectious mononucleosis, or Lymphoma, or Family history of X-linked lymphoproliferative syndrome

SPINK1 (hereditary pancreatitis): - An unexplained documented episode of acute pancreatitis in childhood, or - Recurrent acute attacks of pancreatitis of unknown cause, or - Chronic pancreatitis of unknown cause, particularly with onset younger than 25 years of age, or - A family history of recurrent acute pancreatitis, chronic pancreatitis of unknown cause, and/or childhood pancreatitis of unknown cause consistent with autosomal dominant inheritance




circumstance

155 of 252155 of 252


CPT-4 Code

Description

PHC TAR


Frequency



81405


Procedure, Level 6)

Continued below

Yes Coverage for CPT-4 code 81405 (molecular pathology procedure, level 6) is limited to the listed services. Reimbursement for code 81405 requires an approved TAR and requires providers to document one of the following on the TAR:

ABCD1 (adrenoleukodystrophy): The patient has clinical features

suspicious for adrenoleukodystrophy, and

Measurement of plasma concentration of very long chain fatty acids (VLCFA) is inconclusive, and

The service is required as a confirmatory test for the diagnosis of adrenoleukodystrophy

ACADS (acyl-CoA dehydrogenase, C-2 to C-3 short chain), full gene sequence: The patient has elevated C4-C on newborn screening test, and Confirmation (urine acylglycines or urine organic acids) that C4 (butyrylcarnitine) and/or ethylmalonic acid (EMA) are elevated


GLA (galactosidase alpha [for example, Fabry disease]), full gene sequence: The patient has a family member with documented disease-causing mutation, and

Continued

Once-in-a-lifetime

156 of 252156 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81405


Procedure, Level 6)

Continued below

Yes

The decision whether to initiate enzyme replacement therapy will be contingent on the results

HNF1A (HNF1 homeobox A) - The patient requires the service as a

diagnostic test for MODY, and - Is younger than 25 years of age, and - Has a family history of diabetes, and - Has negative islet of autoantibodies

HNF1B (HNF1 homeobox B) - The patient requires the service as a


LAMP2 (Danon disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glycogen storage disease IIb (Danon disease)

NF2 (neurofibromatosis, type 2): The patient has clinical features suspicious for, or requires the service as a confirmatory test for type 2 neurofibromatosis, OR The patient is at high risk for neurofibromatosis with one or more of the following: A first-degree relative with type 2

neurofibromatosis Multiple spinal tumors

(schwannomas, meningiomas) Cutaneous schwannomas

Continued

Once-in-a-lifetime

157 of 252157 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81405


Procedure, Level 6)

Continued below

Yes

Sporadic vestibular schwannoma younger than 30 years of age, or spinal tumor or meningioma younger than 20 years of age

NPHS2 (steroid resistant nephrotic syndrome [SRNS]) - The patient has clinical diagnosis of

SRNS, and - Treatment will be contingent on the test

results

OTC (ornithine transcarbamylase deficiency) – The patient has clinical signs and symptoms of urea cycle disorders with positive biochemical laboratory results and requires the service as a confirmatory test for ornithine transcarbamylase deficiency

RET (multiple endocrine neoplasia [MEN], type 2A and familial medullary thyroid carcinoma [MTC]) – exons 10, 11, 13 – 16:

- The patient has a personal history of MTC, or MEN, type 2A, or

- The patient has pheochromocytoma and a family history of MTC or pheochromocytoma, or

- The patient has sporadic MEN2-related tumors and is younger than 35 years of age, multicentric tumors in one organ, and/or two different organs affected, or

- The patient has a family history consistent with MEN, type 2A

RET (ret proto-oncogen), targeted sequence analysis:

- The patient has a personal history of primary C cell hyperplasie, MTC, or MEN, type 2A, or Continued

Once-in-a-

lifetime

158 of 252158 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81405


Procedure, Level 6)

Yes

- The patient has a family history

consistent with MEN, type 2A or MTC, and at risk for autosomal dominant inheritance of the syndrome

SLC2A1 (glucose transporter type 1 [GLUT 1] deficiency syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for GLUT 1 deficiency syndrome


SPRED1 (Legius syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Legius syndrome

TCF4 (Pitt-Hopkins syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Pitt-Hopkins syndrome


Once-in-a-

lifetime

159 of 252159 of 252


CPT-4 Code

Description

PHC TAR


Frequency



81406


Procedure, Level 7)

Continued below

Yes Coverage for CPT-4 code 81406 (molecular pathology procedure, Level 7) is limited to the listed services. Reimbursement for code 81406 requires an approved TAR and requires providers to document one of the following on the TAR: ACADVL (very long chain acyl-coenzyme A

dehydrogenase deficiency) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for ACADVL

AFG3L2 (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

ATP7B (Wilson disease): - The patient has clinical features suspicious for Wilson disease, and - Diagnosis cannot be made based on the results of biochemical testing and liver biopsy, and - The patient requires the service as a confirmatory test for Wilson disease

BTK (X-linked agammaglobulinemia): - The male patient has clinical features

suspicious for X-linked agammaglobulinemia, and

- The male patient has less than two percent CD19+ B cells

CDH1 (hereditary diffuse gastric cancer): - Two gastric cancer cases in family, one

confirmed diffuse gastric cancer younger than 50 years of age, or

- Three confirmed diffuse gastric cancer cases in first or second degree relatives, regardless of age, or

Continued

Once-in-a-lifetime

160 of 252160 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81406


Procedure, Level 7)

Continued below

Yes Diffuse gastric cancer diagnosed younger than 40 years of age, or

Personal or family history of diffuse gastric cancer and lobular breast cancer, one diagnosed younger than 50 years of age

CNTNAP2 (Pitt-Hopkins-like syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Pitt-Hopkins syndrome

GCK (glucokinase [hexokinase 4])

- The patient requires the service as diagnostic test for MODY, and


GLUD1 (familial hyperinsulinism): The patient has persistent

hyperinsulinemic hypoglycemia of infancy (PHHI) and failed medical therapy, and

The patient is under evaluation for surgical intervention

HNF4A (hepatocyte nuclear factor 4, alpha) - The patient requires the service as a


Continued

Once-in-a-lifetime

161 of 252161 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81406


Procedure, Level 7)

Continued below

Yes JAG1 (Alagille syndrome) – duplication/deletion – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Alagille syndrome

MUTYH (MYH-associated polyposis) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for MUTYH-associated polyposis

NF2 (neurofibromatosis, type 2): The patient has clinical features suspicious for, or requires the service as a confirmatory test for type 2 neurofibromatosis, or The patient is at high risk for neurofibromatosis with one or more of the following A first-degree relative with type 2


(schwannomas, meningiomas) Cutaneous schwannomas Sporadic vestibular schwannoma

younger than 30 years of age, or spinal tumor or meningioma younger than 20 years of age

PRKCG (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

PYGM (glycogen storage disease type V, McArdle disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glycogen storage disease type V (McArdle disease)

Continued

Once-in-a-lifetime

162 of 252162 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81406


Procedure, Level 7)

Yes SCNN1A (pseudohypoaldosteronism) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for pseudohypoaldosteronism

SCNN1B (Liddle syndrome, pseudohypoaldosteronism) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Liddle syndrome, pseudohypoaldosteronism

SCNN1G (Liddle syndrome, pseudohypoaldosteronism) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Liddle syndrome, pseudohypoaldosteronism

SLC37A4 (glycogen storage disease, type Ib) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glycogen storage disease, type Ib


UMOD (glomerulocystic kidney disease with hyperuricemia and isosthenuria) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glomerulocystic kidney disease with hyperuricemia and isosthenuria

WAS (Wiskott-Aldrich syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Wiskott-Aldrich syndrome


Once-in-a-lifetime

163 of 252163 of 252


CPT-4 Code

Description

PHC TAR


Frequency



81407


Procedure, Level 8)


ABCC8 (familial hyperinsulinism): - The patient has persistent hyperinsulinemic hypoglycemia of infancy (PHHI) who failed medical therapy, and - The patient is under evaluation for surgical intervention

AGL (glycogen storage disease type III) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glycogen storage disease type III

JAG1 (Alagille syndrome) – full gene sequence – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Alagille syndrome

NPHS1 (congenital Finnish nephrosis) - The patient has clinical diagnosis of steroid-resistant nephritic syndrome (SRNS)/congenital Finnish nephrosis, and - Treatment will be contingent on the test results

SPTBN2 (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia


Once-in-a-lifetime

164 of 252164 of 252


CPT-4 Code

Description

PHC TAR


Frequency



81408


Procedure, Level 9)

Yes Coverage for CPT-4 code 81408 (molecular pathology procedure, Level 9) is limited to the listed services. Reimbursement for code 81408 requires an approved Treatment Authorization Request (TAR) and requires providers to document one of the following on the TAR: explaining that the following criteria have been met:

ITPR1 (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

DMD (dsytophin), full gene analysis - Patient has a clinical diagnosis of

dystrophinopathy based on the history, physical examination and elevated creatine kinase (CK) level

- Result of the DMD (dystrophin) deletion or duplication is negative

Once-in-a-lifetime

81409 - 81471

Yes Not a Medi-Cal covered benefit (see below for further detail)

Once-in-a-lifetime


165 of 252165 of 252


CPT-4 Code

Description

PHC TAR


Frequency



Genomic Sequencing

Procedures and Other

Molecular Multianalyte

Assays

81435, 81436

No TAR required

when CPT

codes listed are

billed

Reimbursement for CPT-4 codes 81435 (hereditary colon cancer syndromes; genomic sequence analysis panel, must include analysis of at least seven genes, including APC, CHEK2, MLH1, MSH2, MSH6, MUTYH, and PMS2) and 81436 (…duplication/deletion gene analysis panel, must include analysis of at least eight genes, including APC, MLH1, MSH2, MSH6, PMS2, EPCAM, CHEK2, and MUTYH) is limited to once-in-a-lifetime with a Treatment Authorization Request (TAR). Codes 81435 and 81436 are reimbursable only when billed in conjunction with one of the following ICD-10-CM diagnosis codes:

C18.0 C18.6 Z80.0 C18 – C20.2 C18.7 Z85.030 – Z85.038 C18.3C54.0 – C54.9 C18.8 Z85.040 – Z85.048

C18.4Z80.0 C18.9 Z86.010Z85.42 C18.5Z80.49 C19 Z86.010

Once-in-a-lifetime


Testing for Telomerase

Reverse Transcriptase

(TERT)

81479

Yes Testing for Telomerase Reverse Transcriptase (TERT) gene in patients with glioma may be billed using CPT-4 code 81479 (unlisted molecular pathology procedure). A TAR is required. A TAR for the test requires documentation that the patient has the diagnosis of grade II, III or IV glioma.

Once-in-a-lifetime

Testing for Fetal

Aneuploidy - Cell Free

Fetal DNA Testing

81420, 81479, 81507

Continued below

Yes

Noninvasive prenatal testing for fetal aneuploidy may be billed with CPT-4 codes 81507 (fetal aneuploidy [trisomy 21, 18 and 13] DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy), 81420 (fetal chromosomal aneuploidy genomic sequence Continued

166 of 252166 of 252


CPT-4 Code

Description

PHC TAR


Frequency




Testing for Fetal


Fetal DNA Testing

81420, 81479, 81507

Yes

analysis panel, circulating cell-free fetal DNA in maternal blood, must include analysis of chromosomes 13, 18, and 21) or 81479 (unlisted molecular pathology procedure). A Treatment Authorization Request (TAR) with documentation of the following criteria is required: Patient with singleton gestation only The patient has an increased risk of

aneuploidy due to one or more of the following: - Maternal age 35 years or older at

delivery - Fetal ultrasonographic findings indicating

an increased risk of aneuploidy - History of a prior pregnancy with a

trisomy - Positive test result for aneuploidy,

including first trimester, sequential, or integrated screen, or a quadruple screen

- Parental balanced Robertsonian translocation with increased risk of fetal trisomy 13 or trisomy 21

Reference: The American College of Obstetricians and Gynecologists Committee on Genetics and The Society for Maternal-Fetal Medicine Publications Committee. Committee Opinion Number 545, December 2012.

167 of 252167 of 252


CPT-4 Code

Description

PHC TAR


Frequency



Multianalyte Assays

With Algorithmic

Analyses

81500, 81503,

81506 – 81512

(Note: These are biochemical tests, not genetic tests)

No

CPT-4 codes 81500, 81503, 81506 – 81512 encompass all analytical services required in addition to the algorithmic analysis itself. Codes 81500, 81503 and 81507 – 81512 are reimbursable for females only. Reimbursement for code 81507 is limited to once a year, any provider.


lifetime unless

otherwise noted

Multianalyte Assays

With Algorithmic

AnalysesGene

Expression

81519, 81599 Continued below

NoYes

Gene expression profiling for breast cancer may be billed with CPT-4 code 81519 (oncology [breast], mRNA, gene expression profiling by real time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score) or 81599 (unlisted multianalyte assay with algorithmic analysis). Both codes 81519 and 81599 have a frequency limit of once in a lifetime and require a Treatment Authorization Request (TAR) with documentation of the following criteria: The recipient is estrogen and

progesterone receptor (ER/PgR)-positive. The recipient is HER2-receptor negative. The recipient is lymph node negative. The recipient has stage I or stage II breast

cancer. The recipient is a candidate for

chemotherapy. The assay is used within six months of

diagnosis. The recipient is under consideration for

adjuvant systemic therapy. These benefits are limited to Oncotype Dx, Prosigna (PAM50 risk of recurrence score) and Breast Cancer Index. Use CPT-4 code 81519 Continued

As noted No TAR required for CPT-4 code 81519 billed with ICD-10 code C50

168 of 252168 of 252


CPT-4 Code

Description

PHC TAR


Frequency




Gene Expression

81519, 81599 Genetic Test

when billing for Oncotype Dx. Use CPT-4 code 81599 when billing for Prosigna and Breast Cancer Index. These once-in-a-lifetime benefits may be billed for the same recipient and any provider. Providers need an approved TAR and documentation showing that the recipient has a new second primary breast cancer that meets the necessary criteria as listed above to override the once-in-a-lifetime frequency.Providers must document that all of the following criteria of early stage breast cancer have been met for reimbursement of CPT-4 code 81519 (oncology, mRNA, gene expression profiling by real time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score).

This once-in-a-lifetime benefit may be billed more than once for the same recipient if the provider can prove via documentation that the recipient has a new second primary breast cancer that meets the necessary criteria listed above.

Karyotype (aka

Cytogenetic Studies)

88261 – 88269

88280

No Karyotype testing for codes 88261-3 may be ordered once in a lifetime in children with phenotype of syndrome most commonly associated with a chromosomal abnormality. For perinatal indication, see Medi-Cal guidelines in the Genetic Counseling and Screening section gene coun 2.

Once-in-a-lifetime

169 of 252169 of 252


Description

PHC TAR


Frequency



81161

DMD (dystrophin)

deletion analysis, and

duplication analysis, if

performed

No ICD-10-CM diagnosis code G71.0 (muscular dystrophy) is required on the claim.

Once-in-a-lifetime

81201

APC

gene analysis; full gene

sequence


Once-in-a-lifetime

81202

APC


familial variants

Yes Requires documentation on the Treatment Authorization Request (TAR) of a family history of familial adenomatous polyposis that includes a relative with a known deleterious APC mutation

Once-in-a-lifetime

81203

APC

gene analysis;


variants


Once-in-a-lifetime

81206


analysis; major

breakpoint


1 per month

81207


analysis; minor

breakpoint


1 per month

81208


analysis; other

breakpoint


1 per month

170 of 252170 of 252


Description

PHC TAR


Frequency



81210

BRAF (v-raf murine

sarcoma viral oncogene

homolog B1) gene

analysis, V600E variant

No One of the following ICD-10-CM codes is required on the claim: C18.0 – C18.9, C19, C20, C43.0 – C43.9, C79.2 or D03.0 – D03.9

Once-in-a-lifetime

81211

BRCA1, BRCA2 gene


analysis

Continued below

Yes A TAR for code 81211 requires documentation of one or more of the following numbered criteria: 1. An individual with a family member with a

known deleterious BRCA mutation; OR 2. Personal history of breast cancer plus one or

more of the following: Diagnosed at ≤ 45 years of age; OR Diagnosed at ≤ 50 years of age with:

– An additional breast cancer primary – One or more close blood relatives with breast cancer at any age – One or more close blood relatives with pancreatic cancer – One or more close blood relatives with prostate cancer (Gleason score ≥ 7) – An unknown or limited family history

Diagnosed at ≤ 60 years of age with a triple negative breast cancer

Diagnosed at any age with: – One or more close blood relatives with breast cancer diagnosed at ≤ 50 years of age – Two or more close blood relatives with breast cancer at any age – One or more close blood relatives with invasive ovarian cancer – Two or more close blood relatives with pancreatic cancer and/or prostate cancer (Gleason score ≥ 7) at any age

Continued

Once-in-a-lifetime


171 of 252171 of 252


Description

PHC TAR


Frequency




81211

BRCA1, BRCA2 gene

analysis

Yes – A close male blood relative with breast cancer – For an individual of ethnicity associated with higher mutation frequency (for example, Ashkenazi Jewish), no additional family history may be required

3. Personal history of invasive ovarian cancer 4. Personal history of male breast cancer 5. Personal history of prostate cancer

(Gleason score ≥ 7) at any age with one or more close blood relatives with breast cancer (≤ 50 years of age) and/or invasive ovarian and/or pancreatic or prostate cancer (Gleason score ≥ 7) at any age

6. Personal history of pancreatic cancer at any age with one or more close blood relative with breast cancer (≤ 50 years of age) and/or invasive ovarian and/or pancreatic cancer at any age

7. Personal history of pancreatic cancer and Ashkenazi Jewish ancestry.

8. For an individual without history of breast or ovarian cancer: First or second degree blood relative

meeting any of the above criteria Third degree blood relative (who has

breast cancer and/or invasive ovarian cancer and who has two or more close blood relatives with breast cancer (at least one with breast cancer ≤ 50 years of age) and/or invasive ovarian cancer

Once-in-a-lifetime


81211

(Reflex BRCA1, BRCA2

gene analysis billed with

modifier QP)

Yes A TAR for code 81211 billed with modifier QP requires documentation of the following: A negative result in the single mutation

(codes 81215 or 81217) or three-mutation (code 81212) analysis, and

One or more criteria listed under code 81211

Once-in-a-lifetime


172 of 252172 of 252


Description

PHC TAR


Frequency



81212

BRCA1, BRCA2 gene

analysis; variants

Yes Requires documentation on the TAR of the following: An individual is of an ethnicity associated

with the Ashkenazi Jewish population No additional family history may be

required

Once-in-a-lifetime


81213

BRCA1, BRCA2 gene

analysis; uncommon


variants

Yes Requires documentation on the TAR of one or more criteria listed under CPT-4 code 81211

Once-in-a-lifetime


81215



familial variant


Once-in-a-lifetime


81217



familial variant


Once-in-a-lifetime


81220

CFTR (cystic fibrosis

transmembrane

conductance regulator)

gene analysis; common

variants

No When used to bill for cystic-fibrosis screening requires ICD-10-CM code Z31.430 or Z31.440 Not reimbursable with code 81224 for same date of service, recipient and provider May be billed separately with an appropriate National Correct Coding Initiative (NCCI) associated modifier Refer to the Genetic Counseling and Screening section in the Medi-Cal Manual for additional information

Once-in-a-lifetime

81221

Cystic Fibrosis known

family variants

Yes Not a Medi-Cal covered benefit Testing family members of those previously diagnosed with Cystic Fibrosis (CF)

Once-in-a-lifetime


173 of 252173 of 252


Description

PHC TAR


Frequency



81222

Cystic Fibrosis

Deletion/Duplication

Yes Not a Medi-Cal covered benefit Used to identify causal mutations when only a single common mutation or rare variant of CF are detected. (Previous tests with a screening assay for common mutations and variants followed by CFTR full gene sequence analysis revealed only heterozygosity –a single mutation)

Once-in-a-lifetime


81223

Cystic Fibrosis Full

Gene Sequencing

Yes Not a Medi-Cal covered benefit Used to identify rare mutations in individuals suspected of having CF but where only a single common mutation or variant has been identified

Once-in-a-lifetime


81225

CYP2C19 Gene common

variants

Yes Not a Medi-Cal covered benefit The cytochrome P450 (CYP450) enzymes catalyze the oxidation of many drugs and chemicals. Individual differences of cytochrome P450 activity can result in total absence of metabolism of certain drugs to ultrafast metabolism of drugs. This can lead to adverse drug reactions or a lack of therapeutic effect under standard therapy conditions. CYP2C19 is a gene within the family of the CYP450 superfamily. It metabolizes 15% of all prescribed drugs, such as clopidogrel (Plavix).

Once-in-a-lifetime


174 of 252174 of 252


Description

PHC TAR


Frequency



81226

CYP2D6 Gene common

variants

Yes Not a Medi-Cal covered benefit The cytochrome P450 (CYP450) enzymes catalyze the oxidation of many drugs and chemicals. Individual differences of cytochrome P450 activity can result in total absence of metabolism of certain drugs to ultrafast metabolism of drugs. This can lead to adverse drug reactions or a lack of therapeutic effect under standard therapy conditions. CYP2D6 is a gene within the family of the CYP450 superfamily. It metabolizes 25% of all prescribed drugs, such as codeine, tricyclic antidepressants, classical antipsychotics, and β-blockers. Specific variants in this gene also influence the metabolism of the breast cancer drug, tamoxifen, in postmenopausal women. Genetic variants of CYP2D6 can be used to predict the altered enzyme activity and address the potential effects of metabolized drugs.

Once-in-a-lifetime


81227

CYP2C9 Gene common

variants

Yes Not a Medi-Cal covered benefit The presence of certain variants in the CYP2C9 gene can result in poor metabolizer phenotypes that are associated with lack of enzyme activity and drugs may be metabolized slowly or not at all. This results in increased concentrations of the drug with a reduced or absent therapeutic response and the potential for serious side effects. Warfarin metabolism is reduced by 30% to 50% by the *2 variant and 90% by the *3 variant. Individuals with at least one copy of *2 or *3 have an increased risk of bleeding compared to individuals without *2 or *3. A lower maintenance dose may be required.

Once-in-a-lifetime


175 of 252175 of 252


Description

PHC TAR


Frequency



81228, 81229


Testing

Continued below

Yes Not a Medi-Cal covered benefit. Microarray-based Comparative Genomic Hybridization (aCGH) is medically necessary for the following indications:

Evaluating fetuses with structural abnormalities detected on fetal ultrasound or fetal magnetic resonance imaging; or

For evaluating histologically equivocal Spitzoid melanocytic neoplasms (Spitz nevus and atypical Spitz tumors); or

Analyses of stillbirths with congenital anomalies or in stillbirths in which karyotype results cannot be obtained.

Microarray-based Comparative Genomic Hybridization (aCGH) is medically necessary for diagnosing genetic abnormalities in children with developmental delay/intellectual disability (DD/ID) or autism spectrum disorder (ASD) according to accepted Diagnostic and Statistical Manual of Medical Disorders 5 (DSM 5) when all of the following criteria are met:

If warranted by the clinical situation, biochemical testing for metabolic diseases has been performed and is negative; and

Targeted genetic testing, (for example: FMR1 gene analysis for Fragile X), if or when indicated by the clinical and family history, is negative; and

The member's clinical presentation is not specific to a well-delineated genetic syndrome*; and

Continued




lifetime


176 of 252176 of 252


Description

PHC TAR


Frequency




81228, 81229


Testing

Continued below

Yes In addition to a diagnosis of DD/ID or ASD, the child has one or more of the following: - Two or more major malformations, or - A single major malformation or multiple

minor malformations, in an infant or child who is also small-for-dates, or

- A single malformation and multiple minor malformations, and

- The results for the testing have the potential to impact the clinical management of the member.

* aCGH is considered not medically necessary when a diagnosis of a disorder or syndrome is readily apparent based on clinical evaluation alone.

Continued




lifetime


177 of 252177 of 252


Description

PHC TAR


Frequency




81228, 81229

Yes Chromosomal Microarray-based Comparative Genomic Hybridization (aCGH) is considered experimental and investigational in all other cases of suspected genetic abnormality in children with developmental delay/intellectual disability or autism spectrum disorder. aCGH is considered experimental and investigational for any other indications including the following (not an all-inclusive list) because of insufficient evidence of its effectiveness:

Detection of balanced rearrangements

Evaluation of autoimmune lymphoproliferative syndrome

Evaluation of unexplained epilepsies

Screening for prenatal gene mutations in fetuses without structural abnormalities, such as in advanced maternal age, positive maternal serum screen, previous trisomy, or the presence of "soft markers" on fetal ultrasound

Testing products of conception

Diagnosis of melanoma

Additional criteria for Microarray-based Comparative Genomic Hybridization (aCGH): If not meeting above criteria and a medical geneticist believes it is necessary, he or she may submit specific justification to PHC for review. Notes: The Oligo HD Scan is a type of aCGH. The CombiMatrix DNArray is an aCGH test for developmental delay.




lifetime


178 of 252178 of 252


Description

PHC TAR


Frequency



81235

EGFR (epidermal growth

factor receptor) gene

analysis, common

variants

No One of the following ICD-10-CM codes is required on the claim: C33, C34.00 – C34.92

Once-in-a-lifetime

81243


retardation 1) gene

analysis; evaluation to

detect abnormal alleles


Once-in-a-lifetime

81244


retardation 1) gene

analysis;

characterization of

alleles


Once-in-a-lifetime

81250

G6PC (glucose-6-

phosphatase, catalytic

subunit) gene analysis,

common variants

Yes The patient has clinical features suspicious for, or requires the laboratory service as a diagnostic test for glycogen storage disease, type 1a

Once-in-a-lifetime

81256

HFE (hemochromatosis)

gene analysis, common

variants

No One of the following ICD-10-CM codes is required on the claim: E83.10, E83.110 or E83.118 – E83.119

Once-in-a-lifetime

179 of 252179 of 252


Description

PHC TAR


Frequency



81260

IKBKAP (inhibitor of

kappa light polypeptide

gene enhancer in B-

cells, kinas complex-

associated protein) gene

analysis, common

variants

No Indicated for: Hypotonia in infancy Decreased or absent deep tendon reflexes Decreased taste and absence of fungiform

papillae of the tongue Absence of overflow tears with emotional

crying (alacrima) Absence of axon flare response after

intradermal histamine injection Pupillary hypersensitivity to

parasympathomimetic agents

Once-in-a-lifetime


81265


using Short Tandem

Repeat markers


Once-in-a-lifetime

81266


using Short Tandem

Repeat markers; each

additional specimen


Once-in-a-lifetime

81267

Chimerism



specimen; without cell

selection


1 per month

81268

Chimerism



specimen; with cell

selection


1 per month

180 of 252180 of 252


Description

PHC TAR


Frequency



81270

JAK2 (Janus kinase 2)

gene analysis, p.

Val617Phe (V617F)

variant

No One of the following ICD-10-CM codes is required on the claim: D45, D47.1 or D47.3

Once-in-a-lifetime

81275

KRAS (v-Ki-ras2 Kirsten

rat sarcoma viral

oncogene) gene

analysis, variants in

codons 12 and 13

No One of the following ICD-10-CM codes is required on the claim: C18.0, C18.2 – C20, D01.1, D01.2, D01.40, D01.49, D37.4 or D37.5

Once-in-a-lifetime

81280


analyses; full sequence

analysis

Yes Not split-billable and must not be billed with modifier 26, 99 or TC Document on the TAR a copy of the report of the physician-interpreted 12-lead electrocardiogram (ECG) with pattern consistent with or suspicious for prolonged QT interval, and clinical documentation of one or more of the following: Torsade de pointes in the absence of

drugs known to prolong QT interval T-wave alternans Notched T-wave in three leads Syncope Family members with LQTS Sudden death in family members less than

30 years of age without defined cause

Once-in-a-lifetime

81281


analyses; known familial

sequence variant

Yes Not split-billable and must not be billed with modifier 26, 99 or TC Document on the TAR: The family member being tested is a

Medi-Cal recipient, and There is clinical documentation of at least

one first-degree relative (parent, sibling or offspring) with a laboratory-confirmed LQTS genetic mutation

Once-in-a-lifetime

181 of 252181 of 252


Description

PHC TAR


Frequency



81287

MGMT (0-6

methylguanin-DNA

methyltransferase)


No Indicated for:

The patient has the diagnosis of glioblastoma multiforme, and

Treatment strategy will be contingent on the test results

Reimburseable when billed with ICD-10 : C71.9.

Once-in-a-lifetime,

any provider

While DHCS requires a TAR for this test, PHC has chosen to have no TAR requirement when billed with ICD-10 code C71.9

81288

MLH1 gene analysis;

promoter methylation

analysis

Yes Document the following criteria on the TAR: Patient with colon cancer, and The tumor demonstrates microsatellite

instability or immunohistochemistry results indicating loss of MLH1 protein expression

Once-in-a-lifetime

81291

MTHFR

Methylenetetrahydrofola

te Reductase, DNA

Mutation Analysis

Yes Not a Medi-Cal covered benefit Once-in-a-lifetime


81292


colon cancer,


gene analysis; full

sequence analysis

No One of the following ICD-10-CM codes is required on the claim: C18.0 – C20, C54.0 – C54.9, Z80.0, Z80.49, Z85.030, Z85.038, Z85.040, Z85.048, Z85.42

Once-in-a-lifetime

81293


colon cancer,



familial variants

Yes Document on the TAR family history of Lynch Syndrome that includes a relative with a known deleterious MLH1 mutation

Once-in-a-lifetime


182 of 252182 of 252



Description

PHC TAR


Frequency



81294


colon cancer,


gene analysis;


variants


Once-in-a-lifetime

81295


colon cancer,


gene analysis; full

sequence analysis


Once-in-a-lifetime

81296


colon cancer,



familial variants


Once-in-a-lifetime


81297


colon cancer,


gene analysis;


variants

No One of the following ICD-10-CM codes is required on the claim: C18.0 – C20, C54.0 – C54.9, Z80.0, Z80.49. Z85.030, Z85.038, Z85.040, Z85.048, Z85.42

Once-in-a-lifetime

81298



full sequence analysis


Once-in-a-lifetime

PHC will also reimburse for these ICD-10 codes : C56.1 – C56.9

81299



known familial variants


Once-in-a-lifetime


183 of 252183 of 252




Description

PHC TAR


Frequency



81300




variants


Once-in-a-lifetime

81301

Microsatellite instability

analysis of markers for

mismatch repair

deficiency

No One of the following ICD-10-CM codes is required on the claim: C18.0 or C18.2 – C18.9

Once-in-a-lifetime

81315

PML/RAR-alpha

(promyelocytic


receptor alpha)


common breakpoints


1 per month

81316

PML/RAR-alpha

(promyelocytic


receptor alpha)


single breakpoint


1 per month

81317

PMS2 (postmeiotic




analysis


Once-in-a-lifetime

81318

PMS2 (postmeiotic



analysis; known familial

variants

Yes Document on the TAR family history of Lynch Syndrome that includes a relative with a known deleterious PMS2 mutation

Once-in-a-lifetime


184 of 252184 of 252



Description

PHC TAR


Frequency



81319

PMS2 (postmeiotic



analysis;


variants


Once-in-a-lifetime

81321

PTEN (phosphatase and

tensin homolog) gene


analysis

Continued below

Yes A TAR for CPT-4 code 81321 requires documentation of one or more of the following numbered criteria: 1. Individual with a personal history of: Bannayan-Riley-Ruvalcaba syndrome, or Adult Lhermitte-Duclos disease, or Autism spectrum disorder AND

macrocephaly, or Two or more biopsy-proven

trichilemmomas, or Two or more major criteria (one

macrocephaly), or Three major criteria without macrocephaly,

or One major and three or more minor criteria,

or Four or more minor criteria (please see list

below) 2. At-risk individual:

With a relative who has a clinical diagnosis of Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome for whom testing has not been performed AND who has any one major criterion or two minor criteria

(continued on next page)

Once-in-a-lifetime

185 of 252185 of 252


Description

PHC TAR


Frequency




81321

PTEN gene analysis; full

sequence analysis

Yes Major Criteria Breast cancer Mucocutaneous lesions One biopsy-proven trichilemmoma Multiple palmoplantar keratosis Multifocal or extensive oral mucosal

papillomatosis Multiple cutaneous facial papules (often

verrucous) Macular pigmentation of glans penis Macroencephaly (megalocephaly, ie, ≥97th

percentile) Endometrial cancer Non-medullary thyroid cancer Multiple GI tract hamartomas or

ganglioneuromas Minor Criteria

Other thyroid lesions (adenoma, nodule, goiter)

Mental retardation (IQ ≤75) Autism spectrum disorder Single GI tract hamartoma or

ganglioneuroma Fibrocystic disease of the breast Lipomas Fibromas Renal cell carcinoma Uterine fibroids

Once-in-a-lifetime

81322

PTEN gene analysis;

known familial variant

Yes Requires documentation on the TAR that patient is from a family with a known PTEN mutation

Once-in-a-lifetime

186 of 252186 of 252


Description

PHC TAR


Frequency



81323

PTEN gene analysis;


variant

Yes Requires documentation on the TAR of a negative result in the full sequence analysis in PTEN (CPT-4 code 81321), and that patient meets one or more criteria listed under code 81321

Once-in-a-lifetime

81331

SNRPN/UBE3A


Yes Document the following age-specific criteria on the TAR Birth to 2 years: Hypotonia with poor suck 2 – 6 years: Hypotonia with history of poor

suck and global development delay 6 – 13 years: History of hypotonia with poor

suck (hypotonia often persists); global development delay; and excessive eating (hyperphagia; obsession with food) with central obesity if uncontrolled

13 years – adult: Cognitive impairment – usually mild mental retardation; excessive eating (hyperphagia; obsession with food) with central obesity if uncontrolled; and hypothalamic hypogonadism and/or typical behavior problems (including temper tantrums and obsessive-compulsive features)

Once-in-a-lifetime

Human Leukocyte

Antigen Typing

81370 - 81383

No TAR required

when CPT

codes listed are

billed

CPT-4 codes 81370 – 81380, 81382 and 81383 (human leukocyte antigen typing) are reimbursable only with an ICD-10-CM diagnosis in the range of Z01.812, Z01.89, Z48.21 – Z48.298, Z94.0 – Z94.9. CPT-4 code 81381 (HLA Class I typing, high resolution, one allele or allele group) is only reimbursable with an ICD-10-CM diagnosis of B20, F31.0 – F31.9, G40.001 – G40.919, G50.0, R75, Z21, Z48.21 – Z48.298, Z94.0 – Z94.9

Once-in-a-lifetime

No payment will be made without diagnosis codes listed.

187 of 252187 of 252


CPT-4 Code

Description

PHC TAR


Frequency



81400


Procedure, Level 1)

Continued below

Yes Providers are required to document one of the following on the TAR:

Human Platelet Antigen genotyping: - The patient has clinical features

suspicious for, or requires the service as a confirmatory test for neonatal alloimmune thrombocytopenia, or,

- The patient has clinical features suspicious for, or requires services as a confirmatory test for post transfusion purpura

CCR5 (chemokine C-C motif receptor 5): - Initial test: The use of a CCR5 inhibitor is being

considered, or The patient exhibits virologic failure on

a CCR5 inhibitor - Subsequent tests: A previous Trofile test was performed

including the test date and the results showing that the recipient has a CCR5 virus, and,

The recipient’s previous Trofile test was not less than 90 days from subsequent request, and,

The recipient has clinical scenario such as, but not limited to the following: The treatment with CCR5

antagonist drug therapy was interrupted and the clinician wishes to reinstitute CCR5 antagonist drug therapy, or,

Continued

Once-in-a-lifetime

188 of 252188 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81400


Procedure, Level 1)

Yes The recipient had a Trofile test performed previously that showed that the recipient had the CCR5 virus, but the CCR5 antagonist drug therapy was never initiated.


IL28B - The patient has genotype 1 hepatitis C

virus infection, and, - Treatment will be contingent on the test

results. Claims without documentation showing the preceding criteria have been met will be denied.

Once-in-a-lifetime

81401


Procedure, Level 2)

Continued below


ABCC8 (familial hyperinsulinism): - The patient has persistent

hyperinsulinemic hypoglycemia of infancy (PHHI), failed medical therapy, and

- The patient is under evaluation for surgical intervention

Continued

Once-in-a-lifetime

189 of 252189 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81401


Procedure, Level 2)

Continued below

Yes ABL (c-abl oncogene 1, receptor tyrosine kinase) – The patient has chronic myeloid leukemia (CML) and failed tyrosine kinase inhibitor (TKI) therapy

AR (spinal & bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinal and bulbar muscular atrophy or Kennedy disease

ATN1 (dentatorubral-pallidoluysian atrophy) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for dentatorubral pallidoluysian atrophy



ATXN3 (spinocerebellar ataxia, Machado-Joseph disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia


Continued

Once-in-a-lifetime

190 of 252190 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81401


Procedure, Level 2)

Continued below

Yes ATXN10 (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

ATXN80S (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

CACNA1A (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

CNBP (myotonic dystrophy, type 2) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for myotonic dystrophy, type 2

CSTB (Unverricht-Lundborg disease): The patient has clinical features

suspicious for, or requires the service as a confirmatory test for myoclonic epilepsy type 1, and

Treatment will be contingent on test results

DMPK (dystrophia myotonica-protein kinase) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for myotonic dystrophy type 1

Continued

Once-in-a-lifetime

191 of 252191 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81401

(molecular pathology

procedure, Level 2)

Continued below

Yes E2A/PBX1 (acute lymphocytic leukemia): - The patient has the diagnosis of acute

lymphocytic/lymphoblastic leukemia, and - Treatment or monitoring strategy will be

contingent on the test results

ETV6/RUNX1 (acute lymphocytic leukemia) –The patient has the diagnosis of acute lymphocytic or lymphoblastic leukemia, and requires the test for assessment of cancer prognosis


H19 (Beckwith-Wiedemann syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Beckwith-Wiedemann syndrome

KCNQ1OT1 (Beckwith-Wiedemann syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Beckwith-Wiedemann syndrome

MLL/AFF1 (acute lymphoblastic leukemia): - The patient has the diagnosis of acute lymphoblastic leukemia, and Treatment or monitoring strategy will be contingent on the test results

Continued

Once-in-a-lifetime

192 of 252192 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81401


Procedure, Level 2)

Continued below

Yes MLL/MLLT3 (acute myeloid leukemia): - The patient has the diagnosis of acute myeloid leukemia, and - Treatment or monitoring strategy will be contingent on the test results

MUTYH (MYH-associated polyposis) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for MUTYH- associated polyposis

MT-ATP6 (neuropathy with ataxia and retinitis pigmentosa [NARP], Leigh syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for NARP or Leigh syndrome

PPP2R2B (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

PRSS1 (hereditary pancreatitis):

An unexplained documented episode of acute pancreatitis in childhood, or

Recurrent acute attacks of pancreatitis of unknown cause, or

Chronic pancreatitis of unknown cause, particularly with onset younger than 25 years of age, or

A family history of recurrent acute pancreatitis, chronic pancreatitis of unknown cause, and/or childhood pancreatitis of unknown cause consistent with autosomal dominant inheritance

Continued

Once-in-a-lifetime

193 of 252193 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81401


Procedure, Level 2)

Yes PYGM (glycogen storage disease type V, McArdle disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glycogen storage disease type V

RUNX1/RUNX1T1 (t[8;21]) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for acute myeloid leukemia

TBP (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia


Once-in-a-lifetime

81402


Procedure, Level 3)


KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) – The patient has clinical features suspicious for, or requires the service as a diagnostic test for mastocytosis

Chromosome 1p-/19q- (e.g. glial tumors), deletion analysis – Patient with diagnosis of grade II, III or IV glioma


Once-in-a-lifetime

194 of 252194 of 252


CPT-4 Code

Description

PHC TAR


Frequency



81403


Procedure, Level 4)

Continued below


DNMT3A (acute myeloid leukemia): The patient has diagnosis of acute myeloid leukemia, and The treatment strategy will be contingent on test results

EPCAM (Lynch syndrome) – The patient has one of the following: o Colon cancer o Uterine cancer o Lynch syndrome o Family history of colorectal cancer,

uterine cancer or Lynch syndrome IDH1 – Patient with diagnosis of grade II, III

or IV glioma IDH2 – Patient with diagnosis of grade II, III

or IV glioma JAK 2 (Janus kinase 2) – The patient has

clinical features suspicious for, or requires the service as a diagnostic test for myeloproliferative disorder

KCNC3 (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

KCNJ11 (familial hyperinsulinism): - The patient has persistent hyperinsulinemic hypoglycemia of infancy (PHHI) and failed medical therapy, and - The patient is under evaluation for surgical intervention

Continued



circumstance


195 of 252195 of 252



CPT-4 Code

Description

PHC TAR


Frequency




81403


Procedure, Level 4)

Continued below

Yes KIR (killer cell immunoglobulin-like receptor for hematopoietic stem cell transplantation):

The patient has diagnosis of acute myeloid leukemia, and

The test is used for donor search process for patients considering hematopoietic stem cell transplantation

KRAS (Carcinoma), exon 3, codon 61:

The patient has colorectal cancer, and

The intention to treat or not to treat with anti-EGFR antibodies (cetuximab or panitumumab) will be contingent on the test results

MICA (solid organ transplantation):

The patient is undergoing evaluation for kidney transplantation, or

The patient is post kidney transplantation

MPL (myeloproliferative leukemia virus oncogene, thrombopoietin receptor, TPOR) – The patient has clinical features suspicious for, or requires the service as a diagnostic test for myeloproliferative disorder


Continued



circumstance

196 of 252196 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81403


Procedure, Level 4)

Yes SH2D1A (X-linked lymphoproliferative syndrome) – The patient is a male with the diagnosis of: Common variable immune deficiency,

or Hypogammaglobulinemia, or Hemophagocytic lymphohistiocytosis,

or Severe infectious mononucleosis, or Lymphoma, or Family history of X-linked

lymphoproliferative syndrome

VHL (von Hippel-Lindau tumor suppressor), deletion/duplication analysis – The patient has clinical features suspicious for, or requires the service as a diagnostic test for von Hippel-Lindau syndrome




circumstance

197 of 252197 of 252


CPT-4 Code

Description

PHC TAR


Frequency



81404


Procedure, Level 5)

Continued below

Yes Coverage for CPT-4 code 81404 (molecular pathology procedure Level 5) is limited to the listed services. Reimbursement for code 81404 requires an approved Treatment Authorization Request (TAR) and requires providers to document one of the following on the TAR: ACADS (acyl-CoA dehydrogenase, C-2 to

C-3 short chain), targeted sequence analysis: The patient has elevated C4-C on newborn screening test, and Confirmation (urine acylglycines or urine organic acids) that C4 (butyrylcarnitine) and/or ethylmalonic acid (EMA) are elevated

CD40LG (X-linked hyper IgM syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for hyperimmunoglobulin M syndromes

CSTB (Unverricht-Lundborg disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Unverricht-Lundborg disease

DMPK (dystrophia myotonica-protein kinase) – The patient has clinical features suspicious for, or requires the service as a diagnostic test for myotonic dystrophy


Continued



circumstance

198 of 252198 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81404


Procedure, Level 5)

Continued below

Yes EPM2A (progressive myoclonus epilepsy) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for progressive myoclonus epilepsy

FHL1 (Emery-Dreifuss muscular dystrophy) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Emery-Dreifuss muscular dystrophy



PDX1 (pancreatic and duodenal homeobox 1)

- The patient requires the service as a diagnostic test for (maturity onset diabetes of the young) MODY, and


PRNP (genetic prion disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for genetic prion disease

PRSS1 (hereditary pancreatitis): An unexplained documented episode of acute pancreatitis in childhood, or Recurrent acute attacks of pancreatitis of unknown cause, or Chronic pancreatitis of unknown cause,

particularly with onset younger than 25 years of age, or Continued



circumstance

199 of 252199 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81404


Procedure, Level 5)

Yes - A family history of recurrent acute pancreatitis, chronic pancreatitis of unknown cause, and/or childhood pancreatitis of unknown cause consistent with autosomal dominant inheritance

RET (ret proto-oncogene), common variants The patient has a personal history of primary C cell hyperplasia, Medullary Thyroid Carcinoma (MTC), or Multiple Endocrine Neoplasia (MEN), type 2B, or The patient has a family history consistent with MEN, type 2B or MTC, and at risk for autosomal dominant inheritance of the syndrome

SH2D1A (X-linked lymphoproliferative syndrome) – The patient is a male with the diagnosis of: Common variable immune deficiency, or Hypogammaglobulinemia, or Hemophagocytic lymphohistiocytosis, or Severe infectious mononucleosis, or Lymphoma, or Family history of X-linked lymphoproliferative syndrome

SPINK1 (hereditary pancreatitis): - An unexplained documented episode of acute pancreatitis in childhood, or - Recurrent acute attacks of pancreatitis of unknown cause, or - Chronic pancreatitis of unknown cause, particularly with onset younger than 25 years of age, or - A family history of recurrent acute pancreatitis, chronic pancreatitis of unknown cause, and/or childhood pancreatitis of unknown cause consistent with autosomal dominant inheritance




circumstance

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CPT-4 Code

Description

PHC TAR


Frequency



81405


Procedure, Level 6)

Continued below

Yes Coverage for CPT-4 code 81405 (molecular pathology procedure, level 6) is limited to the listed services. Reimbursement for code 81405 requires an approved TAR and requires providers to document one of the following on the TAR:

ABCD1 (adrenoleukodystrophy): The patient has clinical features

suspicious for adrenoleukodystrophy, and

Measurement of plasma concentration of very long chain fatty acids (VLCFA) is inconclusive, and

The service is required as a confirmatory test for the diagnosis of adrenoleukodystrophy

ACADS (acyl-CoA dehydrogenase, C-2 to C-3 short chain), full gene sequence: The patient has elevated C4-C on newborn screening test, and Confirmation (urine acylglycines or urine organic acids) that C4 (butyrylcarnitine) and/or ethylmalonic acid (EMA) are elevated


GLA (galactosidase alpha [for example, Fabry disease]), full gene sequence: The patient has a family member with documented disease-causing mutation, and

Continued

Once-in-a-lifetime

201 of 252201 of 252


CPT-4 Code

Description

PHC TAR


Frequency




81405


Procedure, Level 6)

Continued below

Yes

The decision whether to initiate enzyme replacement therapy will be contingent on the results

HNF1A (HNF1 homeobox A) - The patient requires the service as a


HNF1B (HNF1 homeobox B) - The patient requires the service as a


LAMP2 (Danon disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glycogen storage disease IIb (Danon disease)

NF2 (neurofibromatosis, type 2): The patient has clinical features suspicious for, or requires the service as a confirmatory test for type 2 neurofibromatosis, OR The patient is at high risk for neurofibromatosis with one or more of the following: A first-degree relative with type 2


(schwannomas, meningiomas) Cutaneous schwannomas

Continued

Once-in-a-lifetime

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CPT-4 Code

Description

PHC TAR


Frequency




81405


Procedure, Level 6)

Continued below

Yes

Sporadic vestibular schwannoma younger than 30 years of age, or spinal tumor or meningioma younger than 20 years of age

NPHS2 (steroid resistant nephrotic syndrome [SRNS]) - The patient has clinical diagnosis of

SRNS, and - Treatment will be contingent on the test

results

OTC (ornithine transcarbamylase deficiency) – The patient has clinical signs and symptoms of urea cycle disorders with positive biochemical laboratory results and requires the service as a confirmatory test for ornithine transcarbamylase deficiency

RET (multiple endocrine neoplasia [MEN], type 2A and familial medullary thyroid carcinoma [MTC]) – exons 10, 11, 13 – 16:

- The patient has a personal history of MTC, or MEN, type 2A, or

- The patient has pheochromocytoma and a family history of MTC or pheochromocytoma, or

- The patient has sporadic MEN2-related tumors and is younger than 35 years of age, multicentric tumors in one organ, and/or two different organs affected, or

- The patient has a family history consistent with MEN, type 2A

RET (ret proto-oncogen), targeted sequence analysis:

- The patient has a personal history of primary C cell hyperplasie, MTC, or MEN, type 2A, or Continued

Once-in-a-

lifetime

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CPT-4 Code

Description

PHC TAR


Frequency




81405


Procedure, Level 6)

Yes

- The patient has a family history

consistent with MEN, type 2A or MTC, and at risk for autosomal dominant inheritance of the syndrome

SLC2A1 (glucose transporter type 1 [GLUT 1] deficiency syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for GLUT 1 deficiency syndrome


SPRED1 (Legius syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Legius syndrome



Once-in-a-

lifetime

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CPT-4 Code

Description

PHC TAR


Frequency



81406


Procedure, Level 7)

Continued below

Yes Coverage for CPT-4 code 81406 (molecular pathology procedure, Level 7) is limited to the listed services. Reimbursement for code 81406 requires an approved TAR and requires providers to document one of the following on the TAR: ACADVL (very long chain acyl-coenzyme A

dehydrogenase deficiency) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for ACADVL

AFG3L2 (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

ATP7B (Wilson disease): - The patient has clinical features suspicious for Wilson disease, and - Diagnosis cannot be made based on the results of biochemical testing and liver biopsy, and - The patient requires the service as a confirmatory test for Wilson disease

BTK (X-linked agammaglobulinemia): - The male patient has clinical features

suspicious for X-linked agammaglobulinemia, and

- The male patient has less than two percent CD19+ B cells

CDH1 (hereditary diffuse gastric cancer): - Two gastric cancer cases in family, one

confirmed diffuse gastric cancer younger than 50 years of age, or

- Three confirmed diffuse gastric cancer cases in first or second degree relatives, regardless of age, or

Continued

Once-in-a-lifetime

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CPT-4 Code

Description

PHC TAR


Frequency




81406


Procedure, Level 7)

Continued below

Yes Diffuse gastric cancer diagnosed younger than 40 years of age, or

Personal or family history of diffuse gastric cancer and lobular breast cancer, one diagnosed younger than 50 years of age

CNTNAP2 (Pitt-Hopkins-like syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Pitt-Hopkins syndrome

GCK (glucokinase [hexokinase 4])

- The patient requires the service as diagnostic test for MODY, and


GLUD1 (familial hyperinsulinism): The patient has persistent

hyperinsulinemic hypoglycemia of infancy (PHHI) and failed medical therapy, and

The patient is under evaluation for surgical intervention

HNF4A (hepatocyte nuclear factor 4, alpha) - The patient requires the service as a


Continued

Once-in-a-lifetime

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CPT-4 Code

Description

PHC TAR


Frequency




81406


Procedure, Level 7)

Continued below

Yes JAG1 (Alagille syndrome) – duplication/deletion – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Alagille syndrome

MUTYH (MYH-associated polyposis) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for MUTYH-associated polyposis

NF2 (neurofibromatosis, type 2): The patient has clinical features suspicious for, or requires the service as a confirmatory test for type 2 neurofibromatosis, or The patient is at high risk for neurofibromatosis with one or more of the following A first-degree relative with type 2


(schwannomas, meningiomas) Cutaneous schwannomas Sporadic vestibular schwannoma

younger than 30 years of age, or spinal tumor or meningioma younger than 20 years of age

PRKCG (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

PYGM (glycogen storage disease type V, McArdle disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glycogen storage disease type V (McArdle disease)

Continued

Once-in-a-lifetime

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CPT-4 Code

Description

PHC TAR


Frequency




81406


Procedure, Level 7)

Yes SCNN1A (pseudohypoaldosteronism) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for pseudohypoaldosteronism

SCNN1B (Liddle syndrome, pseudohypoaldosteronism) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Liddle syndrome, pseudohypoaldosteronism

SCNN1G (Liddle syndrome, pseudohypoaldosteronism) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Liddle syndrome, pseudohypoaldosteronism

SLC37A4 (glycogen storage disease, type Ib) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glycogen storage disease, type Ib


UMOD (glomerulocystic kidney disease with hyperuricemia and isosthenuria) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glomerulocystic kidney disease with hyperuricemia and isosthenuria

WAS (Wiskott-Aldrich syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Wiskott-Aldrich syndrome


Once-in-a-lifetime

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CPT-4 Code

Description

PHC TAR


Frequency



81407


Procedure, Level 8)


ABCC8 (familial hyperinsulinism): - The patient has persistent hyperinsulinemic hypoglycemia of infancy (PHHI) who failed medical therapy, and - The patient is under evaluation for surgical intervention

AGL (glycogen storage disease type III) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glycogen storage disease type III

JAG1 (Alagille syndrome) – full gene sequence – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Alagille syndrome

NPHS1 (congenital Finnish nephrosis) - The patient has clinical diagnosis of steroid-resistant nephritic syndrome (SRNS)/congenital Finnish nephrosis, and - Treatment will be contingent on the test results

SPTBN2 (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia


Once-in-a-lifetime

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CPT-4 Code

Description

PHC TAR


Frequency



81408


Procedure, Level 9)

Yes Coverage for CPT-4 code 81408 (molecular pathology procedure, Level 9) is limited to the listed services. Reimbursement for code 81408 requires an approved Treatment Authorization Request (TAR) explaining that the following criteria have been met:

ITPR1 (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

DMD (dsytophin), full gene analysis - Patient has a clinical diagnosis of

dystrophinopathy based on the history, physical examination and elevated creatine kinase (CK) level

- Result of the DMD (dystrophin) deletion or duplication is negative

Once-in-a-lifetime

81409 - 81471

Yes Not a Medi-Cal covered benefit (see below for further detail)

Once-in-a-lifetime


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CPT-4 Code

Description

PHC TAR


Frequency



Genomic Sequencing

Procedures and Other

Molecular Multianalyte

Assays

81435, 81436

No TAR required

when CPT

codes listed are

billed

Reimbursement for CPT-4 codes 81435 (hereditary colon cancer syndromes; genomic sequence analysis panel, must include analysis of at least seven genes, including APC, CHEK2, MLH1, MSH2, MSH6, MUTYH, and PMS2) and 81436 (…duplication/deletion gene analysis panel, must include analysis of at least eight genes, including APC, MLH1, MSH2, MSH6, PMS2, EPCAM, CHEK2, and MUTYH) is limited to once-in-a-lifetime with a Treatment Authorization Request (TAR). Codes 81435 and 81436 are reimbursable only when billed in conjunction with one of the following ICD-10-CM diagnosis codes:

C18 – C20 Z85.030 – Z85.038

C54.0 – C54.9 Z85.040 – Z85.048

Z80.0 Z85.42 Z80.49 Z86.010

Once-in-a-lifetime


Testing for Telomerase

Reverse Transcriptase

(TERT)

81479

Yes Testing for Telomerase Reverse Transcriptase (TERT) gene in patients with glioma may be billed using CPT-4 code 81479 (unlisted molecular pathology procedure). A TAR is required. A TAR for the test requires documentation that the patient has the diagnosis of grade II, III or IV glioma.

Once-in-a-lifetime

Testing for Fetal


Fetal DNA Testing

81420, 81479, 81507

Continued below

Yes

Noninvasive prenatal testing for fetal aneuploidy may be billed with CPT-4 codes 81507 (fetal aneuploidy [trisomy 21, 18 and 13] DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy), 81420 (fetal chromosomal aneuploidy genomic sequence Continued

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CPT-4 Code

Description

PHC TAR


Frequency




Testing for Fetal


Fetal DNA Testing

81420, 81479, 81507

Yes

analysis panel, circulating cell-free fetal DNA in maternal blood, must include analysis of chromosomes 13, 18, and 21) or 81479 (unlisted molecular pathology procedure). A Treatment Authorization Request (TAR) with documentation of the following criteria is required: Patient with singleton gestation only The patient has an increased risk of

aneuploidy due to one or more of the following: - Maternal age 35 years or older at

delivery - Fetal ultrasonographic findings indicating

an increased risk of aneuploidy - History of a prior pregnancy with a

trisomy - Positive test result for aneuploidy,

including first trimester, sequential, or integrated screen, or a quadruple screen

- Parental balanced Robertsonian translocation with increased risk of fetal trisomy 13 or trisomy 21

Reference: The American College of Obstetricians and Gynecologists Committee on Genetics and The Society for Maternal-Fetal Medicine Publications Committee. Committee Opinion Number 545, December 2012.

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CPT-4 Code

Description

PHC TAR


Frequency



Multianalyte Assays

With Algorithmic

Analyses

81500, 81503,

81506 – 81512

(Note: These are biochemical tests, not genetic tests)

No

CPT-4 codes 81500, 81503, 81506 – 81512 encompass all analytical services required in addition to the algorithmic analysis itself. Codes 81500, 81503 and 81507 – 81512 are reimbursable for females only. Reimbursement for code 81507 is limited to once a year, any provider.


lifetime unless

otherwise noted

Gene Expression

81519, 81599 Continued below

Yes

Gene expression profiling for breast cancer may be billed with CPT-4 code 81519 (oncology [breast], mRNA, gene expression profiling by real time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score) or 81599 (unlisted multianalyte assay with algorithmic analysis). Both codes 81519 and 81599 have a frequency limit of once in a lifetime and require a Treatment Authorization Request (TAR) with documentation of the following criteria: The recipient is estrogen and

progesterone receptor (ER/PgR)-positive. The recipient is HER2-receptor negative. The recipient is lymph node negative. The recipient has stage I or stage II breast

cancer. The recipient is a candidate for

chemotherapy. The assay is used within six months of

diagnosis. The recipient is under consideration for

adjuvant systemic therapy. These benefits are limited to Oncotype Dx, Prosigna (PAM50 risk of recurrence score) and Breast Cancer Index. Use CPT-4 code 81519 Continued

As noted

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CPT-4 Code

Description

PHC TAR


Frequency




Gene Expression

81519, 81599

when billing for Oncotype Dx. Use CPT-4 code 81599 when billing for Prosigna and Breast Cancer Index. These once-in-a-lifetime benefits may be billed for the same recipient and any provider. Providers need an approved TAR and documentation showing that the recipient has a new second primary breast cancer that meets the necessary criteria as listed above to override the once-in-a-lifetime frequency.

Karyotype (aka

Cytogenetic Studies)

88261 – 88269

88280

No Karyotype testing for codes 88261-3 may be ordered once in a lifetime in children with phenotype of syndrome most commonly associated with a chromosomal abnormality. For perinatal indication, see Medi-Cal guidelines in the Genetic Counseling and Screening section gene coun 2.

Once-in-a-lifetime

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PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE

Page 1 1 of 20

Policy/Procedure Number: MP316 Lead Department: Member Services Policy/Procedure Title: Provider Request to Discharge Member & Assistance with Inappropriate Member Behavior




Reviewing Entities:

IQI P & T QUAC


Approving Entities:



Approval Signature: Kevin Spencer / Kelley Sewell Approval Date: 09/21/201607/14/2014


A. MP 301 – Assisting Providers with Missed Appointments B. MP 312 – Processing PCP Selections and Transfers Requests

II. IMPACTED DEPTS.: III. DEFINITIONS:

A. Provider Request to Discharge: A provider’s request to discharge a member from his/her practice. B. Re-assignment: A member is transferred to the care of another Primary Care Provider or Special Case

Managed category, if applicable. C. Member Type U: For the purpose of this policy, members are defined as “Type U Members” if they have

been discharged for reasons other than fraud, threats of violence and/or violent behavior. D. Member Type V: For the purpose of this policy, members are defined as “Type V Members” if they have

been discharged for fraud, threats of violence t and/or violent behavior. Threats of violence includes menacing body language and/or verbal threats of physical violence.

IV. ATTACHMENTS:

A. Form #6 (Provider Request for Discharge/Assistance with Inappropriate Behavior) B. Letter #MS10a (Member Services Notifies PCP of decision) C. Letter #MS10c (Assistance with Inappropriate Behavior at Provider’s Office) D. Letter #MS10d (Notice of PCP Discharged Request Denied) E. Letter #MS10b (Type U) (Notification of PCP Discharge Request Approved) F. Letter #MS10e (Type V) (Notification of PCP Discharge Request Approved Special Member)

V. PURPOSE:

To clarify the circumstances in which a medical provider may discharge a PHC member from his/her practice and the process of member and provider notification. Additional clarification of questions about this process areis directed to the PHC Provider Relations (PR) Department.


A. Assistance with Inappropriate Behavior 1. Prior to requesting discharge, providers may request assistance from PHC when a patient and/or

patient representative displays verbally abusive and/or disruptive behavior in a physician’s office.

2. Examples of verbal abuse and/or disruptive behavior: a. Yelling and/or screaming b. Ethnic slurs c. Foul language

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Policy/Procedure Number: MP316 Lead Department: Member Services

Policy/Procedure Title: Provider Request to Discharge Member & Assistance with Inappropriate Member Behavior

☒External Policy ☐Internal Policy



Page 12 of 5

d. Physical or verbal threats of violence 3. If the provider requests PHC assistance, the following procedure is followed:

a. The provider must notify PHC’s Member Services (MS) Department in writing to request assistance with inappropriate behavior. The provider must provide complete documentation outlining the nature of the problem, including Form #6 titled “Provider Request for Discharge/Assistance with Inappropriate Behavior (Attachment A) for each member included in the request. If additional information is needed from the provider, the MS Department will request the additional information through PHC’s Provider Relations Department.

b. The Provider faxes a request for assistance to PHC’s MS Department at the fax number specified on the Provider Request for Discharge/Assistance with Inappropriate Behavior form, (Attachment A). MS staff documents the request in Amisys or the Call Center System and sends letter #10c(Attachment C) to the member, copying the requesting provider.

c. Incomplete requests: If additional information is needed from the provider, the MS Department requests the information through PHC’s PR Department. The request for assistance with inappropriate behavior will be pended for five (5) business days. If the information is not received within the five (5) business days the request is closed. MS notifies the provider that not enough information was received timely to process the request.

B. Discharge Requests

1. PHC’s uses its best effort is used to provide members the opportunity to be cared for by medical providers with whom a collaborative physician/patient relationship can be developed. Because the relationship is personal in nature, circumstances may arise under which the relationship between a member patient and a provider becomes non-collaborative. Medical providers are permitted to request that a member patient be discharged from his/her practice in certain circumstances, but it is the sole responsibility of PHC to determine if the request meets PHC’s discharge criteria. Providers are expected to have procedures in place that provide guidance to practitioners and staff when dealing with challenging patients. Providers can request sample procedures through PHC’s PRrovider Relations Department.

C. Discharge Criteria

1. Using the written documentation provided by the provider and the discharge criteria listed below, appropriate PHC staff determines if the request for discharge meets PHC’s discharge criteria. Designated MS staff consults the Care Coordination (CC) designee, PHC Chief Medical Officer or designee as needed.

2. The following behaviors are generally considered appropriate criteria for discharge: a. Fraudulently receiving benefits under a health plan contract. b. Fraudulently receiving and/or altering prescriptions, theft of prescription pads, or photocopying

prescriptions. c. Physically abusive behavior exhibited to the provider or office personnel. d. Threatening behavior exhibited in the course of needing or receiving care. e. Credible threat of theReceipt of a notice of a member’s intent to initiate or pursue legal action

(not including a state fair hearing) against the provider and/or his/her associates. f. Refusal by the member to follow recommended medical treatment where the provider believes

there is no alternative treatment, and that refusal severely endangers the health of the member. This situation cannot be ameliorated improved by repeated attempts by PHC’s CC case managerdesignee to intervene, and in the judgment of the designated MS Management staff or the Chief Medical Officer or designee, a change in provider would clearly benefit the member’s health status.

g. A determination by PHC’s CC designee designated MS Management Staff or the Chief Medical

216 of 252216 of 252






Page 13 of 5

Officer or designee that deterioration in the doctor/patient relationship has occurred to the point where continuation might result in adverse consequences to the member’s health or to the safety of the provider or provider’s staff.

h. Documented evidence that the member had been discharged from the practice site in the past before the member became PHC eligible. If a member has been previously discharged from a practice, it is the responsibility of the practice to notify PHC within sixty (60) days of the member’s initial assignment. Exceptions to the sixty (60) day period can be made on a case-by-case basis. The provider’s capitation payment is recouped.

i. Disruptive or verbally inappropriate behavior to the provider, office staff or other patients if counseling and corrective action by the provider has been ineffective. For assistance with inappropriate behavior refer to the section above titled Assistance with Inappropriate Behavior.

j. Three (3) or more missed appointments within the previous six (6) month period or four (4) or more missed appointments within the previous twelve (12) month period, if the provider has made a good faith effort to correct the member’s behavior. Good faith effort is defined as at least one verbal and one written warning or at least two written warnings. All verbal and/or written warnings must informing the member that continued missed appointments will result in discharge. When requesting discharge, Pprovider offices must provide documentation of the verbal warning and one written warningand or two (2) or more written warnings. a copy of the letter sent advising the member that continuing to miss appointments will result in discharge. The verbal and/or written warnings must be within the specified timeframes of the missed appointments. Exceptions: Missed appointments due to an inpatient hospital stay or appointments cancelled 24 hours in advance are not considered missed appointments for the purpose of this policy.

k. If the provider has multiple locations and/or practices, the that provider must specify on the Discharge Request Form if the discharge applies to all locations and/or practices or specific locations and/or practices.

D. Requesting Discharge Process

1. The provider must notify PHC’s MS Department in writing to request a member discharge. The provider must provide complete documentation outlining the nature of the problem, including Form #6 titled “Provider Request for Discharge/Assistance with Inappropriate Behavior” (Attachment A) for each member included in the discharge request. The request must also indicate if the member is or is not in active care for an acute medical condition and/or if the member has diagnostic testing or surgeries scheduled. If additional information is needed from the provider, the MS Department will request the additional information through PHC’s PRrovider Relations Department.

2. By the end of the second business day from the date of receipt, the designated MS staff documents the date the discharge request was received using the DE Remark Code.

3. If the provider does not provide the supporting documentation needed, MS forwards the request to the PRrovider Relations Help Desk with a scanned copy attached noting what additional information is needed. To ensure that the email is forwarded appropriately, the word “Discharge” must be included in the subject field of the email. PRrovider Relations forwards additional information to MS upon request. The request is pended for five (5) business days. If the documentation requested is not received within the five (5) business days, the request is denied.

E. Provider Notification of Decisions

1. Using letter #MS10a (Attachment B), MS notifies providers of the discharge decision in writing. 2. The provider can call the the MSember Services at Department at (800) 863-4155 to check the

status of a request. Direct extensions of MS staff are not provided.

217 of 252217 of 252






Page 14 of 5

F. Member Notification - Approved Requests 1. Member Type V - For the purpose of this policy, members are defined as “Type V Members” if they

have been discharged for fraud, threatening and/or violent behavior. a. The copy of the provider’s discharge submission and documentation is sent to the CC designee. a.b. The CC designee determines if the relationship between the provider and member can be

repaired. If the relationship cannot be repaired, CC designee identifies a new PCP. A list of PCP’s that have agreed in advance to accept “Type V Members” is maintained by the PHC MS Department. However, before a “Type V Member” is assigned to a PCP, the Regional Medical Director CC designee must get approval by the accepting PCP before the assignment is made. The CC designee Regional Medical Director informs the new PCP of the reason the member was discharged and the assignment date to his or her practice. If the CC designee cannot find an accepting PCP, the member is placed in Special Case Managed status and can be seen by any Medi-Cal provider willing to see the member and bill PHC.

b.c. If the member is discharged and meets the definition of a “Type V Member”, the designated MS staff sends the appropriate MS10e (Attachment F) notification letter to the member within ten (10) business days from the date the request was received, or sooner, upon approval of the provider request. The letter explains the reason for the discharge and the effective date of the re-assignment to the new PCP or Special Case Managed status. The member is re-assigned to a PCP in their service area that has agreed to accept “Typethe member V Members”. If there is more than one PCP in the member’s service area that accepts “Type V Members”, the member is given a choice of PCP’s to choose from. Members will remain assigned to this PCP, unless the member requests a PCP transfer and there is another PCP in the member’s service area that accepts “Type V Members”.

c.d. If PHC isn’t able to locate a PCP to accept the member, the member is placed in a Special Case Managed Status and can be seen by any Medi-Cal provider that is willing to see the member and bill PHC. The mMember notification letter #MS10e (Attachment F) is sent and instructs the member to call PHC’s MS Department if they are unable to find a provider.

2. Member Type U – For the purpose of this policy, members are defined as “Type U Members” if they have been discharged for reasons other than fraud, threats of violence and/or violent behavior. a. Member notification letter #MS10b (Attachment E) is sent to the member within ten (10)

business days from the date the request was received. The letter explains the reason for the discharge and the effective date of the re-assignment to the new PCP. The letter also advises the member to choose a new PCP from the PHC Provider Directory if they don’t like the PCP that was assigned to them.

G. Member Notification - Denied Requests 1. Within ten (10) business days from the date the request was received, designated MS staff sends

member notification letter MS10d (Attachment D) informing the member of PHC’s denial of the request and a statement that advises the member of the importance of maintaining a good patient/ physician relationship.

H.G. Transition of Care (applies to both Type U and Type V Members)

1. If the member has diagnostic testing, specialty referrals and/or surgeries scheduled for conditions that could adversely affect the member’s health if delayed, designated MS Staff requests that the CC are Coordination Department work with the member and appropriate providers to ensure that needed medical care is provided. The member may be assigned to Special Case Managed status, depending on the timing of the discharge.

2. If the member is medically unstable, as defined in MS Policy MP312, Processing PCP Selections and Transfer Requests, the PCP will continue to provide care to the member until PHC is able to change the member’s PCP for a period not to exceed two (2) months.

218 of 252218 of 252






Page 15 of 5

I.H. Processing Approved Requests in Amisys

1. To prevent discharged members from relinking or auto assigning to the discharging PCP, the “AX” remark code is entered in Amisys. The member is also placed “On Review” to alert staff of the discharge should the member request this PCP at a later date. Refer to Job Aid (JA) 103-Amisys-Member on Review for instructions on how to place a member on review.

J.I. Discharge of Special Case Managed Members

1. A provider can terminate care of a Special Case Managed Member when the patient/physician relationship becomes non-collaborative, by notifying the member in writing that he/she will no longer be able to provide care for that member. If the member is unstable, the provider should care for the member until the member selects another provider, and the provider provides emergency care for at least 30 days.

2. Primary Care Providers should notify PHC of their intent to discharge a Special Case Managed Member from their practice so that PHC can document the reason for discharge and assist with transition of care, as described above in the section of this policy titled Transition of Care.

K.J. Discharge Requests from Specialists

1. A specialist physician can cease providing care for any member when the physician/patient relationship becomes non-collaborative. In these cases, the specialist physician must notify both the PCP and the patient that they will no longer provide care to the patient. The PCP should refer the member to another specialist for treatment, if specialist care is still necessary.

2. In all cases, the provider discharging a member should assist with continuity of care by transferring appropriate medical records to the new provider.

L.K. Request for Grievance

1. Members may request a grievance or a State Hearing.

M.L. Reporting Violent and/or Fraudulent Behavior 1. Providers are encouraged to report violent and/or fraudulent behavior to the appropriate authorities. 1.2. MS notifies the Compliance Department of suspected fraudulent behavior.


A. SharePoint A. MS Policy and Procedure Manual, B. Provider Manual for all programs

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Associate Director of

Enrollment Unit Member Services X. REVISION DATES:

Medi-Cal 04/27/95; 10/13/99; 06/20/01; 08/15/01; 06/19/02 (Hlth Srvcs Policy); 06/18/03 (Mbr Srvcs Policy); 03/05/04; 05/19/04;11/17/04; 11/16/05; 03/07/08; 08/12/08; 01/21/09; 08/19/09; 12/16/09; 03/23/10; 05/11/11; 01/07/2014; 07/14/14 Healthy Kids 11/16/05; 03/07/08; 08/12/08; 01/21/09; 08/19/09; 12/16/09; 03/23/10; 05/11/11; 01/07/2014; 07/14/14

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Page 16 of 5

PREVIOUSLY APPLIED TO: PartnershipAdvantage: MP316 – 01/01/2007 to 01/01/2015

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Attachment A – Form #6

<New Form #6 > <PHC logo>

Provider Request for Discharge/Assistance with Inappropriate Behavior Section 1 ‐ What would you like PHC to do?

Would you like PHC’s Care Coordination Team to reach out to the member to counsel them on improving their behavior?

Do you want to request that the member be disenrolled from your office(s)? Must attached required

documentation.

Section 2 ‐ Member Information: PHC ID (CIN) #___________________________ Name: ___________________________________ DOB: ________________ Phone #____________________ Section 3 ‐ Member Care Information: 1. Is the member in treatment for an active medical condition? No Yes ‐ attach description of medical condition Are there any diagnostic testing or surgeries scheduled? No Yes ‐ attach list of scheduled procedures and any

active 2. TARs and/or RAFs. Please include TAR & RAF #s:

________________________________________________________________________________________________

Section 4 ‐ Provider Submitting Request: 1. PCP/Med Grp Name: ______________________________ PCP/Group’s PHC PCP#: __________________________

Does discharge apply to all facilities and/or locations affiliated with the group? Yes No If yes, list all the PHC providers or locations that apply:

Have you already communicated with the member regarding your concerns? 2. Yes No N/A If yes, what did you advise the member:

________________________________________________________________________________________________

3. Who do we contact if we have questions regarding the member’s care or the reason for disenrollment:

Print Name: __________________________________ Phone # __________________________

4. Who and where do we fax our decision to: Print Name: ________________________ Phone # _____________________ Fax#: ________________________

Section 5 ‐ Reason for your request: Please check all applicable boxes. If you are requesting to disenroll the patient, attach documentation outlined in the policy. If the action of the member is not specified in the policy, provide documentation outlining the incident or reason for request. Missed appointments Disruptive/verbally inappropriate behavior Suspected fraud Failure to obtain/maintain a collaborative relationship Non‐Compliance/refusal to follow treatment plan.* Threats of violence and/or violent behavior; has behavior been reported to police? Yes No If “No” please explain

why: ___________________________________________________________________________________________________ Other:

__________________________________________________________________________________________________ *Note: All requests for discharge for non‐compliance are reviewed by a PHC Medical Director. Presence of a Substance

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Abuse Disorder alone is not sufficient grounds for discharge. Please refer to specialty care or address treatment as necessary. Signature of Provider: _________________________________ Date: _____________________ Print name of Provider: ________________________________________ Section 6 ‐ Fax to PHC Member Services’ Enrollment Unit:

Lake, Marin, Mendocino, Napa, Solano, Sonoma and Yolo members fax request to (707) 420‐7580. Del Norte, Humboldt, Lassen, Modoc, Shasta, Siskiyou and Trinity members fax request to (530) 223‐

2508.

PHC has ten (10) business days to process your request once it has been received. Please be advised if the form is incomplete or missing required information your request will be denied.

****************************PHC INTERNAL USE*********************************** Member #: DECISION:

Pended Sent to: <Dept/name> Date sent: _______, Due back by: _____________ Approved Effective: _____________ New Assignment: ______________, Date approved: Request Denied Reason: _____________________________________________, Date denied: _________

Referral to Case Management: Yes‐<date> No Letter #/ Date notice sent to provider: Letter #/Date notice sent to member: Call Center/Amisys entries completed: <date>

COMMENTS: MS __________________________________________________________________________________ CC ___________________________________________________________________________________ PR ___________________________________________________________________________________ Member Services Director Signature: __________________________________ Date: _______________ Form #6 (rev 09/13/201601/07/2014)

Provider Request for Discharge/Assistance with Inappropriate Behavior Section 1: Type of Request and Member Information Specify Type of Request (one form is required for each member included in the request): Discharge Request (sections 1‐4 must be completed) Assistance with Inappropriate Behavior (sections 1, 2 & 4 must be completed) Does discharge apply to all facilities and/or locations affiliated with the group? yes no If yes, which facilities and/or locations apply: ____________________________________________________ Member Name: _____________________________________________ ID #: _____________________________ Member Address: ______________________________________________________________________________

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Member Phone: _____________________________________________ DOB: _____________________________ Requesting PCP/Med Grp#: ___________________________________ PHC PCP#: ________________________ Signature of responsible PCP: _________________________________ Date: ______________________________ Section 2: Reason for Discharge or Assistance with Inappropriate Behavior (attach supporting documentation)

Missed appointments Non Compliance Fraud Disruptive\verbally inappropriate behavior Failure to obtain\maintain a collaborative relationship Threats of violence and\or violent behavior; has behavior been reported to police? Yes No If No, Please explain why: _________________________________________________________________ Other __________________________________________________________________________________ Section 3: Reason for Discharge – Non Compliance (attach supporting documentation, if needed). Members with Substance Abuse Disorder are not applicable. Please refer for care or address treatment as necessary. ExplainDescribe: ___________________________________________________________________________________ __________________________________________________________________________________________ Note: All requests for discharge for non‐compliance will be reviewed by a PHC Medical Director. Presence of a Substance Abuse Disorder alone is not sufficient grounds for discharge. Please refer for care or address treatment as necessary. Section 3: Member Care Information Is the member in treatment for an active medical condition? yes no If yes, please attach description of medical condition. Are there any diagnostic testing or surgeries scheduled? yes no If yes, attach list of scheduled procedures, TARs & RAFs, including location & dates in the past 12 months. Section 4: Fax Instructions For Solano, Napa, Sonoma, Mendo, Marin, Lake and Yolo members fax request to (707) 863‐4415; all other providers fax to (530) 223‐2508. Clearly print the name and fax number of the person that PHC should contact after your request is reviewed. Name: ____________________________________ Fax: (_________) __________ ‐ ____________________ ***********************************PHC INTERNAL USE************************************

TAR’s RAF’s Claims DECISION: Request Denied Approved Documentation not provided and/or form not completed Effective: ______________ New Assignment: ________________________________________________

Referred to Case Management: yes no If yes, specify date: __________________________________ COMMENTS: MS __________________________________________________________________________________ CC _____________________________________________________________________________________ PR ____________________________________________________________________________________

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Member Services Director Signature: _________________________ Date: ______________ Form #6 (rev 01/07/2014)

Attachment B: Letter #MS‐10a

Member Services Notifies PCP of decision

(date)

Via FAX: (PHYSICIAN NAME)

(ADDRESS) (CITY, STATE, ZIP CODE)

Re: Request to discharge patient

Dear Dr. <Provider Name>:

The Partnership HealthPlan of California (PHC) has received your request to discharge member:

______________________________, ID#: _____________________. The documentation submitted by your office has been reviewed by PHC. Based on the discharge guidelines outlined in PHC policy, MP 316, your

request has been:

_____ Approved. The member will be transferred from your practice, effective <date>. _____ Denied. It was determined that your request did not meet the discharge guidelines outlined in PHC

policy MP 316. You must continue providing services to this member. _____ Denied. It was determined that your request did not meet the discharge guidelines outlined in PHC

policy MP 316. However, the member has requested to be transferred to another primary care provider. The effective date of the transfer is <eff date>.

_____ Deferred. Not enough information was provided to make a decision. Please provide additional information that specifically details your reason for requesting discharge. At this time, you must continue

providing services to this member. _____ Other:

If you have questions or concerns regarding this discharge request or if you would like to appeal this decision,

please contact your Provider Relations Representative at (707) 863‐4100. Thank you for the excellent care you provide to our members and your continued support of PHC. Sincerely, Provider Relations Department Partnership HealthPlan of California

Attachment C: MS10c

Assistance with Inappropriate Behavior at Provider’s Office

<Date>

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<Member Name> <Member Address> <City>, <State> <zip code> Re: <Member Name> Dear <Member Name or Parent/Legal Guardian>: This letter is to notify you that PHC has been made aware by Dr. <insert name> office that your behavior may have been inappropriate during your recent medical visit. There may be times in the future when something is done at your provider’s office that you do not agree with or are not satisfied with. In these types of situations, it is best to try to resolve the situation in a calm rational manner. Future inappropriate behavior at your provider’s office could result in your provider requesting that you be discharged from his/her practice. If you are not able to resolve problems with your provider or with his/her staff, you should contact the PHC Member Services Department for assistance. Our Member Services staff is here to help you resolve problems, so don’t be afraid to ask for our assistance. Enclosed is the PHC Member Rights and Responsibilities Statement. This Statement is issued to all PHC members and all medical providers. Please review this statement so that you understand what your rights and responsibilities are as a PHC member. <insert closing statement for PA>: <If you have any questions about PartnershipAdvantage (HMO SNP) you may call our Member Services Department at (866) 264‐3626, from 8:00 am to 8:00 pm, seven days a week. TTY users should call the California Relay Service at (800) 735‐2929 or call 711. Don’t forget to visit our website atwww.partnershiphp.org.[JW1] Partnership HealthPlan of California (PHC) is an HMO Plan with a Medicare contract and a contract with the California Medi‐Cal program. Enrollment in Partnership HealthPlan of California depends on contract renewal. This notice is available for free in other languages. Please call our Member Services Department for additional information. Este aviso está disponible gratis en otros idiomas. Por favor llame a nuestro Departamento de Servicios al Miembros para obtener información adicional.> <insert closing statement for Medi‐Cal>: <If you have any questions, concerns or you want this in another format, please call our Member Services Department at (707) 863‐4120 or (800) 863‐4155. We are available to assist you Monday – Friday from 8:00 am to 5:00 pm. TTY users should call the California Relay Service at (800) 735‐2929 or call 711. Don’t forget to visit our website at www.partnershiphp.org. To receive this letter in Spanish or Russian, please call our Member Services Department. Interpreter services are available in most languages through our Member Services Department. Para recibir esta carta en Español por favor llame a nuestro Departamento de Servicios al Miembro. Los servicios de intérprete están disponibles en la mayoría de idiomas a través de nuestro Departamento de

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Servicios para Miembros. Для того, чтобы получить данное письмо на Русском языке, обратитесь в отдел обслуживания участников программы. Услуги переводчиков доступны для большенства языков через отдел обслуживания участников программы.> Sincerely, Member Services Department Partnership HealthPlan of California Enclosures Cc: <Physician Name> PA Ltr #10c (Rev 02/21/2014) H5782 PHC_PHC_4001_MS10c_002 CMS Approved

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Attachment D – MS 10d Notice of PCP Discharged Request Denied<Date>

<Member Name>

<Member Address> <City>, <State> <Zip Code>

Re: <Mbr Reference Name>

Dear <Member Name or Parent/Guardian>:

<insert PCP or medical group name> has requested that you be discharged from <his/her/their>

medical practice. Partnership HealthPlan of California (PHC) has denied <provider name or medical group name> request. You may continue to have <provider name or medical group

name> as your primary care provider or you may choose a new provider.

The patient-doctor relationship is important to maintain to ensure quality treatment of your medical needs. The doctor and the patient must be able to communicate freely. As a PHC member, you have the right to receive confidential, dignified, courteous and considerate

treatment by your medical provider and your provider’s staff. You also have the responsibility to be courteous and cooperative with your PCP, be on time for scheduled appointments, give

proper notice of appointment cancellations and provide your PCP and your PCP’s staff information needed in order to provide the best available medical care.

If you wish to keep <provider name or medical group name> as your medical provider, no

further action is required. If you wish to select a new PCP, please review the enclosed list of PHC contracted providers. Once you have made your selection, please notify PHC of your choice. You

can inform PHC of your choice by calling the PHC Member Services Department or by completing the enclosed selection form and returning it to PHC using the enclosed postage paid

envelope.

<insert closing statement for PA>: <If you have any questions about PartnershipAdvantage (HMO SNP) you may call our Member Services Department at (866) 264-3626, from 8:00 am to 8:00 pm, seven days a week. TTY users

should call the California Relay Service at (800) 735-2929 or call 711. Don’t forget to visit our website at www.partnershiphp.org.[JW2]

Partnership HealthPlan of California (PHC) is an HMO Plan with a Medicare contract and a

contract with the California Medi-Cal program. Enrollment in Partnership HealthPlan of California depends on contract renewal.

This notice is available for free in other languages. Please call our Member Services Department for additional information. Este aviso está disponible gratis en otros idiomas. Por favor llame a nuestro Departamento de Servicios al Miembros para obtener información adicional.> <insert closing statement for Medi-Cal>: <If you have any questions, concerns or you want this in another format, please call our Member Services Department at (707) 863-4120 or (800) 863-4155. We are available to assist you Monday – Friday from 8:00 am to 5:00 pm. TTY users should call the California Relay Service at (800) 735-2929

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or call 711. Don’t forget to visit our website at www.partnershiphp.org. To receive this letter in Spanish or Russian, please call our Member Services Department. Interpreter services are available in most languages through our Member Services Department. Para recibir esta carta en Español por favor llame a nuestro Departamento de Servicios al Miembro. Los servicios de intérprete están disponibles en la mayoría de idiomas a través de nuestro Departamento de Servicios para Miembros. Для того, чтобы получить данное письмо на Русском языке, обратитесь в отдел обслуживания участников программы. Услуги переводчиков доступны для большенства языков через отдел обслуживания участников программы.>

Sincerely, Member Services Partnership HealthPlan of California Enclosures PA Ltr #10d (Rev 02/24/2014) H5782 PHC_PHC_4001_MS10d_003 CMS Approved

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Attachment E – MS 10b (Type U) Notification of PCP Discharge Request Approved

<Date>

<Member Name> <Member Address>

<City>, <State> <zip code>

Re: <Member Name>

Dear <Member Name or Parent/Legal Guardian>:

<Current PCP> has requested <name of discharged member> be discharged from <his/her/their> medical practice. Partnership HealthPlan of California (PHC) has approved this request.

Below is the reason(s) that you have been discharged from your Primary Care Provider (PCP):

Three (3) or more missed appointments within the previous six (6) months. Verbally disruptive and/or abusive.

Physically abusive. Not following recommended medical treatment when another treatment was not

available or appropriate and refusal endangered your health. Breakdown in patient physician and\/or staff relationship.

Fraudulently receiving and/or altering prescriptions. Disenrolled by Specialist

Other (type in other)

Enclosed is a list of PCP’s, a Selection Form and a postage paid return envelope. After you select your new PCP return the enclosed Selection Form using the postage paid return envelope. In order to allow you time to select a new PCP during the month of <month>, you may see any Medi-Cal provider that

is willing to bill PHC. However, you must select a new PCP and notify PHC of your selection by <date>. Your new PCP will be assigned to you <date>. If you do not select a new PCP, PHC will

select one for you. <insert closing statement for PA>: <If you have any questions about PartnershipAdvantage (HMO SNP) you may call our Member Services Department at (866) 264-3626, from 8:00 am to 8:00 pm, seven days a week. TTY users should call the California Relay Service at (800) 735-2929 or call 711. Don’t forget to visit our website at www.partnershiphp.org.[JW3] Partnership HealthPlan of California (PHC) is an HMO Plan with a Medicare contract and a contract with the California Medi-Cal program. Enrollment in Partnership HealthPlan of California depends on contract renewal. This notice is available for free in other languages. Please call our Member Services Department for additional information. Este aviso está disponible gratis en otros idiomas. Por favor llame a nuestro Departamento de Servicios al Miembros para obtener información adicional.> <insert closing statement for Medi-Cal>: <If you have any questions, concerns or you want this in another format, please call our Member Services Department at (707) 863-4120 or (800) 863-4155. We are available to assist you Monday –

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Friday from 8:00 am to 5:00 pm. TTY users should call the California Relay Service at (800) 735-2929 or call 711. Don’t forget to visit our website at www.partnershiphp.org. To receive this letter in Spanish or Russian, please call our Member Services Department. Interpreter services are available in most languages through our Member Services Department. Para recibir esta carta en Español por favor llame a nuestro Departamento de Servicios al Miembro. Los servicios de intérprete están disponibles en la mayoría de idiomas a través de nuestro Departamento de Servicios para Miembros. Для того, чтобы получить данное письмо на Русском языке, обратитесь в отдел обслуживания участников программы. Услуги переводчиков доступны для большенства языков через отдел обслуживания участников программы.> Sincerely, Member Services Department Partnership HealthPlan of California Enclosures PA Ltr #10b (Rev 02/21/2014) H5782 PHC_PHC_4001_MS10b_002 CMS Approved

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Attachment F – MS 10e (Type V) Notification of PCP Discharge Request Approved Special Member Status

<Date>

<Member Name> <Member Address>

<City>, <State> <zip code>

Re: <Member Name>

Dear <Member Name or Parent/Legal Guardian>:

<Current PCP> has requested <name of discharged member> be discharged from <his/her/their> medical practice. Partnership HealthPlan of California (PHC) has approved this request.

Below is the reason(s) that you have been discharged from your Primary Care Provider (PCP):

Fraud

Threatening or violent behavior <insert>

<No Available PCP’s – Special Member: Unfortunately, we do not have any contracted providers available that will accept patients that have been discharged for fraud and\or violent or threatening

behavior. For this reason, you have been placed in a category of members referred to as Special Members. This means that starting <DATE> you can go to any Medi-Cal provider that is willing to see

you and bill PHC for covered Medi-Cal services.

If you are unable to find a doctor to see you, please contact our Member Services Department for assistance.>

<Choice of PCP’s – PCP Assignment: Enclosed is a list of PCP’s, a Selection Form and a postage paid return envelope. After you select your new PCP, return the enclosed Selection Form using the

postage paid return envelope. In order to allow you time to select a new PCP during the month of <month>, you may see any Medi-Cal provider that is willing to see you and bill PHC. However, you

must select a new PCP and notify PHC of your selection by <date>. Your new PCP will be assigned to you <date>. If you do not select a new PCP, PHC will select one for you.[JW4]

If you are unable to find a doctor to see you during the month of <Month>, please contact our Member

Services Department for assistance.>

<No Choice of PCP – PCP Assignment: Starting <date> you will be assigned to <PCP> and will need to see that PCP for all primary care services.>

<insert closing statement for PA>: <If you have any questions about PartnershipAdvantage (HMO SNP) you may call our Member Services Department at (866) 264-3626, from 8 am to 8 pm, seven days a week. TTY users should call the California Relay Service at (800) 735-2929 or call 711. Don’t forget to visit our website at www.partnershiphp.org.[JW5] Partnership HealthPlan of California (PHC) is an HMO Plan with a Medicare contract and a contract

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with the California Medi-Cal program. Enrollment in Partnership HealthPlan of California depends on contract renewal. This notice is available for free in other languages. Please call our Member Services Department for additional information. Este aviso está disponible gratis en otros idiomas. Por favor llame a nuestro Departamento de Servicios al Miembros para obtener información adicional.> <insert closing statement for Medi-Cal>: <If you have any questions, concerns or you want this in another format, please call our Member Services Department at (707) 863-4120 or (800) 863-4155. We are available to assist you Monday – Friday from 8:00 am to 5:00 pm. TTY users should call the California Relay Service at (800) 735-2929 or call 711. Don’t forget to visit our website at www.partnershiphp.org To receive this letter in Spanish or Russian, please call our Member Services Department. Interpreter services are available in most languages through our Member Services Department. Para recibir esta carta en Español por favor llame a nuestro Departamento de Servicios al Miembro. Los servicios de intérprete están disponibles en la mayoría de idiomas a través de nuestro Departamento de Servicios para Miembros. Для того, чтобы получить данное письмо на Русском языке, обратитесь в отдел обслуживания участников программы. Услуги переводчиков доступны для большенства языков через отдел обслуживания участников программы.> Sincerely, Member Services Department Partnership HealthPlan of California Enclosures PA Ltr #10e (Rev 02/21/2014)

H5782 PHC_PHC_4001_MS10e_002 CMSSection 1- What would you like PHC to do? Would you like PHC’s Care Coordination Team to reach out to the member to counsel them on improving their behavior? Do you want to request that this member be reassigned to another PCP? Do you want to request that the member be disenrolled from your office(s)? Section 2- Member Information: PHC ID (CIN) #___________________________ Name: _______________________________ DOB: ____________ Phone #___________________ Section 3-Member Care Information: Is the member in treatment for an active medical condition? Yes-attach description of medical condition No Are there any diagnostic testing or surgeries scheduled? Yes- No If yes, attach list of scheduled procedures and any active TARs and/or RAFs. Please include TARs & RAF #s: _______________________________________________ Section 4-Provider Submitting Request: PCP/Med Grp Name: ___________________________________PCP/Group’s PHC PCP#: _____________________ Does discharge apply to all facilities and/or locations affiliated with the group? Yes No If yes, list all the PHC providers or locations that apply:

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Have you already communicated with the member regarding your concerns and if so what did you advise the member of? Yes No N/A If yes what did you advise the member: _____________________________________________________________ __________________________ Who do we contact if we have questions regarding member’s care or the reason for disenrollment: Print Name: ___________________ Phone # ______________

Who and where do we fax our decision to:

Print Name: _____________________ Phone # _______________ Fax: (______) ____________ Section 5-Reason for your request: Please give details and/or provide justification for your request: _________________________________________________________________________________________________ Please check all applicable boxes. If you are disenrolling the patient, attach required documentation. If the action of the member is not specified in the policy provide documentation outlining the incident or reason for request.

Missed appointments Disruptive\verbally inappropriate behavior Fraud Failure to obtain\maintain a collaborative relationship Non-Compliance-Refusal to follow treatment plan.* Threats of violence and\or violent behavior; has behavior been reported to police? Yes No If “No” please explain

why:

___________________________________________________________________________________________________

Other: __________________________________________________________________________________________________ *Note: All requests for discharge for non-compliance are reviewed by a PHC Medical Director. Presence of a Substance Abuse Disorder alone is not sufficient grounds for discharge. Please refer to specialty care or address treatment as necessary.

Signature of Provider: _________________________________ Date: _____________________ Print name of Provider: ________________________________ Section 6-Fax to PHC Member Services’ Enrollment Unit: Solano, Napa, Sonoma, Mendocino, Marin, Lake and Yolo members fax request to (707) 863-4415. For all other members fax to (530) 223-2508. PHC has 10 business days to process your request once it has been received. Please be advised if the form is incomplete or missing required information your request will be denied. ***********************************PHC INTERNAL USE************************************ Member #: DECISION:


Referral to Case Management: Yes-<date> No Letter #/ Date notice sent to provider: Letter #/Date notice sent to member:

Call Center/Amisys entries completed: <date> COMMENTS: MS __________________________________________________________________________________ CC _____________________________________________________________________________________ PR ____________________________________________________________________________________

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Member Services Director Signature: _________________________ Date: ______________ Form #6 (rev 7/20/201601/07/2014)

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PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE

Page 1 of 7

Policy/Procedure Number: MP316 Lead Department: Member Services Policy/Procedure Title: Provider Request to Discharge Member & Assistance with Inappropriate Member Behavior




Reviewing Entities:

IQI P & T QUAC


Approving Entities:



Approval Signature: Kevin Spencer / Kelley Sewell Approval Date: 09/21/2016


A. MP 301 – Assisting Providers with Missed Appointments B. MP 312 – Processing PCP Selections and Transfers Requests

II. IMPACTED DEPTS.: III. DEFINITIONS:

A. Provider Request to Discharge: A provider’s request to discharge a member from his/her practice. B. Re-assignment: A member is transferred to the care of another Primary Care Provider or Special Case

Managed category, if applicable. C. Member Type U: For the purpose of this policy, members are defined as “Type U Members” if they have

been discharged for reasons other than fraud, threats of violence and/or violent behavior. D. Member Type V: For the purpose of this policy, members are defined as “Type V Members” if they have

been discharged for fraud, threats of violence and/or violent behavior. Threats of violence includes menacing body language and/or verbal threats of physical violence.

IV. ATTACHMENTS:

A. Form #6 (Provider Request for Discharge/Assistance with Inappropriate Behavior)

V. PURPOSE: To clarify the circumstances in which a medical provider may discharge a PHC member from his/her practice and the process of member and provider notification. Additional clarification of questions about this process are directed to the PHC Provider Relations (PR) Department.


A. Assistance with Inappropriate Behavior 1. Prior to requesting discharge, providers may request assistance from PHC when a patient and/or

patient representative displays verbally abusive and/or disruptive behavior in a physician’s office. 2. Examples of verbal abuse and/or disruptive behavior:

a. Yelling and/or screaming b. Ethnic slurs c. Foul language d. Physical or verbal threats of violence

3. If the provider requests PHC assistance, the following procedure is followed: a. The provider must notify PHC’s Member Services (MS) Department in writing to request

assistance with inappropriate behavior. The provider must provide complete documentation outlining the nature of the problem, including Form #6 titled “Provider Request for Discharge/Assistance with Inappropriate Behavior (Attachment A) for each member included in

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Page 2 of 5

the request. b. The Provider faxes a request for assistance to PHC’s MS Department at the fax number

specified on the Provider Request for Discharge/Assistance with Inappropriate Behavior form, (Attachment A). MS staff documents the request in Amisys or the Call Center System and sends letter #10c to the member, copying the requesting provider.

c. Incomplete requests: If additional information is needed from the provider, the MS Department requests the information through PHC’s PR Department. The request for assistance with inappropriate behavior will be pended for five (5) business days. If the information is not received within the five (5) business days the request is closed. MS notifies the provider that not enough information was received timely to process the request.

B. Discharge Requests

1. PHC’s best effort is used to provide members the opportunity to be cared for by medical providers with whom a collaborative physician/patient relationship can be developed. Because the relationship is personal in nature, circumstances may arise under which the relationship between a patient and a provider becomes non-collaborative. Medical providers are permitted to request that a patient be discharged from his/her practice in certain circumstances, but it is the sole responsibility of PHC to determine if the request meets PHC’s discharge criteria. Providers are expected to have procedures in place that provide guidance to practitioners and staff when dealing with challenging patients. Providers can request sample procedures through PHC’s PR Department.

C. Discharge Criteria

1. Using the written documentation provided by the provider and the discharge criteria listed below, appropriate PHC staff determines if the request for discharge meets PHC’s discharge criteria. Designated MS staff consults the Care Coordination (CC) designee, PHC Chief Medical Officer or designee as needed.

2. The following behaviors are generally considered appropriate criteria for discharge: a. Fraudulently receiving benefits under a health plan contract. b. Fraudulently receiving and/or altering prescriptions, theft of prescription pads, or photocopying

prescriptions. c. Physically abusive behavior exhibited to the provider or office personnel. d. Threatening behavior exhibited in the course of needing or receiving care. e. Credible threat of the member’s intent to initiate or pursue legal action (not including a state

hearing) against the provider and/or his/her associates. f. Refusal by the member to follow recommended medical treatment where the provider believes

there is no alternative treatment, and that refusal severely endangers the health of the member. This situation cannot be improved by repeated attempts by PHC’s CC designee to intervene, and in the judgment of the Chief Medical Officer or designee, a change in provider would clearly benefit the member’s health status.

g. A determination by PHC’s CC designee or the Chief Medical Officer or designee that deterioration in the doctor/patient relationship has occurred to the point where continuation might result in adverse consequences to the member’s health or to the safety of the provider or provider’s staff.

h. Documented evidence that the member had been discharged from the practice site before the member became PHC eligible. If a member has been previously discharged from a practice, it is the responsibility of the practice to notify PHC within sixty (60) days of the member’s initial assignment. Exceptions to the sixty (60) day period can be made on a case-by-case basis. The provider’s capitation payment is recouped.

i. Disruptive or verbally inappropriate behavior to the provider, office staff or other patients if

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Page 3 of 5

counseling and corrective action by the provider has been ineffective. For assistance with inappropriate behavior refer to the section above titled Assistance with Inappropriate Behavior.

j. Three (3) or more missed appointments within the previous six (6) month period or four (4) or more missed appointments within the previous twelve (12) month period, if the provider has made a good faith effort to correct the member’s behavior. Good faith effort is defined as at least one verbal and one written warning or at least two written warnings. All verbal and/or written warnings must inform the member that continued missed appointments will result in discharge. Provider offices must provide documentation of the verbal warning and one written warning or two (2) or more written warnings. The verbal and/or written warnings must be within the specified timeframes of the missed appointments. Exceptions: Missed appointments due to an inpatient hospital stay or appointments cancelled 24 hours in advance are not considered missed appointments for the purpose of this policy.

k. If the provider has multiple locations and/or practices, the provider must specify on the Discharge Request Form if the discharge applies to all locations and/or practices or specific locations and/or practices.

D. Requesting Discharge Process

1. The provider must notify PHC’s MS Department in writing to request a member discharge. The provider must provide complete documentation outlining the nature of the problem, including Form #6 titled “Provider Request for Discharge/Assistance with Inappropriate Behavior” (Attachment A) for each member included in the discharge request. The request must also indicate if the member is or is not in active care for an acute medical condition and/or if the member has diagnostic testing or surgeries scheduled. If additional information is needed from the provider, the MS Department will request the additional information through PHC’s PR Department.

2. By the end of the second business day from the date of receipt, the designated MS staff documents the date the discharge request was received using the DE Remark Code.

3. If the provider does not provide the supporting documentation needed, MS forwards the request to the PR Help Desk with a scanned copy attached noting what additional information is needed. To ensure that the email is forwarded appropriately, the word “Discharge” must be included in the subject field of the email. PR forwards additional information to MS upon request. The request is pended for five (5) business days. If the documentation requested is not received within the five (5) business days, the request is denied.

E. Provider Notification of Decisions

1. Using letter #MS10a, MS notifies providers of the discharge decision in writing. 2. The provider can call the MS Department at (800) 863-4155 to check the status of a request. Direct

extensions of MS staff are not provided.

F. Member Notification - Approved Requests 1. Member Type V - For the purpose of this policy, members are defined as “Type V Members” if they

have been discharged for fraud, threatening and/or violent behavior. a. The copy of the provider’s discharge submission and documentation is sent to the CC designee. b. The CC designee determines if the relationship between the provider and member can be

repaired. If the relationship cannot be repaired, CC designee identifies a new PCP. CC designee must get approval by the accepting PCP before the assignment is made. The CC designee informs the new PCP of the reason the member was discharged and the assignment date to his or her practice. If the CC designee cannot find an accepting PCP, the member is placed in Special Case Managed status and can be seen by any Medi-Cal provider willing to see the member and bill PHC.

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Page 4 of 5

c. If the member is discharged and meets the definition of a “Type V Member”, the designated MS staff sends MS10e notification letter to the member within ten (10) business days from the date the request was received, or sooner, upon approval of the provider request. The letter explains the reason for the discharge and the effective date of the re-assignment to the new PCP or Special Case Managed status. The member is re-assigned to a PCP in their service area that has agreed to accept the member.

d. If PHC isn’t able to locate a PCP to accept the member, the member is placed in a Special Case Managed Status. The member notification letter #MS10e is sent and instructs the member to call PHC’s MS Department if they are unable to find a provider.

2. Member Type U – For the purpose of this policy, members are defined as “Type U Members” if they have been discharged for reasons other than fraud, threats of violence and/or violent behavior. a. Member notification letter #MS10b is sent to the member within ten (10) business days from the

date the request was received. The letter explains the reason for the discharge and the effective date of the re-assignment to the new PCP. The letter also advises the member to choose a new PCP from the PHC Provider Directory if they don’t like the PCP that was assigned to them.

G. Transition of Care (applies to both Type U and Type V Members) 1. If the member has diagnostic testing, specialty referrals and/or surgeries scheduled for conditions

that could adversely affect the member’s health if delayed, designated MS Staff requests that the CC Department work with the member and appropriate providers to ensure that needed medical care is provided. The member may be assigned to Special Case Managed status, depending on the timing of the discharge.

2. If the member is medically unstable, as defined in MS Policy MP312, Processing PCP Selections and Transfer Requests, the PCP will continue to provide care to the member until PHC is able to change the member’s PCP for a period not to exceed two (2) months.

H. Processing Approved Requests in Amisys 1. To prevent discharged members from relinking or auto assigning to the discharging PCP, the “AX”

remark code is entered in Amisys. The member is also placed “On Review” to alert staff of the discharge should the member request this PCP at a later date. Refer to Job Aid (JA) 103-Amisys-Member on Review for instructions on how to place a member on review.

I. Discharge of Special Case Managed Members

1. A provider can terminate care of a Special Case Managed Member when the patient/physician relationship becomes non-collaborative, by notifying the member in writing that he/she will no longer be able to provide care for that member. If the member is unstable, the provider should care for the member until the member selects another provider, and the provider provides emergency care for at least 30 days.

2. Primary Care Providers should notify PHC of their intent to discharge a Special Case Managed Member from their practice so that PHC can document the reason for discharge and assist with transition of care, as described above in the section of this policy titled Transition of Care.

J. Discharge Requests from Specialists

1. A specialist physician can cease providing care for any member when the physician/patient relationship becomes non-collaborative. In these cases, the specialist physician must notify both the PCP and the patient that they will no longer provide care to the patient. The PCP should refer the member to another specialist for treatment, if specialist care is still necessary.

2. In all cases, the provider discharging a member should assist with continuity of care by transferring appropriate medical records to the new provider.

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Page 5 of 5

K. Request for Grievance

1. Members may request a grievance or a State Hearing.

L. Reporting Violent and/or Fraudulent Behavior 1. Providers are encouraged to report violent and/or fraudulent behavior to the appropriate authorities. 2. MS notifies the Compliance Department of suspected fraudulent behavior.


A. SharePoint B. Provider Manual for all programs

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Associate Director of Enrollment

Unit Member Services X. REVISION DATES:

Medi-Cal 04/27/95; 10/13/99; 06/20/01; 08/15/01; 06/19/02 (Hlth Srvcs Policy); 06/18/03 (Mbr Srvcs Policy); 03/05/04; 05/19/04;11/17/04; 11/16/05; 03/07/08; 08/12/08; 01/21/09; 08/19/09; 12/16/09; 03/23/10; 05/11/11; 01/07/2014; 07/14/14 Healthy Kids 11/16/05; 03/07/08; 08/12/08; 01/21/09; 08/19/09; 12/16/09; 03/23/10; 05/11/11; 01/07/2014; 07/14/14 PREVIOUSLY APPLIED TO: PartnershipAdvantage: MP316 – 01/01/2007 to 01/01/2015

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Attachment A – Form #6

<New Form #6 > <PHC logo>

Provider Request for Discharge/Assistance with Inappropriate Behavior Section 1 ‐ What would you like PHC to do?

Would you like PHC’s Care Coordination Team to reach out to the member to counsel them on improving their behavior?

Do you want to request that the member be disenrolled from your office(s)? Must attached required

documentation.

Section 2 ‐ Member Information: PHC ID (CIN) #___________________________ Name: ___________________________________ DOB: ________________ Phone #____________________ Section 3 ‐ Member Care Information: 1. Is the member in treatment for an active medical condition? No Yes ‐ attach description of medical condition 2. Are there any diagnostic testing or surgeries scheduled? No Yes ‐ attach list of scheduled procedures and any

active TARs and/or RAFs. Please include TAR & RAF #s: ________________________________________________________________________________________________

Section 4 ‐ Provider Submitting Request: 1. PCP/Med Grp Name: ______________________________ PCP/Group’s PHC PCP#: __________________________

Does discharge apply to all facilities and/or locations affiliated with the group? Yes No If yes, list all the PHC providers or locations that apply:

2. Have you already communicated with the member regarding your concerns? Yes No N/A If yes, what did you advise the member: ________________________________________________________________________________________________

3. Who do we contact if we have questions regarding the member’s care or the reason for disenrollment:

Print Name: __________________________________ Phone # __________________________

4. Who and where do we fax our decision to: Print Name: ________________________ Phone # _____________________ Fax#: ________________________

Section 5 ‐ Reason for your request: Please check all applicable boxes. If you are requesting to disenroll the patient, attach documentation outlined in the policy. If the action of the member is not specified in the policy, provide documentation outlining the incident or reason for request. Missed appointments Disruptive/verbally inappropriate behavior Suspected fraud Failure to obtain/maintain a collaborative relationship Non‐Compliance/refusal to follow treatment plan.* Threats of violence and/or violent behavior; has behavior been reported to police? Yes No If “No” please explain

why: ___________________________________________________________________________________________________ Other:

________________________________________________________________________________________________ *Note: All requests for discharge for non‐compliance are reviewed by a PHC Medical Director. Presence of a Substance Abuse Disorder alone is not sufficient grounds for discharge. Please refer to specialty care or address treatment as necessary. Signature of Provider: _________________________________ Date: _____________________

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Print name of Provider: ________________________________________ Section 6 ‐ Fax to PHC Member Services’ Enrollment Unit:

Lake, Marin, Mendocino, Napa, Solano, Sonoma and Yolo members fax request to (707) 420‐7580. Del Norte, Humboldt, Lassen, Modoc, Shasta, Siskiyou and Trinity members fax request to (530) 223‐

2508.

PHC has ten (10) business days to process your request once it has been received. Please be advised if the form is incomplete or missing required information your request will be denied.

****************************PHC INTERNAL USE*********************************** Member #: DECISION:


Referral to Case Management: Yes‐<date> No Letter #/ Date notice sent to provider: Letter #/Date notice sent to member: Call Center/Amisys entries completed: <date>

COMMENTS: MS __________________________________________________________________________________ CC ___________________________________________________________________________________ PR ___________________________________________________________________________________ Member Services Director Signature: __________________________________ Date: _______________ Form #6 (rev 09/13/2016)

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POLICY/ PROCEDURE

Page 1 of 2

Policy/Procedure Number: ADM21 Lead Department: Administration

Policy/Procedure Title: Members on PHC Committees ☐External Policy ☒ Internal Policy



Reviewing Entities:

☐ IQI ☐ P & T ☐ QUAC


Approving Entities:

☒ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ CAC

☒ CEO ☐ COO ☐ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER

Approval Signature: Elizabeth Gibboney Approval Date: 08/26/2016


A. N/A

II. IMPACTED DEPTS: A. Administration B. Member Services C. Quality Improvement

III. DEFINITIONS:

A. Consumer – is a PHC member or parent/guardian of a PHC member. B. Compensation – non-wages paid to committees members.

IV. ATTACHMENTS: A. CAC Consumer Member Compensation Request Form, ADM21a B. Q/UAC Physician / Consumer Member Compensation Request Form, ADM21b

V. PURPOSE: A. This policy outlines compensation paid to committee members serving on Partnership HealthPlan of

California (PHC) Consumer Advisory Committee (CAC) and Quality/Utilization Advisory Committee (Q/UAC) who want to receive the optional compensation and reimbursement for actual mileage for attending meetings.


A. Guidelines: 1. Consumer Advisory Committee members must submit a CAC Consumer Member Compensation

Request Form, ADM21a after each meeting to the Administrative Assistant to receive compensation. 2. Quality/Utilization Advisory Committee members must submit a Q/UAC Physician / Consumer

Member Compensation Request Form, ADM21b after each meeting to the Administrative Assistant to receive compensation.

B. Consumer Advisory Committee Members Compensation Rate Consumer members may request the following compensation for attending CAC meetings:

1. $50.00 compensation for all CAC meetings attended for which a committee member must travel to a meeting at a PHC location.

2. Committee members may request the optional mileage reimbursement for actual mileage expenses incurred for attending CAC meetings at the current IRS mileage reimbursement rate.

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Policy/Procedure Number: ADM21 Lead Department: Administration

Policy/Procedure Title: Members on PHC Committees ☐ External Policy ☒ Internal Policy



Page 2 of 2

3. Committee members who use public or group transportation (e.g. taxi, paratransit, etc) to get to a CAC meeting, may request a transportation reimbursement in lieu of a mileage reimbursement.

C. Q/UAC Physician / Consumer Member Compensation Rate: 1. $50.00 compensation for all Q/UAC meetings attended for which a committee member must travel

to a meeting at a PHC location. 2. Committee members may request the optional mileage reimbursement for actual mileage expenses

incurred for attending Q/UAC meetings at the current IRS mileage reimbursement rate. 3. Committee members may request a “flat rate option” for compensation in lieu of a mileage

reimbursement. VII. REFERENCES:

N/A VIII. DISTRIBUTION:

A. SharePoint IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:

A. Board Clerk

X. REVISION DATES: A. Agenda Item 9.4 on 03/24/10 B. Agenda Item 9.7 on 12/14/11 C. Agenda Item 3.5 on 08/24/16 PREVIOUSLY APPLIED TO: ADM36 (Retired)

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Q/UAC PHYSICIAN / CONSUMER MEMBER COMPENSATION REQUEST FORM ADM21b

Meeting attended: Meeting Date PHC Office Location

Quality/Utilization Advisory Committee (Q/UAC)

Attendance Stipend Note: If you plan to donate the stipend, please make your request in writing to the PHC Administrative Assistant.

$50.00 compensation for all Q/UAC meetings attended in-person at one of PHC’s regional offices.

$100.00 “flat rate option” compensation for all Q/UAC meetings attended in-person at one of PHC’s regional offices without a mileage reimbursement.

Check Information for Attendance Stipend

Make Check Payable to:

Address City Zip Code

Mileage Reimbursement Note: In lieu of a mileage reimbursement, a committee member can take the “flat rate option” for compensation.

Reimbursement for mileage related to round trip travel from home or place of business to the meeting.

Round trip mileage was miles at the current IRS rate of .54 cents per mile = $

Total Compensation: $

Check Information for Mileage or Transportation Reimbursement

Committee Member Signature Make Check Payable to:

Printed Name Address City Zip Code

Please send or give this form to: PHC Administrative Assistant

Partnership HealthPlan of California 4665 Business Center Drive Fairfield, CA 94534 (707) 863-4241 / FAX: (707) 420-7883

Date Received By

For PHC use only below this line.

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Prepared By: Nadine Harris, RN and Lauri Stevenson, RN Reporting Period: 1/1/2016 – 6/30/2016

Site Review Compliance Report August 2016

Overview Facility Site Reviews are conducted for credentialing and re-credentialing purposes. It is a state mandate that PCP sites meet patient safety and access standards in order to see PHC members. There are two components:

1) Facility Site Review (FSR) – domains: a. Access/Safety b. Personnel c. Office Management d. Clinical Services e. Preventive Services f. Infection Control

2) Medical Record Review (MRR) – domains: a. Format b. Documentation c. Continuity/Coordination d. Pediatric Preventive e. Adult Preventive f. OB/CPSP Preventive

Methodology Facility Site Review and Medical Record Review data is gathered by the PHC Nurses who are DHCS Certified to conduct these reviews at the network provider sites.

• The Facility Site Review portion looks at areas ranging from Access and Safety to Infection Control with an overall passing score of 80%.

• For the Medical Record Review, a random sample of members’ records is selected. The sample can range from 10 to 30 records depending on the number of PCPs at the site. An 80% overall score is required to pass. If any of the domains fall below 80%, a Corrective Action Plan is required for the entire review.

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Review Location and Populations Served Review findings cover the following regions: 1. North West ( Del Norte, Humboldt counties) 2. North East (Siskiyou, Modoc, Trinity, Shasta and Lassen counties) 3. South East (Napa, Solano, Yolo) 4. South West (Mendocino Lake, Sonoma and Marin counties) Review Summary

Facility Site Review: 1. SE – Significant improvement seen in Personnel. 2. SW – No significant changes were noted. 3. NE – No significant changes were noted. 4. NW – No significant changes were noted.

Medical Record Review 1. SE – Significant improvement seen in Pediatric and Adult Preventive Domains. 2. SW - Significant increase in the Pediatric Preventive Domain. 3. NE – Significant decrease was noted in Pediatric and Adult Preventive screening scores. 4. NW – Significant improvement noted in Pediatric Preventive, however Adult Preventive noted a significant decrease.

Review Nurses’ Comments: Site Review nurses have noticed that for the most part, the facilities do well with the Site Review portion of the Review or “Part A”. For “Part B”, or the Medical Record Review, the majority of sites struggle with the Preventive Measure criteria, most noticeably the Adult Preventive Measures. Many sites receive a Corrective Action Plan in Preventive Criteria. The areas most noted to fall short are:

1) Initial or subsequent IHEBA/SHA (especially adults) 2) Risk Assessment for TB exposure (both adults and pediatrics)

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3) Documented Pap smears 4) Colorectal cancer screening in adults over 50 years old 5) Immunizations for Adults this includes Tdap, Pneumovax (where indicated) and flu 6) Immunizations for adolescents 7) Well child for children over 5 8) Annual hearing and vision screening and dental assessments/referral for children

In addition to preventive measures, another area of frequent low scoring is documentation of offering or discussion of Advanced Healthcare Directive. Ideas to Explore

• Continue to monitor and report trended data to IQI and QUAC semi-annually. • Work continues with IT on the electronic FSR/MRR template to facilitate increased efficiency of DHCS reporting and track /

trend data on all areas measured in the FSR/MRR Tools. Use of an electronic tool will allow PHC to report data to assist on other initiatives, such as advance care planning, immunizations, and other areas related to patient safety. We are on schedule to be testing this tool beginning in October, and the timeline for “go live” is January 1, 2017..

• We have begun to share best practices on the website and take time at each review to educate providers on the areas in which they are struggling.

• Strengthen the standardization of the review process with regular reviewer meetings and education.

• Strengthen Facility Site IRR in the next quarter.

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Facility Site Review:

Table 1 2014 – Facility Site Reviews by Region

Jul-14 – Dec-14: SE SW NE NW

Access & Safety 93% 100% 95% 96%

Personnel 94% 96% 100% 98%

Office Mgmt. 97% 100% 100% 97%

Clinical Services 91% 96% 90% 91%

Preventive Services 97% 98% 96% 98%

Infection Control 91% 99% 100% 94%

Sites: 17 14 2 7

Compliance 94% 98% 97% 96%

Table 2 2015 – Facility Site Reviews by Region Jan-15 - Jun-15: SE SW NE NW

Access & Safety 99% 98% 100% 96% Personnel 95% 100% 100% 95% Office Mgmt. 100% 100% 96% 100% Clinical Services 96% 100% 98% 90% Preventive Services 99% 100% 100% 100% Infection Control 98% 99% 100% 89% Sites: 18 12 2 1

Compliance 98% 100% 99% 95%

84%86%88%90%92%94%96%98%

100%

Facility Site Scores - December 2014

SE SW NE NW

80%85%90%95%

100%

Facility Site Scores - June 2015

SE Jun-15 SW NE NW

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Table 3 2016 – Facility Site Reviews by Region

85%

90%

95%

100%

Access &Safety

Personnel OfficeMgmt.

ClinicalServices

PreventiveServices

InfectionControl

Facility Site Review Scores - June 2016

SE SW NW NE

Jan - Jun-16: SE SW NW NE Access & Safety 99% 98% 96% 97% Personnel 100% 98% 98% 98% Office Mgmt. 100% 99% 99% 99% Clinical Services 98% 99% 97% 98% Preventive Services 100% 99% 97% 99%

Infection Control 99% 97% 90% 98% Sites: 10 15 6 12 Compliance 99% 98% 96% 98%

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Medical Record Review:

Table 4 - 2014 – MR Results by Region

Jul - Dec-14: SE SW NE NW

Format 98% 97% 98%

Documentation 88% 95% 91%

Coord/Cont 98% 98% 100%

Peds 85% 85%

Adults 76% 75% 73%

OB

Sites 17 11 1

Compliance 89% 90% 91%


Jan - Jun-15: SE SW NE NW

Format 100% 98% 96% 99% Documentation 91% 88% 89% 88% Coord/Cont 99% 98% 100% 96% Peds 60% 75% 85% 54% Adult 74% 76% 81% 77% OB 99% 97% 69% Sites 18 11 1 6 Compliance 87% 89% 87% 83%

40%50%60%70%80%90%

100%

Medical Record Review Scores -December 2014

SE SW NE NW

40%50%60%70%80%90%

100%

Medical Record Review Scores -June 2015

SE SW NE NW

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50%60%70%80%90%

100%

Medical Record Review Scores - June 2016

SE SW NW NE

Jan - Jun-16: SE SW NW NE

Format 100% 99% 99% 98%

Documentation 94% 89% 89% 86%

Coord/Cont 100% 99% 100% 99%

Peds 92% 87% 81% 80%

Adult 85% 75% 71% 71%

OB 100% 100% 91%

Sites 8 20 9 14

Compliance 95% 91% 90% 88%

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Partnership HealthPlan of CaliforniaCurrent Members With a Primary or Secondary Tobacco/Nicotin DiagnosisClaim or Service Between January-July 31, 2016 As of Report Run Date 9/15/2016

Region County#Members With

Tobacco / Nicotin Dx

%By Region GTPP August 2016 Eligibility

DEL NORTE 579 5% 4 11,381 HUMBOLDT 1,809 27% 22 51,763 LASSEN 245 6% 5 7,214 MODOC 111 5% 4 2,986 SHASTA 2,332 46% 37 60,559 SISKIYOU 691 11% 9 17,438 TRINITY 151 0% 0 4,550

Northern Region 5,918 55% 81 155,891

Region County#Members With

Tobacco / Nicotin Dx

%By Region GTPP August 2016 Eligibility

LAKE 1,611 23% 15 29591MARIN 585 3% 2 37389MENDOCINO 1,290 20% 13 36619NAPA 602 3% 2 28909SONOMA 2,411 11% 7 113186SOLANO 1,954 32% 21 114727YOLO 1,042 9% 6 53893

Southern Region 9,495 45% 66 414,314

15,413 100% 147 570,205

Note: There are so many CMR GTPP records that did not match the claims data due to State Mom or dummy CMR Identifier

Northern Region

Southern Region

Grand Total == >>

Northern Region, 81

Southern Region, 66

PREGNANT WOMEN TOBACCO USERS

Northern Region, 5,918

Southern Region, 9,495

TOBACCO USERS BY REGION

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