provider advisory group meeting november 16, 2018 lunch ... · provider advisory group meeting...

Provider Advisory Group Meeting November 16, 2018

Lunch: 12:00 pm Meeting: 12:30 – 1:30 pm

1. Standing Agenda Items - 12:30 pm1.1. Welcome and Introduction1.2. Facilitator: Joel D. Moncada LAc1.3. Review of Minutes1.4. Review of Agenda

2. Presentations2.1. The Whys of Eyes – Why Get a Diabetic Eye Exam – Bradley Sandler, M.D.

3. Old Business3.1 None

4. New Business4.1. PHC Update – Liz Gibboney, CEO4.2. Report from the Physician’s Advisory Committee – Robert Moore, M.D., Chief Medical

Director 4.3. Update on PHC’s Wellness and Recovery Program – Liz Leslie, Program Manager 4.4. Report from Provider Relations – Rose Rad – Medi-cal Enrollment Verification 4.5. Report from Provider Education Team – Lisa O’Connell, Provider Relations Education

Manager – CCS Transition (Whole Child Model) 4.6. Claims Department - Rebecca Mannella-Claims Resolution Manager

5. Provider Topics of Interest5.1. Topics of Interest, Upcoming Events, Health Fairs and Trainings: All Attendees

Meeting Locations: Main Office Southeast: 4665 Business Center Drive, Fairfield

Video conferencing is available at our regional offices: Southwest Regional Office at 495 Tesconi Circle, Santa Rosa Northeast Office at 3688 Avtech Parkway, Redding Northwest Regional Office at 1036 5th Street, Suite E, Eureka

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MEETING MINUTES

Meeting Name: Provider Advisory Group Date: 8-17-18 Time: 12:30 pm to 1:30 pm Location: Redding (Host) Fairfield; Santa Rosa, Eureka, & Redding via video PHC Attendees: Michael Vovakes, MD, Robert Moore MD, Jeff Ribordy Stephanie Phipps, Judy Paul, Melissa Perez, Gloria Turner, Debra McAllister, Amy Turnipseed, Rebecca Garcia, Camille Williams, Mark Aguirre, Dani Alfaro, Jenica Taitano, Jeanette Camarena, Lisa O’Connell, Carol Parker Lynne DiModica, Carol Parker, Kim Palfini, Kris Devan, Jennifer Oakes, Sharon McFarlin, Dani Carpenter, Barbara Crandall, Cindy Crandall, Nai Chadderdon,

Guests: Maria Christ, Abby Josang, Linda Alm RN, Kim Omey, Janis Polos, Marianne Hutchins, Matthew Ward, Antoinette Jones, Laura Dougan, Martha Ugbinada, Sarah Ullerig, Marsha Johnson, Nicholas Lewis, Michele Zander, Lynda Brennan, Sara Hardier RN, Cheryl Coulter, James Harbin, Veronica Revillq, Jennifer Elsaz, Joy Mozdy, Jamie Wilborn, Zosima Inton, Pam Sakamoto, Celine Regalia, Rebekah Kim, Caitlin Nevadoni, Vita Marks, Maike Palomino, Gail Kent

Agenda Topic Minutes Action Items Agenda Item #1 Standing Agenda Items

1.1. Introductions: Kelley Sewell introduced guest facilitator Laura Dougan, Director of Clinical Operations, Shasta Community Health Center 1.3. Review of Minutes-Reviewed

Presented as information only

Agenda Item #2 New Business

2.1 Immunizations – Sandra McMasters, Senior Health Educator • When prevention efforts work, the spread of preventable diseases decreases, along with disease awareness.

Low disease awareness=increased focus on vaccine risks. Parents have low tolerance for vaccine risks. Full and complicated immunization schedules have increased distrust and fear of risks.

• Health care professionals are still the most trusted source of vaccine information and advice for most parents. • Shasta County Public Health re-phrased how they spoke to parents about vaccines the summer of 2015 and

saw an improvement in their rates. • If a parent declines vaccines once, it does not guarantee they always will. Continue to remind parents about

the importance of keeping their child up to date on vaccines during future visits and work with them to get their child caught up if they fall behind.


Agenda Item #3 Old Business

None

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Agenda Item #4 Presentation

4.1 PHC Update – Amy Turnipseed updated group on PHC key initiatives: • The Carr and Mendocino Complex fires have impacted our staff and providers due to evacuations, and a few

lost homes. The good news: all provider offices are currently open. • CCS transition to Whole Child Model. CCS conditions were formerly managed at the County level. We are

close to an MOU. A Pediatric Quality Committee is forming under Dr. Vovakes. PHC is also looking for members to establish a Family Advisory Committee for CCS families.

• NCQA Accreditation is progressing; we have an Interim Survey date of June 14, 2019 • Wellness & Recovery (aka Drug Medi-Cal) Program. PHC proposing a regional model contracting with

counties to provide treatment services. We are currently working with the State (DHCS) on approval. 4.2 Report from the Claims Department-Rebecca Manella, Claims Resolution Manger

Rebecca shared Immunization Billing Modifiers 4.3 Report from Provider Relations – Kelley Sewell, NR Member Services & Provider Relations Director

August trainings in the NR have be canceled due to the fires, so the September trainings have been opened to PCP’s

4.4 Report from Physician's Advisory Committee – Michael Vovakes, MD., NR Medical Director, HS Office of CMO spoke to the group regarding HEDIS. He reminded provider they can go to the PHC Website at www.partnershiphp.org under Quality to view the HEDIS measures and our 2017 performance results. He asked that interested providers sign up for an October Opioid conference, but I can’t find any info about it on the webpage.


Agenda Item #5 Provider Topics of Interest

No one else had any additional comments or questions, meeting was adjourned.

Next Meeting November 16, 2018 - Fairfield (Host) Any suggestions for next agenda

http://www.partnershiphp.org/

11/14/2018

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The Why’s of Eyes: What to know about Diabetic Retinopathy

An eye wise review of what to look for and think about for our patients with diabetes

Presented by

Bradley Sandler, M.D.Solano Eye Specialists

How prevalent is diabetic retinopathy?

• Worldwide: Results of a 2015 global meta-analysis of 35 countries estimated 285 million people with diabetes.

• Diabetic retinopathy is expected to be present in around one third of that population, therefore, around 100 million are effected.

• Source: NCBI database

11/14/2018

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More diabetics more eye disease

• If we review the incidence of diabetic retinopathy from studies in the 1990s, early 2000s and onward we see what we already know is confirmed.

• Diabetes is on the rise, the percentage of diabetic eye disease holds fairly steady and therefore the number of patients with diabetic eye disease likewise rises.

• Source: National Eye Institute and CDC

What about diabetic retinopathy here?

• Though the worldwide estimated rate of diabetics with eye disease is one third, the National Eye Institute (U.S.) has statistical support to show that 40%-45% of the U.S. diabetic population has some retinopathy

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What about diabetic retinopathy here?

• I could show you some statistical tables to illustrate the increase of diabetes but I thought these tables would be just as enlightening.

• All of us here have patients, friends, co-workers and family members who are diabetic. This is not some obscure disease, it is epidemic. You all know this.

Not good anywhere but worse in some places

Source:Prevent Blindness America

11/14/2018

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How do we classify diabetic retinopathy?

We use a lot of capital letters all ending in DR = Diabetic Retinopathy

When you get an eye consult report back you may see some of these abbreviations; NPDR is the most common term you will see in the Assessment/Impression.

BDR and NPDR are synonyms.

Visually Threatening DiabeticRetinopathy (VTDR)

Background Diabetic Retinopathy (BDR)

Non-Proliferative Diabetic Retinopathy (NPDR)

Proliferative Diabetic Retinopathy (PDR)

How do we classify diabetic retinopathy?

• Mild Non-Proliferative Diabetic Retinopathy

• - w/ or w/o Macular Edema (ME)

• Moderate Non Proliferative Diabetic Retinopathy


• Severe Non Proliferative Diabetic Retinopathy


11/14/2018

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It’s not all about ME

• Macular Edema (ME)

• aka DME (diabetic macula edema)

• Macular edema refers to swelling of the central retina or macula. Our central 5 degrees of vision, the part of our vision that gives us the best discrimination is called the macula.

More pictures please…

• Let’s take a look at diabetic retinopathy

• This is what I tell my patients:

• We know that diabetes is a blood sugar control problem but the way it effects our bodies is as a vascular disease.

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• In short, two problems happen to the blood vessels from diabetes, they either close off or leak.

• Blood vessels basically carry two components: red blood cells and everything else which we label as serum (platelets, wbc, proteins, etc).

• We call rbc leakage hemorrhages• We call serum leakage exudates


• Patient vision can vary despite the severity of the disease.

• Besides, how many of our patients are stoic and claim, no matter what,“I’m fine”

• In other words, histories aren’t always reliable and advanced eye disease may be present even with decent vision.

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• Even patients with wonderful glycosylated hemoglobin (HgA1C) levels can have diabetic retinopathy.

• The eye is the only place in the body that we can see the blood vessels without any skin or mucous membranes to cover them.

What is Proliferative disease?

• We’ve seen pictures of mild, moderate and severe non-proliferative diabetic retinopathy (NPDR). With NPDR we’ve seen what happens when blood vessels leak.

• The next level up in disease is proliferative diabetic retinopathy (PDR). That is the body’s response to the vessels closing off gradually.

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• The body recognizes the lack of adequate circulation and in response it sends out a call for help to hurry up and grow new blood vessels.

• This messenger is known as Vascular Endothelial Growth Factor (VGEF or “veg-eff”).


• You might consider that a good remedy – current vessels are not working, so build new ones!

• Unfortunately, the new blood vessels are quickly and poorly manufactured and are one cell layer thick. They tend to break and bleed easily…

• a vitreous hemorrhage may result.

11/14/2018

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• Blood is opaque. Depending on the degree of hemorrhage you either see poorly through a fog or not at all. The patient can’t see out of the eye and the doctor can’t see inside the eye.

• When your diabetic patient calls you and tells you they lost their vision, this is the most likely reason why.

What to do? The take home message(s)

• Currently, only about 60% of people with diabetes have yearly screenings for diabetic retinopathy. Refer, Refer, Refer.

• People with Type 1 diabetes should have annual screenings for diabetic retinopathy beginning 5 years after the onset of their disease, whereas those with Type 2 diabetes should have a prompt examination at the time of diagnosis and at least yearly examinations thereafter.

• Source: American Academy of Ophthalmology, preferred practice patterns

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• Maintaining near-normal glucose levels and near-normal blood pressure lowers the risk of retinopathy developing and/or progressing, so patients should be informed of the importance of maintaining good glycosylated hemoglobin levels, serum lipids, and blood pressure.

• Women who develop gestational diabetes do not require an eye examination during pregnancy and do not appear to be at increased risk of developing diabetic retinopathy during pregnancy. However, patients with diabetes who become pregnant should be examined early in the course of the pregnancy.



• Referral to an ophthalmologist (M.D.) is required when there is any non-proliferative diabetic retinopathy (NPDR), proliferative retinopathy (PDR), or macular edema (ME).


11/14/2018

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• Intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents have been shown to be an effective treatment for center-involving diabetic macular edema (ME) and also as an alternative therapy for proliferative diabetic retinopathy.

• At this time, laser photocoagulation remains the preferred treatment for non-center-involving diabetic macular edema (ME)


In conclusion

Diabetes is a multi-system disease. I call it a “wastebasket disease” because any medical condition that occurs to a diabetic is from diabetes until proven otherwise. It is estimated that 40%-45% of our diabetic patients have eye disease. That means when you see 5 diabetic patients during your AM shift tomorrow, 2 of them will most likely have eye disease. Refer, Refer, Refer.

If you have questions – Please ask. The eye can be a bit of a foreign place to work. Don’t “wing it” – if you have a concern or are unsure about any question regarding an eye, please think of your eye care providers to provide help. Allow us to be a part of the team.

11/14/2018

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Bradley Sandler, M.D.

All PHC Providers* Must be Enrolled in Medi-Cal • All Medi-Cal Managed Care Plan Providers* must be enrolled in Medi-Cal no later

than December 31, 2018. This is a state and federal mandate.

• Your organization, and all associated provider sites must also be enrolled inMedi-Cal.

• After December 31, 2018, we will not be able to reimburse providers who providecare to PHC members unless they are enrolled in Medi-Cal.

• DHCS will not allow us to have providers in the network who are not Medi-Calapproved.

Preferred Enrollment Process Using PAVE for Expedited Enrollment DHCS has a new online Medi-Cal enrollment platform: Provider Application and Validation for Enrollment (PAVE). PAVE is the most efficient and timely way to enroll in Medi-Cal. We strongly encourage you to use the online system to expedite enrollment. Submitting paper applications takes considerably longer to process.

Link to PAVE: http://www.dhcs.ca.gov/provgovpart/Pages/PAVE.aspx

*FQHC - RHC - IHS ProvidersIf you are classified as an FQHC, RHC, or IHS, the individual providers must enroll as Ordering Referring, Prescribing (ORP).

Resources Please e-mail any PHC Health Plan Questions to:

Rose Rad, Provider Relations Credentialing Supervisor [email protected]

DHCS PAVE Portal Information http://www.dhcs.ca.gov/provgovpart/Pages/PAVE.aspx

Time Sensitive Reminder All PHC Providers* Must be Enrolled in Medi-Cal

Eureka | Fairfield | Redding | Santa Rosa (707) 863-4100 | www.partnershiphp.org

http://www.dhcs.ca.gov/provgovpart/Pages/PAVE.aspx

mailto:[email protected]

http://www.dhcs.ca.gov/provgovpart/Pages/PAVE.aspx

2018 PHC Primary Care Providers Webinar

Whole Child Model for CCS Members

You are invited to a webinar for PHC Primary

Care Providers (PCPs) on the Whole Child Model

(WCM) for members who receive California

Children’s Services. The Department of Health

Care Services (DHCS) will implement the WCM on

January 1, 2019, in all 14 PHC counties. Under

the WCM, CCS members will be able to choose a

local Medical Home. These CCS members will be

linked to your practice site.

This webinar is an opportunity for us to share information, answer questions, and respond to your

concerns. We hope to learn from you as well. We are committed to sharing information with you

to facilitate a smooth transition process.

Whole Child Model for CCS-Eligible Members:

An Informational Webinar for PHC Primary Care Providers

November 29, 2018 (two sessions offered)

9:30 – 10:30 a.m. or 12:00 – 1:00 p.m.

Click on link that follows or copy and paste into browser window

https://attendee.gotowebinar.com/rt/721565895389410050

to register for either of the above scheduled webinars.

After registering, participants will receive a confirmation email with instructions on how to join the webinar.

Any questions, please contact: [email protected]

Our Mission: To help our members, and the communities we serve, be healthy

Eureka | Fairfield | Redding | Santa Rosa

(800) 863-4155 | www.partnershiphp.org

2018_WCM CCS Webinar_11.29.18





PHC Whole Child Model: FAQs for Providers

Page 1 of 2

What is the Whole Child Model (WCM) program?

A program developed out of Senate Bill (SB) 586 to improve care coordination for primary, specialty, and behavioral health services for California Children Services (CCS) and non-CCS conditions. The benefits are consistent with CCS program standards and provided by CCS paneled providers, specialty care centers, and pediatric acute care hospitals.

What children qualify for WCM?

A child would qualify if he/she is:

Under the age of 21

A PHC member

Eligible for CCS How will we find out if the patient is a CCS-eligible member prior to rendering services?

PHC contracted providers can use the PHC Provider Portal (https://provider.partnershiphp.org/UI/Login.aspx) to verify eligibility and note whether the member is flagged as a CCS member. Providers may also call our Member Services (800-863-4155) to see if a member is CCS-eligible.

After January 1, 2019, who determines CCS eligibility?

Eligibility will remain the responsibility of each county’s CCS program or DHCS depending upon county of the child’s residence.

Does a PCP need to complete a Referral Authorization (RAF) for a CCS member to be seen by a specialist?

No. Do PCP services for a Whole Child Member require a TAR?

Most PCP services do not require a TAR. Please refer to the PHC TAR requirements at http://www.partnershiphp.org/Providers/HealthServices/Documents/MCTARRequirements.pdf.

Will WCM members be linked to a PCP?

Many of our PHC CCS members already have a Medical Home/PCP and this will continue. Transitioning CCS members will be able to choose a Medical Home/PCP and will not be capitated to the provider, but will be paid Fee-for-Service (FFS). We do not expect any disruption for your existing patients

Will WCM members be capitated to a PCP office?

No. The provider will be paid Fee-for-Service (FFS). If providers are currently credentialed with PHC, but not CCS-paneled, do they need to become CCS-paneled by CCS?

If a physician would like to see a CCS member for a CCS condition, then he/she must be paneled for CCS. To access the CCS provider paneling application, please visit: https://cmsprovider.cahwnet.gov/PANEL/index.jsp.

Whole Child Model:

FAQs for Primary Care Providers (PCPs)

https://provider.partnershiphp.org/UI/Login.aspx

http://www.partnershiphp.org/Providers/HealthServices/Documents/MCTARRequirements.pdf

https://cmsprovider.cahwnet.gov/PANEL/index.jsp


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After January 1, 2019, will PHC contract providers that are interested in participating in the CCS program?

Providers wanting to contract with PHC to provide care must be Medi-Cal certified. Providers can contact our Provider Relations (707-863-4100 or [email protected]) for more information on this process.

How will Partnership work with the Counties’ Medical Therapy Program/Unit (MTP/MTU)? The MTP/MTU will continue to provide therapy to members and make recommendations for DME needs. PHC will review the TARs received from the DME provider(s).

Will WCM members have access to the CCS provider network? PHC is committed to ensure that our members receive continuity of care whenever possible for a minimum of 12 months. When a CCS-eligible child or youth is already receiving care from a non-contracted provider, the child or youth may remain with that non-contracted CCS provider for up to 12 months, if the provider: 1. Agrees to continue care for the child2. Accepts the contract rate3. Has no outstanding quality of care issues4. Willing to bill PHC. PHC will work closely with these children and their families to ensure

access to care

Will the WCM affect my PCP QIP? If yes, how? The impact will be small for family medicine sites and slightly larger for pediatric sites. The changes to note will be as follows:

Because additional patients may be assigned to you, there will be an increase in membermonths, which will affect your total potential payout. More member months = more payoutbecause for any given measure, the formula for payout is (rate x QIP points x MM). Actualtotal payout will depend on the actual performance of the total population.

The number of patients in your denominator may go up depending on the measure. This isdetermined by how many patients have been assigned to you continuously for 9 monthsduring the measurement year, and the specific measure in question. This will primarilyimpact the pediatric practices and the measures for which you are held accountable.

The same exclusions for QIP denominators will still apply – meaning no one who is enrolledin another type of insurance (e.g. Medicare, Medi-Medis) will be included in the denominator.

For more information regarding the QIP program, please e-mail: [email protected].

Will a WCM member have a case manager or care coordinator? Yes, PHC has Care Coordination staff dedicated to the WCM program.




Page 1 of 5

What is the Whole Child Model (WCM) program?

A program developed out of Senate Bill (SB) 586 to improve care coordination for primary, specialty, and behavioral health services for California Children Services (CCS) and non-CCS conditions. The benefits are consistent with CCS program standards and provided by CCS paneled providers, specialty care centers, and pediatric acute care hospitals.

What children qualify for WCM?

A child would qualify if he/she is: • Under the age of 21 • A PHC member • Eligible for CCS

How will we find out if the patient is a CCS-eligible member prior to rendering services?


After January 1, 2019, who determines CCS eligibility?

Eligibility will remain the responsibility of each county’s CCS program or DHCS depending upon county of the child’s residence.

How will the hospital’s relationship with county CCS staff change?

After January 1, 2019: • County CCS staff remain responsible for determining CCS eligibility • Treatment for CCS-eligible conditions should be submitted and billed to PHC • Please see the PHC TAR requirements at


How will the outpatient provider’s relationship with county CCS staff change? After January 1, 2019: • County CCS staff remain responsible for determining CCS eligibility • Treatment for CCS-eligible conditions should be submitted and billed to PHC • Please see the PHC TAR requirements at


Will SAR's approved prior to January 1, 2019, be honored for continuing care that started prior to January 1, 2019?

Yes. PHC will honor and pay for all services approved on a SAR until the SAR expires, as long as the member remains eligible for coverage. When the SAR expires and care needs are ongoing, the provider will be required to submit at Treatment Authorization Request (TAR) at least 15 business days prior to the expiration date. To access a list of TAR Requirements go to http://www.partnershiphp.org/Providers/HealthServices/Documents/MCTARRequirements.pdf.

Whole Child Model: FAQs for Providers




Page 2 of 5

Does a PCP need to complete a Referral Authorization (RAF) for a CCS member to be seen by a specialist?

No. After January 1, 2019, what will the authorization process entail?

PHC will use our standard review processes for all requested services. • New TAR(s) will be reviewed for medical necessity based upon:

o PHC’s policies o CCS Numbered Letters o Evidence Based Guidelines

• Pediatric Medical Directors provide program oversight o Any potential TAR denial will require medical director review

• Expiring SAR(s) / TAR(s) require a new TAR 15 business days prior to expiration • Please see the PHC TAR requirements at

http://www.partnershiphp.org/Providers/HealthServices/Documents/MCTARRequirements.pdf Do PCP services for a Whole Child Member require a TAR?

Most PCP services do not require a TAR. Please refer to the PHC TAR requirements at http://www.partnershiphp.org/Providers/HealthServices/Documents/MCTARRequirements.pdf.

Do all Medical Supply / Durable Medical Equipment items need an authorization?

Certain medical supplies / durable medical equipment do not require a TAR. Please see the PHC TAR requirements at http://www.partnershiphp.org/Providers/HealthServices/Documents/MCTARRequirements.pdf.

After January 1, 2019, what will the authorization and payment process for neonatology services entail?

Neonatology services: • That started prior to January 1, 2019, may be covered under existing SARs. Providers

should submit their claims directly to the PHC, noting the SAR number on that claim • NICU concurrent review process will cover Inpatient Neonatal Services that begin on or after

January 1, 2019 • Outpatient follow-up visits do not require a TAR

After January 1, 2019, who authorizes CCS hospital services?

TARs for scheduled hospital admissions require a TAR. For unplanned hospital admissions, PHC will perform concurrent review for all hospital services.

How will Partnership work with the Counties’ Medical Therapy Program/Unit (MTP/MTU)?

The MTP/MTU will continue to provide therapy to members and make recommendations for DME needs. PHC will review the TARs received from the DME provider(s).

Will the appeal and fair hearing process be available to CCS children under PHC managed care? Yes. All CCS children will retain their rights to CCS program appeals and fair hearings.

Will WCM members have access to the CCS provider network?

PHC is committed to ensure that our members receive continuity of care whenever possible for a minimum of 12 months. When a CCS-eligible child or youth is already receiving care from a





Page 3 of 5

non-contracted provider, the child or youth may remain with that non-contracted CCS provider for up to 12 months, if the provider: 1. Agrees to continue care for the child 2. Accepts the contract rate 3. Has no outstanding quality of care issues 4. Willing to bill PHC. PHC will work closely with these children and their families to ensure

access to care Will WCM members be linked to a PCP?

Many of our PHC CCS members already have a Medical Home/PCP and this will continue. Transitioning CCS members will be able to choose a Medical Home/PCP and will not be capitated to the provider, but will be paid Fee-for-Service (FFS). We do not expect any disruption for your existing patients

Will WCM members be capitated to a PCP office?

No. The provider will be paid Fee-for-Service (FFS). If providers are currently credentialed with PHC, but not CCS-paneled, do they need to become CCS-paneled by CCS?

If a physician would like to see a CCS member for a CCS condition, then he/she must be paneled for CCS. To access the CCS provider paneling application, please visit: https://cmsprovider.cahwnet.gov/PANEL/index.jsp.

After January 1, 2019, will PHC contract providers that are interested in participating in the CCS program?

Providers wanting to contract with PHC to provide care must be Medi-Cal certified. Providers can contact our Provider Relations (707-863-4100 or [email protected]) for more information on this process.

For physical / occupational therapy offices, how can we find out if the patient is a CCS-eligible member prior to rendering services?


Will the WCM affect my PCP QIP? If yes, how?

The impact will be small for family medicine sites and slightly larger for pediatric sites. The changes to note will be as follows: • Because additional patients may be assigned to you, there will be an increase in member

months, which will affect your total potential payout. More member months = more payout because for any given measure, the formula for payout is (rate x QIP points x MM). Actual total payout will depend on the actual performance of the total population.

• The number of patients in your denominator may go up depending on the measure. This is determined by how many patients have been assigned to you continuously for 9 months during the measurement year, and the specific measure in question. This will primarily impact the pediatric practices and the measures for which you are held accountable.

• The same exclusions for QIP denominators will still apply – meaning no one who is enrolled

https://cmsprovider.cahwnet.gov/PANEL/index.jsp




Page 4 of 5

in another type of insurance (e.g. Medicare, Medi-Medis) will be included in the denominator. For more information regarding the QIP program, please e-mail: [email protected].

Is PHC’s drug criteria different from CCS’ medication criteria?

PHC and CCS may have differences in their formulary and drug criteria, however, PHC will comply with all WCM State requirements.

How can a provider verify if a medication is on the PHC formulary?

The provider can access the formulary on the PHC website www.partnershiphp.org or at https://client.formularynavigator.com/Search.aspx?siteCode=9588242881.

Can providers submit for early authorization(s) to PHC prior to January 1, 2019, to prevent interruption in care for their patients?

Please do not submit any TAR(s) for CCS members residing in current carve-out counties prior to January 1, 2019. These carve-out counties are prepared to continue to process SARs until EOB December 31, 2018. Based on current state instructions, all SARs in pending status with CCS after December 31, 2018, will continue to be the responsibility of the county. You may want to ensure refills are available through this transition to avoid potential issues.

Will providers need to submit SARs to CCS after January 1, 2019?

After January 1, 2019, medications that are non-formulary to PHC will require a TAR submitted to PHC for review and consideration. Though certain PHC drug criteria may be different from CCS. PHC will ensure our pharmacy processes are compliant with all WCM requirements set forth by the State.

If a medication is non-formulary, how does a provider submit a TAR to PHC?

The provider has two options: 1. They can provide the TAR information: diagnosis, medical justification, and any other

relevant information to the patient’s dispensing pharmacy so that they can submit the TAR on their behalf

2. The provider can submit the TAR themselves using our paper TAR form and faxing it to the PHC Pharmacy Department (707-419-7900). The PHC Pharmacy TAR form can be found with this link: http://www.partnershiphp.org/Providers/Pharmacy/Documents/TAR/MCTAR.pdf

Are CCS-paneled clinicians required to go through the specialty pharmacy referenced for specialty or limited distribution drugs (LDDs)?

Yes. • Walgreens is our direct contract specialty pharmacy for limited set of specialty medications • If Walgreens does not carry a certain specialty medication, the CCS-paneled clinician can

have the prescription filled through another specialty pharmacy that have access to the medication

• Walgreens can deliver prescriptions to the member’s home or to a local Walgreens Pharmacy

After January 1, 2019 which CCS services will be paid by PHC?

PHC will receive and process claims for all CCS and non-CCS covered services for PHC Medi-Cal members. Claims can be submitted to PHC electronically using the PHC’s secure EDI site or



https://client.formularynavigator.com/Search.aspx?siteCode=9588242881

http://www.partnershiphp.org/Providers/Pharmacy/Documents/TAR/MCTAR.pdf


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via hard copy claim mailed to the following address: PHC, PO Box 1368, Suisun City, CA 94585-1368. NOTE: for all services authorized on a SAR by the County CCS programs prior to January 1,

2019, the SAR Number will need to be noted on the claim form in order for those services to be paid.

When submitting a claim to PHC do providers need to include “CCS” on the claim?

No. When submitting a CCS claim, providers need to ensure the CCS diagnosis is included on the claim as well as the SAR number if the service was authorized under a SAR prior to January 1, 2019.

Do any of these changes affect patients with PHC as secondary insurance?

Yes. There are some children included in WCM where PHC is the secondary insurance. A provider should ensure benefits are billed to primary insurance before billing PHC.

After January 1, 2019 what will the payment process for neonatology services entail?

PHC will also pay for CCS inpatient neonatology services effective January 1, 2019. Providers should submit their claims directly to PHC. The State originally planned to assume responsibility of payment for these services; however, in early June of 2018, the State decided PHC would assume this responsibility instead. Note: All members that are not assigned to PHC, those services will continue to be processed

by the County CCS offices. There are numerous services and benefits provided to CCS families that are not included in regular Medi-Cal. Will PHC continue to provide those enhanced services to CCS children and their families under WCM?

Yes. Can providers refer members for behavioral health services? If so, are these only for certain CCS diagnoses?

PHC works with a partner, Beacon Health Options (Beacon), to provide these services. Members can be referred by their provider or they can call Beacon directly at 1 (855) 765-9700.

Will PHC provide transportation benefits to CCS children and their families?

Yes. PHC will follow the same transportation benefits that they received from their county programs.

Will a WCM member have a case manager or care coordinator? Yes, PHC has Care Coordination staff dedicated to the WCM program.

2018 Provider Education Calendar

(Southern Region)



PHC Whole Child Model Presentations

November 28 12:00pm-1:00pm Whole Child Model for CCS Members Connection Center, Room 105 3240 Kerner Blvd., Marin CA

November 29 9:30am-10:30am/12:00 – 1:00pm PHC Primary Care Provider (PCP) Webinar – Whole Child Model

PHC Whole Child Model Presentations

December 5 11:30am-1:00pmWhole Child Model for CCS Members Mendocino Coast District Hospital, Redwoods Room 700 River Drive, Fort Bragg CA

December 6 11:30am-1:00pm Whole Child Model for CCS Members Adventist Health Ukiah Valley, Main Conference Room 275 Hospital Drive, Ukiah CA

December 12 12:00pm-1:00pm Whole Child Model for CCS Members PHC Santa Rosa Office – Santa Rosa Conference Room 495 Tesconi Circle, Santa Rosa CA

November 2018

December 2018


https://register.gotowebinar.com/rt/8768768353157829635

2018 Provider Education Calendar

(Southern Region)



December 13 12:00pm-1:00pm Whole Child Model for CCS Members Hansen Family Health Center 215 W Beamer St, Woodland CA

December 14 11:00am-12:00pm Whole Child Model for CCS Members Adventist Health Clearlake 15230 Lakeshore Drive, Clearlake CA

December 14 1:30pm-2:30pm Whole Child Model for CCS Members Sutter Lakeside Hospital 5176 Hill Road East, Lakeport CA

December 18 12:00pm-1:00pm Whole Child Model for CCS Members PHC Fairfield Office – Solano Conference Room 4665 Business Center Drive, Fairfield, CA

December 2018 continued


Use the appropriate modifier:

SK Member of high-risk population

(use only with codes for

immunization)

SL State-supplied vaccine Used for Vaccines For Children (VFC)

program recipients through 18 years of

age.

Make sure to use the age appropriate vaccine. Refer to the Medi-Cal manual immunization code list

(www.medi-cal.ca.gov) or the Partnership website under Providers; Claims; Preventive Services @

www.partnershiphp.org.

Remember to include influenza vaccination as this directly affects your HEDIS and QIP scores.

ICD-10 Coding Tip - Influenza Codes J09.X1 Influenza due to identified novel influenza A virus with pneumonia J09.X2 Influenza due to identified novel influenza A virus with other respiratory manifestations J09.X3 Influenza due to identified novel influenza A virus with gastrointestinal manifestations J09.X9 Influenza due to identified novel influenza A virus with other manifestations J10.08 Influenza due to other identified influenza virus with other specified pneumonia J10.1 Influenza due to other identified influenza virus with other respiratory manifestations Covered by Medi-Cal:

OSELTAMIVIR PHOSPHATE Capsules 30 mg ea 45 mg ea 75 mg ea Oral suspension 6 mg/ml 60 ml ml

On PHC formulary as a Tier 2 (with restrictions):

oseltamivir oral capsule 30 mg Tamiflu 2 Formulary, limited to quantity of #10 per fill, two fills per year.; QL (10

per 1 Fill)

oseltamivir oral capsule 45 mg, 75 mg Tamiflu 2 QL (10 per 1 Fill)

oseltamivir oral suspension for reconstitution Tamiflu 2 QL (180 per 1 Fill); AL (Max 12 Years)

oseltamivir phos 45 mg capsule Tamiflu 2 QL (10 per 1 Fill)

oseltamivir phos 75 mg capsule Tamiflu 2 QL (10 per 1 Fill)



FLU SEASON IS UPON US!!!!

A SUMMARY OF FLU BILLING TIPS
