1. 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)
Introduction…
Welcome everyone….
Introduce self and CCS team…then begin slide presentation.
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.

2. California Children’s Services (CCS)
What is CCS?
Statewide program
Pays for medical treatment of children with certain physical limitations and chronic health conditions or diseases. Serves approximately 183,000 clients.
Provides direct medical therapy services through Medical Therapy Units (MTU) located in public schools
Funded with state, county, and federal tax monies
Payer of last resort
What is CCS?
There are CCS Offices in every county. Every client is given one CCS identification number.
Currently Fresno CCS provide services to approximately 8600 clients
When a CCS client requires a treatment or service that is considered medically eligible and it is not a benefit of their insurance plan, it “may be” covered by CCS.
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.
CCS authorizes services only, Xerox processes and pays your claims.

3. CCS Eligibility Criteria
Be under the age 21
Have a CCS medically eligible condition
Reside in Fresno County
Have full Scope Medi-Cal, OR
Have a family income of $40,000 or less (reported as AGI on the state tax form), OR
Have out-of-pocket medical expenses exceeding 20% of family’s Adjusted Gross Income (AGI)
CCS Eligibility Criteria:
They need to be under 21 and meet the other criteria.
A client must have a CCS medically eligible condition in order to qualify for CCS.
The CCS program is responsible for case management and authorization of services only related to the CCS eligible medical condition.
These conditions are determined by CCS medical professionals.
The client’s physical residence determines which county is responsible for CCS services.
CCS requires clients to apply for Medi-Cal.
The CCS eligible medical condition is “Carved Out” of Medi-Cal managed care plans. How does the “Carve Out” work? The “Carve Out” means that Medi-Cal managed care plans are not required to provide services for a child’s CCS eligible condition.
Have a family income of $40,000 or less based on current state tax return.
Have out-of-pocket medical expenses exceeding 20% of the family’s Adjusted Gross Income.
Example: Family AGI of $61,000; medical expenses must exceed 20% of their AGI, which in this case would be $12,200. These medical expense must also be related to the CCS medical condition.
The client does not need to be a dependent of their parents if they are over 18 or an emancipated minor.

4. Financial Eligibility is NOT Required for:
An adopted child with an existing CCS eligible medical condition.
Medical Therapy Program (MTP) only services.
Clients with full-scope Medi-Cal with no share of cost.
FINANCIAL ELIGIBILITY IS NOT REQUIRED:
When services are authorized for diagnostic purposes only. Meaning a CCS eligible condition has yet to be established.
After a CCS eligible diagnosis is established, we will then determine whether the client is financially eligible for CCS services.
A CCS eligible medical condition must be identified prior to adoption, otherwise the family will be subjected to Financial and Residential (F/R) requirements.
When a case is open as MTP only, physical therapy and occupational therapy are the only approved services. If durable medical equipment (DME) or treatment services are prescribed, the family will be subjected to financial and residential requirements.

5. CCS Eligible Conditions
CCS medical eligibility is disease–specific and
covers only what is related to the CCS
eligible condition.
Life-threatening
Physically disabling and
Require medical, surgical, or
rehabilitative services
An overview of medical eligible conditions can be found at:
CCS ELIGIBLE CONDITIONS:
CCS medical eligibility is disease–specific and covers only what is related to the CCS eligible condition.
-Life-threatening
-Physically disabling and
-Require medical, surgical, or rehabilitative services
For example: Sandy has a CCS eligible condition of diabetes. She also has psoriasis. Psoriasis can be a CCS eligible condition. However, she is only authorized for diabetes and her psoriasis is a type that does not meet the criteria for eligibility. Only her services for diabetic care will be authorized by CCS and payable by Xerox. All other services will be denied by CCS.

6. CCS Caseload Distribution
Fresno County currently case manages approximately 8,579 children.
Here is a breakdown of Fresno CCS’s caseload as of June 2014.
Full scope Medi-Cal is 83.8%, 7,138
TLICP is 8.6%, 734
Straight CCS is 7.6%, 652.
Most CCS children are Medi-Cal or TLICP (Targeted Low Income Children Program) participants so their care is mostly funded with State and Federal dollars. The County pays 17.5% of medical services needed for 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. The CCS program is the payer of last resort. Therefore, if Medi-Cal or private insurance does not cover services for the CCS-eligible client, then CCS will pay it. Fresno may pay a client’s Medi-Cal Share of Cost under certain specific circumstances.

7. Fiscal Unit & Office Assistants Admitting Interviewers
CCS Doctors & Nurses
Review for medical eligibility; provide case management
Fiscal Unit & Office Assistants
Assist staff with correspondence, provider billing issues
Admitting Interviewers
Review for residential & financial eligibility
Occupational/
Physical Therapist
Provide therapy services to CCS clients
FRESNO COUNTY CCS TEAM
THE FRESNO CCS TEAM:
CCS Doctors & Nurses review medical records to determine medical eligibility. (the CCS condition)
Admitting Interviewers collect information regarding residence and financial status and determines eligibility to the CCS program.
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.
Office Assistants will help you get forms and direct you to the staff person who can help you.

8. How to Become a CCS Provider…
Eligibility Requirements:
Have an active National Provider Identifier # (NPI)
Be licensed as a physician by the Medical Board of CA
Be certified in your field of practice
Must be an active Medi-Cal provider to be a CCS paneled provider
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. The provider needs to have their NPI# and be registered in the Department of Health Care Services. 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.
Example: A client recently received a transplant, CCS will authorize the specialist including the primary care physician (PCP), however, the specialist must be an approved paneled provider. If the PCP wants to be included in the continuity of the care of the client, they must be a CCS approved provider as well.
Different level of medical professions requires different certifications.
Remember, just because a provider is Medi-Cal approved, DOES NOT
mean they are automatically CCS approved.

9. How to Become a CCS Provider
For questions, call the Provider Services Unit at: (916)

10. How does a client apply for CCS?
Obtain an application with complete instructions on the State’s CCS Website
Providers may assist families in completing the CCS application
If you have additional questions about or regarding the application, call your local CCS office for assistance.
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 packet is a copy of a CCS application.
(HANDOUT OF APPLICATIONS, BOOKLET PGS 1-5)

11. Facts About the Service Authorization Request (SAR)
A Service Authorization Request (SAR) is the Request and the SAR number is the Authorization.
Statewide uniformity.
SAR is linked to claims payments.
SAR numbers may be shared.
SAR can be viewed on-line at:
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.
REIMBURSEMENT: If you have a valid SAR and your claim is completed correctly you will receive payment faster.
SAR NUMBERS MAY BE SHARED-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.
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.

12. How to obtain a Service Authorization Request (SAR) from CCS…
Complete the Service Authorization Request (SAR):
* New Referral Client
* Established Client
The SAR form is available online at:
There are 2 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 DOES SERVICE BEGIN: Tommy broke his leg on August 5, His payer source is full scope Medi-Cal with no share of cost. The emergency room sends a SAR request by fax on February 14, Tommy’s first date of eligibility will begin on August 5, 2013.
Medi-Cal is retroactive meaning you can back date to the first day of service.
Here are additional facts about all SAR types…..
(EXAMPLE OF APPLICATIONS, BOOKLET PGS 6-10)

13. SAR Requirements Date of Request
Requested provider name, address, and NPI #
Contact name and phone number
Client demographics
Client Index Number (CIN) #
Confirmed or presumed diagnosis
Requested services
Documentation, including medical reports
Facility name (where services will be performed, if other than office)
Additional services requested for other providers
Sign and date the 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 by mail.
Client demographics
CIN# = Client Identification number.
Confirmed or presumed dx, your findings.
Requested services: Billing code with description of services
Documentation: include medical reports and client’s CCS number on your report as it will expedite the process.
Facility name: include the facility name where services will be performed if other than the provider’s office
Additional services requested for other providers
PLEASE, sign and date your form. No signature will delay your request for authorization.
ALL SAR REQUEST TYPES WILL NEED THIS INFORMATION.
ON THE FRESNO COUNTY WEBSITE WE HAVE AN ELECTRONIC SAR FOR YOUR USE……

14. Established SAR ESTABLISHED SAR: lets review…
Box# 3 Provider number, your NPI#
Box#5 Contact person, contact phone number
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
(EXAMPLE ESTABLISHED SAR REQUEST, BOOKLET PGS 13-14)

15. Established SAR Continued
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 Xerox or CCS, see if your questions are addressed in the instructions.

16. Electronic SAR (eSAR) www.fcdph.org/esar Adobe Reader must be use
Can be completed online or saved for later use
Can be printed and mailed or faxed
Mail to:
California Children’s Services Fax: (559)
PO Box 11867
Fresno, CA 93721
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 so that 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 use the eSAR.
ASK ABOUT ADOBE READER!!!

17.
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 or any SAR form to CCS.
Our Fax number is listed on the front of the Provider Training handbook (559)
Handout: Online SAR request showing Red fields (p. 16)

18. Inpatient Authorization
Inpatient admission requires a hospital’s National Provider Identifier (NPI) number and doctor’s NPI number on the SAR.
The facility & the doctor must be CCS approved.
Facility cannot share authorizations with rendering doctors, nor can physicians use facility authorizations for payment.
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.
Labs, radiology, pharmacy can bill under the physician’s authorization; however, physicians who have not submitted a SAR, as an indirect provider, we suggest you submit a SAR to CCS.

19. Service Code Groupings (SCG)
SCGs are groups of reimbursable codes that are authorized to CCS-paneled provider or approved facility for the care of a client’s CCS-eligible medical condition. A SCG contains a listing of the codes that allow the provider to provide care for the client without needing to obtain separate SARs. The SCG removes barriers for accessing care for CCS clients.
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. This will ensure for timely processing.
Refer to pages (p ) For service code groupings.

20. How Are SCGs Used?
Physician’s SAR number may be shared with other health care providers from whom the physician has requested services, such as laboratory, pharmacy or radiology.
Pharmacies may bill services previously authorized with an SCG without obtaining another SAR, with the exception of drugs requiring separate authorization.
Physician’s SAR number may be shared with other health care providers from whom the physician has requested services, such as laboratory, pharmacy or radiology.
Pharmacies may bill services previously authorized with an SCG without obtaining another SAR, with the exception of drugs requiring separate authorization.
Example of How SCG’S are 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.
REITERATE……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.

21. 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, Page 21)

22. 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 p. 20

23. Service Code Groupings (SCG)
A list of the current SCGs and their codes are on the State’s CCS website.
The most recent codes 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.
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.
After one year from an effective-date, the symbol is removed.
After one year from an end-date, the code with the strike-through and symbol is removed completely from the manual page.
Available are a list of the codes with effective dates in addition with a generic list of the SCG.
Example: Q0144 w
Examples: X5922 q
w January 1, 2013
q May 1, 2012

24. Tips for CCS Providers
If a client does NOT have full scope Medi-Cal the referral must be received by CCS within the next business day
Urgent requests should be processed within 2 business days
Non-urgent requests should be processed within business days
Providers should share their authorized SAR number with other providers, when appropriate
Keep a copy of the CCS-authorized SAR until it expires
Use the eSAR.
These are important tips for CCS providers.
If a client does NOT have full scope Medi-Cal the referral must be received by CCS within the next business day.
For example, if the client does not have full scope Medi-Cal and was seen on Friday, the REFERRAL must be submitted by Monday in order for CCS to review for
authorization.
The effective date for service is the date the request is received by CCS so get your requests in ASAP to provide service for your clients.
Urgent requests should be processed within 2 business days, non urgent requests within business days.
Some examples of urgent requests:
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.
Some examples of non-urgent requests:
Requests are generally for services and supplies which have already been provided to a CCS client
without an authorized SAR.
Providers should share their SAR authorization with other providers when appropriate.
All clients receive a copy of their authorization.
The initial visit authorized under the SAR is covered under referring doctor.
eSAR: Use eSAR and receive a confirmation receipt notice.