1. Welcome to California Children’s Services (CCS) Authorization and Claims Enhancement

2. What is CCS
California Children’s Services (CCS) is a statewide program that treats children with certain physical limitations and chronic health conditions or diseases.
The California Department of Health Care Services manages the CCS program.

3. Program Overview and Administrative Items (Module A)

4. Program Overview What type of services does the CCS program offer?
diagnostic and treatment
dental care
medical case management, and
physical and occupational therapy

5. Program Overview, cont. What are some CCS-eligible medical conditions:
Cystic Fibrosis
Sickle Cell Disease
Heart Disease
Cancer
Traumatic Injuries

6. Program Overview, cont. What are CCS eligibility requirements?
California resident
Under 21 years of age
Have a CCS-eligible medical condition
Family adjusted gross income of $40,000 or less in the most recent tax year.
(Exception: Family’s out of pocket expenses for CCS-eligible condition exceeds 20% of family’s adjusted gross income.)

7. Program Overview, cont.
CCS provides services to approximately _______ children statewide. These services are provided through a network of:
CCS paneled specialty providers
CCS paneled subspecialty providers
CCS approved hospitals
Special Care Centers
175,000

8. California Healthy Families Program & Medi-Cal Managed Care

9. Program Overview, cont.
The CCS program is responsible for case management and authorization of services only related to the CCS-eligible medical condition for:
Healthy Families Subscribers
Medi-Cal Managed care beneficiaries

10. Program Overview, cont.
The CCS-eligible medical condition is “carved out” of Healthy Families and Medi-Cal Managed Care plans responsibility.
The “carve out” means that Healthy Families and Medi-Cal Managed Care plans are not capitated to provide services for a child’s CCS eligible condition.

11. Program Overview, cont.
The CCS-eligible medical condition is “carved” into five counties Medi-Cal Managed Care plans:
Santa Barbara
San Mateo
Solano
Napa
Yolo

12. Program Overview, cont.
Requests for authorization of CCS services are submitted
No prior billing to Healthy Families/Medi-Cal Managed Care is necessary.
to the appropriate CCS county office.

13. Program Overview, cont.
The Healthy Families/Medi-Cal Managed Care plans are responsible for providing:
primary care and
prevention services not related to the CCS-eligible medical condition

14. Program Overview, cont.
Approximately of the CCS program’s caseload are clients who have Medi-Cal eligibility.
80%

15. Program Overview, cont.
The remaining 20% of the CCS program’s caseload includes:
CCS clients with no other program eligibility and referred to as CCS-only clients, or
CCS clients enrolled in the Healthy Families (HF) program and referred to as CCS/HF clients.

16. Administrative Items
Telephone listings for State CMS Branch, CCS county offices, Medi-Cal, and EDS are located in your workbook on pages A8-A18.

17. Administrative Items, cont.
Important Websites
Paneled Providers and Approved Hospitals
Overview of CCS “Medical Eligibility”
This Computes!
Forms and Publications

18. Administrative Items, cont.
Important websites
Medi-cal rates
Claim Completion instructions
Provider bulletins
Provider manuals

19. Referral Process (Module B)

20. CCS Referral Process What is a CCS referral?
A request directed to the CCS program to authorize medical services for a potential CCS client who meets the following criteria:
Is from birth up to 21 years of age
Has or is suspected of having a CCS eligible medical condition
Is a California Resident

21. CCS Referral Process, cont.
Who can make a referral to the CCS Program?
Family
School
Public Health Nurse
Family Doctor
Physician Specialist
Anyone can make a referral to the CCS program

22. CCS Referral Process, cont.
CCS referrals should be made to the CCS program as early as possible because CCS does not pay for services provided before the date of referral, unless the applicant is full-scope Medi-Cal, no share of cost.

23. CCS Referral Process, cont.
How are referrals made to the CCS Program?
New Referral Service Authorization Request (SAR) Form.
Medical report or letter with a specific request for services from CCS.
Written request by a parent/legal guardian.
By Telephone.

24. CCS Referral Process, cont.
It is important that providers send medical reports documenting the suspicion or confirmation of a CCS eligible medical condition to the appropriate CCS county or State Regional Office.

25. CCS Referral Process, cont.
A case may be opened for diagnostic services to confirm the presence or absence of the suspected CCS-eligible medical condition.
A case may be opened for treatment when a CCS-eligible medical condition is confirmed and all other program eligibility requirements have been met.
The CCS program encourages all families to apply and sign the CCS Program Services Agreement.

26. Provider Paneling & Hospital Approval (Module C)

27. Provider Paneling What is Paneling?
The process of the CCS program to review and approve providers by ensuring they meet specific criteria and are qualified to provide services for CCS clients with special health care needs.
The CMS Branch requires that all physicians be CCS paneled in order to be issued an authorization to provide services to CCS clients.

28. Provider Paneling, cont.
In addition, CCS paneling is required for the following allied health care providers:
Audiologists
Dietitians
Occupational Therapists
Orthotists
Pediatric Nurse Practitioners
Physical Therapist

29. Provider Paneling, cont.
In addition, CCS paneling is required for the following allied health care providers:
Prosthetists
Psychologists
Registered Nurses
Respiratory Care Practitioners
Social Workers
Speech-Language Pathologists

30. Provider Paneling, cont.
It is important to note that all providers applying for CCS paneling must have the following:
A National Provider Identifier (NPI)
NPI registered with the DHCS

31. Provider Paneling, cont.
Exception:
The following are exempt from the provider number requirements since the facility bills for services rendered via the facility’s provider number:
Allied Health providers, who are employees of a hospital or facility.
Physicians who are employees of a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC).

32. Provider Paneling, cont,
The CMS Branch no longer panel dental providers. Dental providers includes:
Dentists
Orthodontists
Maxillofacial Surgeons

33. Provider Paneling, cont,
Dental providers requesting to participate in the CCS program must have an active Denti-Cal provider number and or NPI provider number.
Provider requirements for paneling are listed by provider type on pages C 4 – C 9.

34. Provider Paneling, cont,
Paneling Categories for Physicians:
Full Approval Status
Provisional Status
Temporary Status
Exceptional Status

35. Provider Paneling, cont,
A CCS panel application can be obtained by:
Accessing the CCS website and clicking on the “Forms and Publications” link.
Calling the Provider Services Unit at (916) and request an application.

36. Hospital Approval

37. CCS Hospital Approval
The CCS program approves and assigns various types of approval levels to inpatient hospitals, based on CCS standards and requirements.

38. CCS Hospital Approval, cont.
A hospital may receive one of the following approval levels:
Tertiary Hospital
Pediatric Community Hospital
General Community Hospital
Special Approval
Limited Approval

39. CCS Hospital Approval, cont.
Hospital approval levels and CCS standards and requirements can be found on the CCS website.
Under the “Forms and Publications” Manual of Procedures link.

40. Service Code Groupings (SCG) and Service Authorization Request (SAR) Forms (Module D)

41. Prior Authorization
The CCS program requires prior authorization for health care services related to a CCS client’s CCS-eligible medical condition.

42. Service Code Groupings (SCG)
What are service code groupings?
Groups of codes that are authorized to CCS-paneled or approved providers for the care of a CCS client’s CCS eligible medical condition.
The SCG contains a listing of codes that allow the provider to care for the CCS client’s CCS eligible medical condition without needing to obtain repeated single prior authorizations.

43. Service Code Groupings (SCG), cont.
01-Physician
02- Special Care Center
03-Transplant
04-Communiation Disorder Center
05-Cochlear Implant Centers
06-High Risk Infant

44. Service Code Groupings (SCG)
07-Orthopedic
08-FQHC/RHC
09-Chronic Dialysis Clinics
10-Opthamology
11-Medical Therapy
12-Podiatry

45. Service Code Groupings (SCG), cont.
Physician Authorizations
The physician’s authorization number may by shared with other health care providers that the physician has requested services, such as:
Laboratory
Pharmacy
Radiology
Physician Specialists

46. Service Code Groupings (SCG), cont.
Physician Authorizations
The physician’s authorization number should be used only for those services related to the CCS-eligible medical condition.

47. Service Code Groupings (SCG), cont.
Pharmacy
Drugs prescribed by the authorized physician are covered in the Physician’s SCG and do not require a separate authorization. However, drugs listed on page D 6 does require prior authorization.
Medical supplies always require prior authorization.

48. Service Code Groupings (SCG), cont.
Pharmacy
The prescribing physician must provide the pharmacy with the CCS authorization number.

49. Service Code Groupings (SCG), cont.
Diagnostic Laboratory/Radiology
Laboratory and Radiology tests related to the client’s CCS-eligible medical condition and requested by the authorized physician are covered if they are listed in the Physician’s SCG.
Laboratory and Radiology tests not covered in the Physician’s SCG require a separate authorization.

50. Service Code Groupings (SCG), cont.
The physician must provide the laboratory with the CCS authorization number.

51. Service Code Groupings (SCG), cont.
Providers authorized to use the physicians authorization number must be indicated on the claim as the billing or rendering provider.
The authorized physicians provider number must be indicated on the claim as the referring physician.

52. Service Code Groupings (SCG), cont.
Emergency Room Authorizations
Physicians rendering emergency services in a hospital, clinic or outpatient facility and the facility is issued a CCS authorization for a Service Code Grouping (SCG) 01, the physician may utilize the facility’s authorization to bill for services rendered.

53. Service Code Groupings (SCG), cont.
The physician must indicate the facility’s provider number as the referring provider.
This excludes surgeries and applies to outpatient services only.

54. Inpatient Hospital Authorizations

55. Inpatient Hospital Authorizations
There are two components to authorizations for an inpatient hospital stay:
Physician Authorization
Hospital Authorization

56. Inpatient Hospital Authorizations, cont.
Physician Authorization
The paneled physician with primary responsibility for the care of the CCS client while hospitalized requires an authorization from the CCS program.

57. Inpatient Hospital Authorizations, cont.
Physician Authorization, cont.
If the physician already has an existing Service Code Grouping SAR for this client, a separate SAR is not required.

58. Inpatient Hospital Authorizations, cont.
Physician Authorization, cont.
The physician’s authorization may be shared with other physicians as requested by the authorized physician.

59. Inpatient Hospital Authorizations, cont.
The hospital must also receive an authorization from the CCS program for the anticipated length of stay.
The hospital cannot share the physician’s authorization and the physician cannot share the hospital’s authorization.

60. Inpatient Surgery Authorizations

61. Inpatient Surgery Authorizations
There are two components for inpatient surgery authorizations:
Physician Authorization
Facility Authorization

62. Inpatient Surgery Authorizations, cont.
Physician Authorization
Physicians must receive prior authorization from the CCS program for all surgical procedures. The SAR must include all specific procedures anticipated for the surgery.
Please note: Most surgical procedure codes are not included in Service Code Groupings.

63. Inpatient Surgery Authorizations, cont.
Facility Authorization
The CCS-approved hospital must receive an authorization for the number of inpatient day required for the surgical procedure and post operative care.
If the CCS client requires additional days in the hospital, the hospital must request a modification to the authorization to include the additional days.

64. Outpatient Surgery Authorizations

65. Outpatient Surgery Authorizations, cont.
Physician Authorization
Physicians must receive prior authorization for all surgical procedures.
The SAR must include all specific anticipated surgical procedure codes as well as Service Code Grouping 01.

66. Outpatient Surgery Authorizations, cont.
Physician Authorization, cont.
The physician’s authorization must be shared with the outpatient facility.
Surgery authorizations for elective surgery may be requested for a specified time period during which the surgery can take place.

67. Outpatient Surgery Authorizations, cont.
Facility Authorization
The outpatient surgery facility must bill utilizing the physician’s authorization/SAR number.
Remember, you must indicate the authorized physician’s provider number as the referring provider.

68. Pharmacy Authorizations

69. Pharmacy Authorizations, cont.
Drugs for treatment of CCS-eligible medical conditions, other that those requiring prior authorization, do not require a separate authorization.
The pharmacy should use the authorization/SAR number of the prescribing physician.

70. Pharmacy Authorizations, cont.
Compound drugs require prior authorization only if one or more of the components is a drug requiring prior authorization.
If a specific non-generic brand name drug is medically necessary for a CCS client, the specific NDC must be authorized.

71. Durable Medical Equipment (DME)

72. Durable Medical Equipment (DME), cont.
DME services related to the client’s CCS-eligible medical condition must be requested by the CCS-paneled physician.
DME services must be prior authorized.

73. Durable Medical Equipment (DME), cont.
The CCS program requires that the appropriate modifier be included on the request for DME:
NU- New equipment, purchase
RR- Rental
RP- Repair and replacement

74. Physical, Occupational & Speech Therapy

75. Physical, Occupational & Speech Therapy, cont.
Requests for therapy services must be submitted to the CCS program for review.
Requested therapy must be from a CCS-paneled therapist.
The request must be for the CCS-eligible medical condition.

76. Physical, Occupational & Speech Therapy, cont.
Requests for therapy must include:
Specific procedure codes
Number of therapy visits requested
Time period of requested services

77. Physical, Occupational & Speech Therapy, cont.
Requests for therapy must include:
Copy of the physician’s prescription
Documentation from the physician demonstrating medical necessity
Current therapy report, if applicable

78. Home Health Agency Services

79. Home Health Agency, cont.
Home health agency (HHA) services must be related to the CCS-eligible medical condition.
Home health agency services must be requested by the authorized physician.
The request must be submitted to the CCS program.

80. Home Health Agency, cont.
The physician may request home health services using the CCS/GHPP Discharge Planning SAR.
The CCS program may authorize the initial home assessment and up to three additional visits if requested by the discharging physician.
For additional HHA visits, a request and the unsigned plan of treatment must be submitted for prior authorization.

81. Home Health Agency, cont.
Home health services not requested on the Discharge Planning SAR or requested prior to hospitalization must be submitted within three days of the date the services started.
Services provided during this three day grace period must be included in the request.

82. Medical Supplies

83. Medical Supplies, cont.
Medical supplies related to the client’s CCS-eligible medical condition require prior authorization.
Medical supplies may be requested and authorized with or without the two digit manufacturer code.

84. Medical Supplies, cont.
If the five-digit medical supply code and a specific two-digit manufacturer code is requested on the SAR and authorized, the provider must enter the entire seven-digit code on the claim.
The provider must not substitute another manufacturer code when billing.

85. Medical Supplies, cont.
The following medical supply groupings may now be requested on the SAR and authorized if appropriate:
Tracheostomey Care Supplies
Respiratory Suction Supplies
Oxygen Delivery Supplies, Accessories and Refills
Enteral Feeding Supplies – Bolus/Gravity
Enteral Feeding Supplies – Pump

86. Service Authorization Request (SAR) Forms

87. SAR Forms, cont.
SAR forms are used by providers to request authorization of services from the CCS program.
Requested services must be procedure code specific or by Service Code Grouping, if applicable.
Inpatient admissions must be requested by days.

88. SAR Forms, cont. There are three different types of SAR forms:
CCS/GHPP New Referral SAR
CCS/GHPP Established Client SAR
CCS/GHPP Discharge Planning SAR

89. SAR Forms, cont. The referral SAR is used to:
Refer a potential CCS client to the CCS program
Request authorization of an initial service
Request must be procedure code specific

90. SAR Forms, cont. The established client SAR is used to:
Request authorization of services related to the CCS-eligible medical condition for an established CCS client.
The request must be procedure code specific or by Service Code Grouping, if applicable.

91. SAR Forms, cont. The discharge planning SAR is used to:
Request authorization of services related to the CCS-eligible medical condition for a CCS client being discharged from an inpatient hospital stay.
The request must be procedure code specific or by Service Code Grouping, if applicable.

92. SAR Forms, cont.
The requested services may include, but are not limited to:
Medical Supplies
Community Services
Other medically necessary services related to the CCS-eligible medical condition

93. Submission of SAR Forms
SAR Forms, cont.
Submission of SAR Forms
Providers are to submit SARs to the appropriate CCS county or State CCS regional office based on the client’s county of residence.

94. Online access to SAR Forms
SAR Forms, cont.
Online access to SAR Forms
SAR forms are available on the CMS Website:
Providers can complete them on line and print out the form and either mail or fax them to the appropriate CCS county or State CCS regional office based on the client’s county of residence.

95. SAR Forms, cont. Completions of SAR forms
SAR form completion instructions are located on pages D 14 – D 25 of your workbook.

96. SAR Forms, cont. SAR Status
Once a SAR has been received and processed by the CCS program, the provider will receive written notification from the CCS program regarding the status of the submitted SAR.

97. SAR Forms, cont.
There are three types of SAR status a provider may receive:
Approved
Cancelled
Modified
If a SAR is denied, the provider will receive a denial letter from the CCS program. This denial may be used as documentation for follow up.