21-469 Prior Authorization Changes for California Children’s Services
Date: 06/30/21
Coordinate care to reduce member concerns
Effective immediately, office visits for pediatric subspecialists no longer require prior authorization. In-office procedures will need a prior authorization for pediatricians with a subspecialty listed below:
- Cardiologists
- Dermatologists
- Endocrinologists
- Gastroenterologists
- Geneticists
- Nephrologists
- Neurologists
- Ophthalmologists
- Orthopedists
- Otolaryngologists (ear, nose, throat)
- Podiatrists
- Pulmonologists
- Urologists
Note: This prior authorization change for CCS affects fee-for-service Medi-Cal providers only.
Referrals for CCS-eligible conditions
Providers and participating physician groups (PPGs) should refer members with a potential California Children’s Services (CCS)-eligible condition to CCS. Submit a Service Authorization Request (SAR) for the following referral types:
Referral type | Use this SAR form |
|---|---|
New | New Referral CCS/GHPP Client |
Existing open or closed cases | Established CCS/GHPP Client |
The CCS program reviews requests for medical necessity. If CCS approves the request, it issues an authorization for the SAR. The CCS program may open the case for either diagnostic or treatment services.
24-hour referral time limits
Providers need to send a referral within 24 hours. You must also inform the parent or legal guardian of the referral. This applies to:
- Primary care physicians (PCPs), specialists and participating physician groups (PPGs) who identify a potential CCS-eligible condition.
- Hospitals for an inpatient admission.
Avoid California Children’s Services (CCS) denials
Providers must notify and refer a potentially eligible child to CCS in a timely manner.
- CCS retro-authorizes only to the date of the referral.
- Submit all supporting documents within 24 hours after the initial notification.
- Emergency and after-hours services – submit a referral within 24 hours or the next business day after you provided services.
Documents to submit with a Service Authorization Request (SAR)
Providers must include all required documents with the SAR. The documents must clearly support medical necessity tied to the potential CCS-eligible condition, such as:
- Completed new referral CCS client SAR form or letter with required information.
- Medical history with enough medical information to determine the evidence or suspicion of a CCS-eligible condition.
- Recent medical records that relate to the eligible diagnosis or condition. Documents may include prescriptions, clinic visit reports, physical therapy evaluations, and other relevant medical records.
- Description of the services for your request.
- Name of the CCS-paneled provider who will perform the services on the request (if known).
- Name and phone number of the referral source.
- Completed CCS application form (if available).
Paneled providers and payments
CCS will make payments when all care is in the CCS program, given by CCS-paneled providers in a CCS-approved facility. This does not apply to certain trauma care.
Linking a member with a CCS-paneled provider initially will reduce any disruption of ongoing care needs. Hospitals and specialty care clinics need to list the paneled provider who has oversight of the member’s care on the SAR.
To access the paneled-provider lists or to become a CCS-paneled provider, go to:
- Paneled-provider lists
- Become a CCS-paneled provider
CCS program billing guidelines
Once CCS authorizes the requested services, which include a service code grouping with the specific service codes, claims for services should follow the CCS program claim billing guidelines. You can submit claims to the CCS fiscal intermediary only if CCS determines they meet all three criteria below:
- The member is medically eligible.
- CCS has approved the member for the CCS program.
- CCS has issued a SAR for the service.
Refer to the table below for guidance on submitting claims with or without a SAR number beginning with 91 or 97:
Information on claim form | CCS-only client/CCS Healthy Families client1 | CCS/Medi-Cal Client |
|---|---|---|
Provider number CSM-1500: Box 33A UB-04: Box 56 Pharmacy 30-1 or 30-3: Box 3 Pharmacy POS2: NCPDP3 specified | National Provider Identifier Note: Do not use a CCS/GHPP4 only (CGP)5 provider number | National Provider Identifier Note: Do not use a CGP provider number |
Client ID CMS-1500: Box 1A UB-04: Box 60 Pharmacy 30-1 or 30-3: Box 6 Pharmacy POS: NCPDP specified | Client’s identification (ID) number as it appears on the plastic Benefits Identification Card (BIC), paper | Client’s ID number as it appears on the plastic Benefits Identification Card (BIC), paper Medi-Cal ID card or SAR |
Service Authorization Request (SAR) CMS-1500: Box 23 UB-04: Box 63 Pharmacy 30-1: Boxes 29, 50, 71 Pharmacy 30-4: Box 31 Pharmacy POS: NCPDP specified | 11-digit SAR number (Example: 97212345780) | 11-digit SAR number (Example: 97212345780) |
Where claims are submitted for CCS-authorized services. | Medi-Cal fiscal intermediary | Medi-Cal fiscal intermediary (If a CCS client resides in Napa, San Mateo, Santa Barbara, Solano or Yolo county, submit claims per CCS county office policy) |
1 CCS-only clients are the CCS children or CCS/Healthy Families Program children who are not eligible for full-scope, no Share of Cost Medi-Cal
2 POS = place of service
3 NCPDP = National Council for Prescription Drug Programs
4 GHPP = Generally handicapped persons program
5 CGP = CCS/GHPP provider
Coordinate care with CCS
All services require prior authorization – except emergency and after-hours services.
- PPG responsibilities – The PPG or the Plan continues to authorize all medically necessary covered services to the member until CCS approves the referral for the eligible condition.
- Emergency care with inpatient admission – When an inpatient admission for emergency treatment is required and the hospital is not CCS-approved, the PPG must coordinate care and arrange for post-stabilization transfer to a CCS-approved facility.
- CCS responsibilities – Once the member is eligible, the CCS program assumes case management responsibilities. This includes prior authorization and payment for all services related to the CCS-eligible medical condition. It also includes care for newborn stabilization prior to transfer to a CCS-approved neonatal intensive care unit (NICU).
- Primary care physician (PCP) responsibilities – The PCP gives primary care services to the member for medical conditions not eligible for the CCS program or ones CCS does not cover. This includes coordinating with CCS and CCS-paneled specialists to ensure continuity of care for those conditions that the CCS program does cover.
Contacts and references
- CCS contacts in your county. Contact the county CCS program by phone, or you can fax a referral and request forms to refer eligible children to CCS.
- Public Programs Team – call 844-925-0962 for help with SAR referrals and CCS training.
- Regulatory requirements for the California Code of Regulations, Title 22, Sections 41515.1-41518.9, CCS Medical Eligibility.
Live web page coming soon!
Watch for additional training opportunities and updates to our new CCS web page with resources, tools and contacts. You will be able to view information related to CCS referrals, care coordination and more.
Additional information
Providers are encouraged to access California Health & Wellness Plan’s (CHWP’s) provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CHWP at 877-658-0305.