1. Overview of California Children’s Services (CCS)
FRESNO COUNTY DEPARTMENT OF PUBLIC HEALTH
CHILDREN’S MEDICAL SERVICES
CALIFORNIA CHILDREN’S SERVICES
AGENDA
Welcome
Overview of California Children’s Services (CCS)
The CCS Client
CCS application and provider requirements
Service Authorization Requests (SARs)
Service Code Groupings (SCGs)
SARs that need separate authorizations
Pharmacy
Provider Tips
Break
Getting Paid
The Claim Process
Remittance Advice Detail (RADs)
Common Denials
Medi-Cal Share of Cost
Emergency Medi-Cal
Crossover Claims
Timeliness
Helpful Resources
Questions???
Welcome to the Children’s Medical Services, California Children’s Services provider in-service. (Introductions) I will give you a brief overview of CCS in Fresno County. In the blue folder you will find handouts and examples of the subjects covered today. The CCS Fiscal Unit created the Provider In-Service booklet in your packet. Any web sites, phone numbers or addresses mentioned today will be in your booklet.
We will start with what CCS is and how it works. We will review the CCS application / authorizations and provider requirements, SAR form and eSAR. In Basic Reminders we will discuss the service code grouping web site and SAR’s that need their own authorizations, for example a pharmacy.
The last portion will deal with Getting Paid. Sally will review the process from claim submission to payment. This will cover the Remittance Advice Detail also known as your RAD, common denials and solutions to edits. Share of Cost , Emergency Medi-Cal, Crossover claims and timeliness will be reviewed and additional resources will be discussed, now lets get started.

2. WELCOME TO CCS California Children’s Services
Children’s Medical Services
Fresno County Department of Public Health
1221 Fulton Mall, 2nd Floor
Fresno, CA 93721
(559)
Fax: (559)
California Children's Services provides preauthorized services. Our office hours are 8 to 5. We have voice mail and our fax machines run 24/7.
Request for services provided in an emergency setting or during the weekends or holidays should be submitted the next working day.

3. California Children’s Services (CCS)
Statewide program.
Pays for medical treatment of children with certain physical limitations and chronic health conditions or diseases.
Medi-Cal, Healthy Families carve out.
Payer of last resort.
Funded with state, county, and federal tax monies.
There are CCS Offices in every county. Every client is given one CCS identification number.
When a CCS client requires a treatment or service that is considered medically necessary and it is not a benefit of their insurance or medical plan it can be covered by CCS.
Carve out: How does it work? The CCS eligible medical condition is “Carved Out” of Healthy Families and Medi-Cal managed care plans. The “Carve Out” means that H/F and Medi-Cal managed care plans are not required to provide services for a child’s CCS eligible condition.
“ CCS is the payer of last resort”
All payer sources are primary over CCS. Any benefits allowed by Medi-Care,
SSI, Medi-Cal programs or private insurance must be addressed before CCS funds are used.
The CCS program is responsible for case management and authorization of services only related to the CCS eligible medical condition for H/F subscribers and Medi-Cal managed care beneficiaries.
CCS authorizes services only, Affiliated Computer Systems or ACS processes and pays your claims.

4. CCS Eligibility Criteria
Be under age 21.
Have a CCS medically eligible condition.
Reside in Fresno County.
Family income of $40,000 or less (reported as AGI on the state tax form), OR
Out-of-pocket medical expenses are expected to be more than 20% of family income, OR
Have Full-scope Medi-Cal, no share of cost OR
Have Healthy Families.
CCS Eligibility Criteria:
The client does not need to be a dependent of their parents. They need to be under 21 and meet the other criteria.
The eligible condition is specific to the client. A client may have other conditions related to other CCS conditions but their eligibility will be determined by their specific diagnosis.
The client’s residence address determines which county is responsible for CCS services.
Additional criteria for review:
Family income is under $40,000.
Out of pocket medical expenses are expected to be more than 20% of family income.
Client has full scope Medi-Cal with no share of cost.
Or has Healthy Families.

5. Financial Eligibility is NOT Required for:
Diagnostic services only.
Adopted child with a known CCS eligible medical condition.
Medical Therapy Program (MTP) services only.
Full-scope Medi-Cal, no share of cost, OR
To initiate a Healthy Families Case.
WHEN FINANCIAL ELIGIBILITY IS NOT REQUIRED.
When services are authorized for diagnostic purposes only. After a diagnosis is established, Fresno CCS will determine whether the client is medically eligible for CCS services.
ADOPTED CHILD WITH A KNOWN CCS ELIGIBLE MEDICAL CONDITION.
(MTP) Services are specifically authorized for therapy only. Other services are not authorized.
Client has full scope Medi-Cal with no share of cost.
Initiate Healthy Families.

6. CCS Eligible Conditions
Most problems that are:
Life-threatening
Physically disabling and
Require medical, surgical, or
rehabilitative services
CCS medical eligibility is disease – specific and
covers only what is related to or impacts the CCS
eligible condition.
CCS ELIGIBLE CONDITIONS:
By being disease specific CCS will cover services or carve out services related to the specific CCS condition from the client’s payer source. This is how carve out works.
It does not cover services for any or all CCS conditions. It must be related to the client’s CCS condition. A client can have multiple CCS conditions but it does not mean any or all CCS conditions will apply.
For example: Sandy has a CCS eligible condition of malocclusion. She also has psoriasis. Psoriasis can be a CCS eligible condition. However, she is only authorized for malocclusion and her psoriasis is a type that does not meet the criteria for eligibility. Only her services for malocclusion will be authorized by CCS and payable by ACS. All other services will be denied by CCS.

7. FRESNO CCS’S KIDS
Fresno County currently case manages approximately 7,797 children.
Here is a breakdown of Fresno CCS’s caseload.
Full scope Medi-Cal is 83%, 6,466.
Medi-Cal with SOC is 2%, 167.
Healthy Families is 8%, 672.
Straight CCS is 12%, 492.
Information is based on Business objects report for January 2012.
Most CCS children are Medi-Cal or HF participants so their care is mostly funded with State and Federal dollars. The County pays 17.5% of medical services needed for HF kids whose parents make less than/equal to $40k/yr. The County pays 50% of medical services needed for clients whose family income is less than/equal to $40k who do not have Medi-Cal or HF. The CCS program is the payer of last resort. Therefore, if Medi-Cal or HF or private insurance does not cover services for the CCS-eligible client, then CCS will pay it. Fresno will pay a client’s Medi-Cal Share of Cost under certain circumstances. Paying the SOC reduces the County’s costs toward medical treatment for these clients. An unpaid monthly SOC will default to the County paying 50% of the child’s medical expenses for that month.

8. THE FRESNO CCS TEAM Occupational/Physical Therapists
Office Assistants will help you get forms and direct you to the staff person who can help you.
Admitting Interviewers collect information regarding residence and financial status used to determine eligibility. Residential and financial status are part of what determines eligibility to the CCS program.
CCS Doctors & Nurses review medical records to determine medical eligibility. (the CCS condition)
Physical/Occupational Therapists determine and provide therapy services to CCS clients. They provide these services at Medical Therapy Units located on three elementary school sites, two in Fresno and one in Clovis.
Fiscal Unit assist with paying program expenses and provider billing issues.
Handouts: Inserts
In your Provider Training Booklet we included 2 handouts, the first , Fresno County CA.Childs Serv has a listing of some of the CCS eligible conditions and services. The second“California Children’s Services Program has more information about our staff and maps to our Medical Therapy Units,
Occupational/Physical Therapists
provide therapy services to CCS clients

9. How to Apply for CCS…
How does a client apply for CCS?
You can obtain an application with the complete instructions on the State’s CCS website shown here. If you are having trouble completing these forms, please check the website or contact CCS and ask for assistance.
Providers may assist families in completing a CCS application. After reading the instructions on the back of the application if you have additional questions you can call your local CCS office for assistance.
In your booklet is a copy of a CCS application.
(HANDOUT OF APPLICATIONS, BOOKLET PGS 1-4)

10. How to Become a CCS Provider…
Have an active National Provider Identifier (NPI) #.
Be licensed as a physician by Medical Board of CA.
Be certified in your field of practice.
Remember, just because a provider is Medi-Cal approved, does not mean they are automatically CCS approved.
Once CCS paneled by the state, no recertification is needed.
PROVIDER REQUIREMENTS: TO BECOME A CCS PROVIDER YOU MUST HAVE THE FOLLOWING:
The NPI number is a National Standard Identifier for health care providers. Active NPI numbers are listed on the Provider Master File or PMF. The provider needs to have their NPI# registered with the PMF. If your NPI is not active you will need to reapply.
Be licensed by Medical Board of CA.
Be certified in field of practice:
CCS Paneled: The Health Care Provider Taxonomy Code or (HCPTC) is used in classifying health care providers according to type or specialty. The code set is structured into 3 distinct levels that include provider type, classification and area of expertise. This criteria must be met to be a State approved CCS provider.
Remember, just because a provider is Medi-Cal approved, DOES NOT
mean they are automatically CCS approved.

11. How to Become a CCS Provider…
For questions, call the Provider Services Unit at:
(916)
TO OBTAIN CCS APPROVAL A PROVIDER MUST APPLY.
Applications can be downloaded from this website. I strongly recommend when you review the website you check out the frequently asked questions regarding NPI registration. The FAQ’s cover claim billing and other general provider questions and are very informative.
We have discussed the CCS program, what it is and how it works. We have reviewed client and provider requirements. Now let’s review how to request services from CCS.
(EXAMPLES OF APPLICATIONS, BOOKLET PGS 5-8)

12. How to Request Services from CCS…
Request prior authorization.
Complete the Service Authorization Request (SAR):
* New Referral Client
* Established Client
* Discharge Planning
Please remember that CCS is a pre-authorization program and you must have an authorization prior to services being rendered except in the case of emergency. If you do not have an authorization and you render services you may not get paid. The only time when retroactive authorization is allowed is if the client has full scope Medi-Cal with no SOC.
There are 3 types of Service authorization requests:
NEW: When referring a client for the first time to the CCS program you will need to complete a New Referral Client SAR.
When requesting services for an existing CCS client you will need to complete an ESTABLISHED Client SAR.
When a client is being discharged from an impatient hospital you will need to complete a DISCHARGE Planning SAR.
WHEN DOES SERVICE BEGIN: Tommy broke his leg on Saturday. His payer source is full scope Medi-Cal with no share of cost. The emergency room sends a SAR request by fax on Tuesday. Tommy’s first date of eligibility can begin on Saturday.
Jimmy broke his leg the same day. The emergency room faxes a SAR request on Tuesday. He has Healthy Families. His effective date will be the date the form was received. The request was not sent in the next working day and Healthy Families does not retroactive authorizations.
Here are additional facts about all SAR types…..
(EXAMPLE OF APPLICATIONS, BOOKLET PGS 4-5-6)

13. Facts About the SAR
A SAR is the Request and the SAR number is the Authorization.
Statewide uniformity.
Online access.
Service Code Groupings (SCGs) may be shared.
Linked to claims payments.
SAR is an acronym that stands for Service Authorization Request and you will need to complete one when you are requesting services from CCS.
STATEWIDE UNIFORMITY. Same forms are used Statewide. So no matter what county you’re requesting services from your form is the same.
ONLINE ACCESS: You are able to access these forms online through the CCS website with complete instructions and they can be mailed or faxed to our office.
SCG’s PROACTIVE COORDINATION OF CARE: How does a SAR help with the proactive coordination of care? It gives the physician the ability to share their authorization number with other health care providers working together for the care of the client such as a lab, pharmacy or radiologist without them having to request another SAR. I have more information on this when we get to Service Code Groupings.
REIMBURSEMENT: If you have a valid SAR and your claim is completed correctly you will receive payment faster.

14. SAR Requirements Approved provider name and NPI #.
Contact name and phone number.
Client demographics.
Insurance information, CIN #.
Confirmed or presumed diagnosis.
Requested services.
Documentation, including medical reports.
Additional services requested for other providers.
Sign and date your form.
SAR REQUIREMENTS: WE HAVE A LIST OF ITEMS YOU NEED TO COMPLETE YOUR SAR REQUEST.
Name of approved provider with their provider number.
List your contact and a phone number, if we have a question we would rather call than return your request.
Client information. You can obtain information when doing your client’s eligibility or POE.
Insurance information, CIN# = Client Identification number.
Confirmed or presumed dx, your findings.
Requested services, no SAR is needed if you have no services to request.
Documentation, including medical reports. Helpful to include the client’s CCS number on your report to make sure it gets to the right person or chart, we have many duplicate names.
Services for other health care providers, will these services require a separate authorization?
PLEASE, sign and date your form. No signature will delay your request for authorization.
ALL SAR REQUEST TYPES WILL NEED THIS INFORMATION.

15. Established SAR ESTABLISHED SAR: lets review…
Box# 3 Provider number, your NPI#
Box#5 Contact person, contact phone number: If we have a question and can’t reach you, we may have to return your request.
Box#8 Client information: Provide as much information as you can. If you have the CCS number please list it. I had mentioned earlier a CCS client is issued one identification number only. If their case was transferred from another county or closed, the case will be reopened with their original CCS number.
Box#16 Requested services : If the services requested are other than ongoing physician authorizations or SCG centers you need a new SAR. The instructions on the back of the form lists instructions regarding frequency, units and quantity. Check the Medi-Cal website for updates regarding units/quantity.
Handout: Established SAR Request (15)
(EXAMPLE ESTABLISHED SAR REQUEST, BOOKLET PGS 17-18)

16. Established SAR Continued
ADDITIONAL SERVICES REQUESTED FROM HEALTH CARE PROVIDERS. *Boxes# 24-29: Include discharge date even if not payable.
Boxes# 30-31: are for information on the providers you are referring to.
Boxes# 32-33, Please be sure to sign and date your request.
Please take the time to read the instructions on the back of the SAR form. Some fields may require you list units or quantity. Before you call ACS or CCS see if your questions are addressed in the instructions.

17. Fresno’s Electronic SAR (eSAR)
Need Adobe Reader to use.
Can be completed online or saved for later use.
All SAR forms submitted via will receive a notification receipt from CCS.
FRESNO’S ELECTRONIC SAR, (eSAR) !!!!!!!!
This a relatively new service, as you see the requirements are
You will Need Adobe Reader to use.
This form Can be completed online or saved for later use.
All SAR forms submitted via will receive a notification receipt from CCS. When you send your eSAR request by you will receive a notification from CCS. Now you know your request has been received and when. The notification of SAR receipt and the ability to save your SAR online are excellent reasons to try the eSAR.

18.
Here is what the eSAR looks like. It has fields like the SAR form found on the Children’s Medical Services/California Children’s Services website. The format looks a little different. The fields in RED must be filled out in order to the form to the Fresno CCS office.
Remember with eSAR you will receive a notification of receipt.
You can fax your eSAR and any SAR form to CCS.
Handout: Online SAR request showing Red fields (18)
Booklet page 23

19. Requests for Admission to a Hospital
Both a Hospital SAR # and a Dr’s SAR # are required. (Both the facility & the doctor must be CCS approved.)
No Dr’s SAR # = No payment for the doctor and most of the indirect providers that bill under a Dr’s Authorization.
Inpatient Request/Facility and Professional Services
The SAR authorization is not interchangeable. Both the facility and professional services must be CCS approved. There must be a hospital/facility SAR# and a Doctor's SAR#. You cannot use one for the other.
Because a SAR is shared with indirect providers such as labs, radiology, pharmacy and any referred doctors without SAR authorization will not get paid. If you are an indirect provider and the doctor has not or will not request a SAR, I suggest you as an indirect provider, apply, after all you want to get paid for your services.

20. If Medi-Cal Managed Care has denied your claim(s), please attach a
copy of the denial and resubmit your request to our office.
(Before we begin our portion on SCG) we need to discuss Inappropriate CCS Referrals and Incomplete CCS Referrals.
Inappropriate CCS Referrals: Fresno CCS will return your claims and SAR requests when the requests are for services unrelated or not primarily for the CCS condition. You can review a list of eligible conditions by going to the CCS website. The web address is in the Resources part of your booklet. Submitting a bill or statement for payment is not a request. One example of an inappropriate referral is for routine care. Another example is for a SAR when a primary provider has been given a SAR and your office wants a SAR with your doctor’s name on it.
Incomplete CCS Referrals: Fresno CCS returns your request for services for a new client. The information received does not document the suspicion or confirmation of a CCS eligible medical condition. Eligibility determination requires appropriate medical records. If you are radiology, pharmacy or lab before you provide service, obtain the SAR or SAR number from the requesting doctor’s office. The SAR can be used only for services related to the CCS eligible condition.
Example Booklet pages 25-26

21. Service Code Groupings (SCG)
A group of reimbursable codes authorized to CCS-approved providers that allow the provider flexibility in providing medically necessary services to CCS clients.
Enables the provider to render care to a CCS client without the need for requesting additional procedure-specific SARs.
SERVICE CODE GROUPINGS (SCG)
WHAT ARE THEY? They are bundles of codes that allow the provider flexibility in providing medically necessary services to CCS clients, thereby eliminating the need to request separate authorizations from CCS.
It allows the provider the ability to provide services covered under their SCG without obtaining additional authorizations. If you receive a SCG 01, all the codes listed under this Services Code Grouping are authorized for that provider.
WHO GETS THEM? SCG’s are authorized to Special Care Centers and physicians who are treating the CCS eligible condition. Please share SAR numbers with other providers, everyone providing services wants to get paid.

22. How Are SCGs Used?
An approved provider with a SCG can refer their client for listed services and the services would be authorized when the approved provider name and NPI number are listed as the referring provider on the claim.
Secondary providers such as pharmacies and labs may provide listed services previously authorized with a SCG without obtaining another SAR for these services.
HOW ARE SCG’S USED? : Your client is referred for lab work, the codes used by the lab are listed under the provider’s Service Code Grouping. As the referring physician, the lab and physicians would bill using the same SAR number.
It is important when sharing a SAR you enter information in the correct area on your claim. Your claim can be delayed or denied if this information is not listed correctly.
You may request a SAR for your provider and receive a SAR with a different doctor’s name listed. As long as the claim lists the primary provider on the SAR as the referring provider with their NPI number listed in the correct area the SAR will the accepted. This will be discussed in more detail during the 2nd half of our presentation.

23. Service Code Groupings (SCGs)
SCG 01 – Physician Service (Medications, Labs, Office Visits)*
SCG 02 – Special Care Centers (includes all codes of SCG 01) (Specialized groups of doctors, center service codes)*
SCG 03 - Transplant Centers (includes all codes of SCG 01 & 02) (Medical services related to transplants)*
SCG 04 – Communication Disorder Centers (Hearing tests, speech therapy, audio rehabilitation)
SCG 05 – Cochlear Implant (Hearing screening, cochlear implants, comprehensive or diagnostic evaluations)*
SCG 06 – High Risk Infant Follow-Up (HRIF) (Pediatric evaluation, development testing, office consultations)*
SCG 07 – Orthopedic Surgeon (includes SCG 01)
SCG 08 – Rural Health Clinic (RHC) & Federally Qualified Health Center (FQHC) (Provider at one of these clinics is serving in conjunction with a CCS-authorized Special Care Center or authorized specialist/sub-specialist)
SCG 09 – Chronic Dialysis Clinic (Home Dialysis, IV infusion therapy, dialysis training)*
SCG 10 – Ophthalmology (Strabismus, cataracts, glaucoma)*
SCG 11 – Medical Therapy (All physical & occupational therapies, evaluations & testing)*
SCG 12 – Podiatry (Severe foot deformities)*
*Included, but not limited to these examples.
Check website for the most current information:
There are 12 service code groupings. We will briefly discuss SCG 01 and 02. .
01-Physician Service: Diagnosis and treatment of the CCS client which included medicines,labs, and office visit.
02-Special Care Centers: Diagnosis and treatment related to the Special Care Center. All the codes in SCG 01 are included in 02. Cardiology, Orthopedic or Hematology Centers to name a few of the centers which include SCG 01.
03-Diagnosis and treatment related to the Transplant Center such has kidney, liver and heart transplants to name a few and all the SCG 01 and 02 are included in this SCG.
04-Diagnosis and treatment are related to the Communications Disorder Center. Some of the services covered under this SCG are hearing testing, speech therapy and Audio Rehabilitation.
05-Cochlear implants, 06-HRIF=High Risk Infant Follow up, 07-Orthopedic Surgeon (Includes 01), 08-Rural Health , FQHC, 09-Chronic Dialysis, 10-Ophthalmology, 11-Medical Therapy, 12-Podiatry.
We have included the web address and encourage you to see what is covered under the service code groupings.
In your provider in-service booklet we included N.L regarding implementation of SCG 51, surgery . This SCG excludes specific codes that are not payable under this SCG. Most SCG’s include the codes they will pay for. It’s worth looking into.
(Booklet: SCG 51, Pages 29-34: N.L )

24. You will then be taken to this portion of the page.
Click Here
You will then be taken to this portion of the page.
This a view of the actual website. From this site you can look up the codes related to each Service Code Grouping.
Example: SCG website, address, Booklet pages 27-28

25. Service Code Groupings (SCG)
A list of the Current SCGs and their codes are online on the State CCS website. The most recent codes added are in bold, underlined, & given a symbol to indicate the effective-date in the SCG. Codes that are end-dated are bold, with a strike-through and a symbol indicating the end-date from the SCG.
Examples
Q0111-Q0113 a X7588 a
Service code groupings, codes changes. New codes are added, some codes are removed.
When reviewing your codes, Please read the information at the top of your screen. It will contain information on when your code is effective or when your code is no longer valid.
The most recent codes added are in bold, underlined and given a symbol to indicate the effective date.
See the strike through code. It is important to check the dates the code is in effect and when it is no longer used.

26. Service Code Groupings (SCG)
After one year from an effective-date, the symbol is removed, and after one year from an end-date, the code with the strike-through and symbol is removed completely from the manual page.
You, as providers, will be requesting services, we may tell you a code is invalid but it is your responsibility to verify and update your information.
BOTTOM LINE, IT’S YOUR MONEY. $$$
X7588 a

27. Pharmacy Authorizations
If a physician’s SCG includes the appropriate drugs to treat the CCS condition, the pharmacy is not required to submit a separate SAR.
List of drugs that require separate authorizations is found on the SCG website.
Medical supplies not included in the SCG will require a separate SAR.
Prescribing physicians must include SAR number on the prescription.
The rendering pharmacy must bill using the physician’s SAR number.
Pharmacy must wait 24 hours from authorization of SAR to process claim.
Online billing questions and concerns should be addressed to ACS.
We listed important information regarding pharmacy authorizations. As we earlier mentioned
the SCG includes drugs to treat the CCS condition, drugs that do not require a separate SAR.
Drugs that require separate authorization. The list can change at any time.
Medical Supplies guidelines have changed. I strongly encourage you to check the websites
mentioned. Here you will find the most current information available, checking once a week is
good practice.
Prescribing Physician If SAR number is not listed call the prescribing doctor.
Rendering pharmacy must bill using the physician’s SAR number. It is good practice to keep a
copy of the SAR.
Pharmacy must wait 24 hours: From date SAR was issued, providers must wait 24 hours before
billing for services, this applies to all types of service.
Online billing questions and concerns should be addressed to ACS.
We do not have online claims training or access at this time. The CCS online operators can
assist you as you are entering your claim.

28. Fresno County’s Tips for CCS Providers
Prior authorization is needed on all requests.
CCS will process inpatient and urgent requests within 2 business days.
Non-urgent requests will be processed within business days.
Use the eSAR. You will know we received your request.
Providers should share their authorized SAR # with other providers, when appropriate.
Inform your clients to keep a copy of the CCS-authorized SAR until it expires.
These are important tips for CCS providers.
CCS requires prior authorization for all requests.
Inpatient and urgent requests, within 2 business days. Some examples include;
day surgery, hospital admissions, diabetic supplies, hearing aides or repairs, first
time requests for DME ,ventilators or oxygen, first time request for insulin
pumps, cochlear implants, transplant or transplant evaluations.
Non urgent requests, within 30 business days. Requests are generally for
services and supplies which have already been provided to a CCS client and
without an authorized SAR.
eSAR: Use eSAR and receive a confirmation receipt notice.
Providers sharing their SAR authorization.
Providers and clients should keep a copy of their SAR. All clients receive a
copy of their authorization. The authorization contains information as stated for
the CCS eligible condition.
Remember the effective date for some payer sources is the date the request
is received by CCS so get your requests in ASAP!

29. 10 Minute Break
THIS CONCLUDES MY PORTION OF TODAY'S PRESENTATION. OUR NEXT SPEAKER WILL BE DISCUSSING OUR NEXT SECTION WHICH WILL BE CLOSE TO OUR HEARTS.
10 MINUTE BREAK (MENTION BREAK ROOM AND BATHROOMS)