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California Health & Wellness is no longer a Medi-Cal plan starting January 1, 2024. Regardless of the county you live in, your Medi-Cal service and benefits will not be impacted by the health plan changes since you will be assigned to a new health plan. The county you live in determines your new health plan. Learn more
California Health & Wellness is no longer a Medi-Cal plan starting January 1, 2024. Regardless of the county you live in, your Medi-Cal service and benefits will not be impacted by the health plan changes since you will be assigned to a new health plan. The county you live in determines your new health plan. Learn more

20-524 California Children's Services, SAR Forms and Claims Guidelines

Date: 07/08/20

Help your Medi-Cal members with their special health care needs and refer them to CCS

The California Children’s Services (CCS) program provides specialized medical care, rehabilitation services and case management for Medi-Cal members up to age 21 with certain medical or surgical conditions. Members must meet program eligibility requirements to enroll in the CCS program.

Refer to the information in this update on coverage, Service Authorization Request (SAR) forms, referrals, and claims billing.

Coverage responsibility

Any services related to CCS-eligible medical conditions:

  • Are carved-out services, under the Medi-Cal managed care program and not covered by Health Net*.
  • Require prior authorization from the local CCS office.
  • Must be provided by CCS-paneled providers and/or at CCS-approved facilities or special care centers.
  • Must be approved by the CCS program.

The member remains enrolled with the plan or its subcontracting health plans to receive:

  • Primary care services.
  • Services unrelated to the CCS-eligible condition.
  • CCS-eligible medically necessary services that the CCS program has not yet authorized.

Refer eligible children within 24 hours

Refer potentially eligible children to CCS, using the New Referral CCS/GHPP Client SAR form, as follows:

  • PCPs, specialists and participating physician groups (PPGs) – within 24 hours of identifying a potential CCS eligible condition and inform the parent or legal guardian of the referral.
  • Hospitals – within 24 hours of inpatient admission and inform the parent or legal guardian of the referral.

CCS and participating entities may deny requests if providers fail to notify and refer a potentially eligible child to CCS in a timely manner. CCS retro-authorizes only to the date of referral. Submit all supporting documentation within 24 hours after the initial notification.

Referral form must include the following documentation:

  • Completed new referral CCS Client SAR form or letter with required information.
  • Medical history with sufficient medical information to ascertain the evidence or suspicion of a CCS-eligible condition.
  • Recent medical records pertaining to eligible diagnosis or condition.
  • Description of services being requested.
  • Name of CCS-paneled provider who will perform the requested services (if known).
  • Name and telephone number of the referral source.
  • Completed CCS Application form (if available).

Providers referring a member with an existing open or previously closed case with CCS should make a new referral using the Established CCS/GHPP Client SAR form.

Use correct SAR forms

Providers must provide documents to support medical necessity at the time the SAR is submitted. Documents may include prescriptions, clinic visit reports, physical therapy evaluations, and other relevant medical records. The CCS program reviews requests for services and issues an authorization for the SAR after medical necessity is determined.

To avoid denials for CCS treatment and services, once a member is determined to be CCS-eligible, the SAR must be submitted to CCS to approve all diagnostic and treatment services. This excludes emergency and after-hour services. Use the correct SAR form, as listed below.

  • New Referral CCS/GHPP Client SAR form – Refer a potential CCS member suspected of having a CCS-eligible medical condition. The case may be opened by the CCS program for either diagnostic or treatment services.
  • CCS/GHPP Discharge Planning SAR form – Request specific services for a child discharged from an inpatient hospital stay. These may include, but are not limited to, the following:

-    Home health agency services.

-    Durable medical equipment (DME).

-    Orthotics.

-    Medical supplies.

-    Community services.

-    Specialty or subspecialty provider follow-up visits.

-    Other medically necessary services related to the CCS-eligible medical condition.

  • Established CCS/GHPP Client SAR form – Request authorization for specific services related to the treatment of the child’s CCS-eligible medical condition. This form is used for the below services:

-    Hospital admissions.

-    Surgeries.

-    Transplants.

-    Extension of services (a new SAR number is issued).

-    Medical services related to the CCS-eligible condition.

The plan continues to provide all medically necessary covered services to the member until CCS confirms eligibility and issues an authorization for the requested services, including a service code grouping that includes the specific service codes.

CCS contacts and references

Providers may contact the county CCS program by phone, or fax referral and request forms for eligible children to CCS.

For more information on CCS, please see the following references:

CCS program claims billing guidelines

Submit claims to CCS fiscal intermediary only if CCS has determined all of the below three criteria:

  • The member is medically eligible.
  • CCS has opened the member to 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.

 

With SAR

Without SAR

 

CCS-only client/CCS HF client

CCS/Medi-Cal client

CCS-only client/CCS HF client

CCS/Medi-Cal client

Provider Number

CMS-1500: Box 33A

UB-04: Box 56

Pharmacy 30-1 or 30-4: Box 3

Pharmacy POS: NCPDP specified

National Provider Identifier

Note: Do not use a CCS/GHPP-only (CGP) provider number.

National Provider Identifier

Note: Do not use a CGP provider number.

National Provider Identifier

Note: Do not use a CGP 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 30-4: Box 6

Pharmacy POS: NCPDP specified

Client’s ID number as it appears on the plastic Benefits Identification Card (BIC), paper
Medi-Cal ID card or SAR

Client’s ID number as it appears on the plastic Benefits Identification Card (BIC), paper
Medi-Cal ID card or SAR

Leave field blank

Client’s ID number as it appears on the plastic Benefits Identification Card (BIC) or paper
Medi-Cal ID card

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

(For example:  97123456780)

11-Digit SAR number

(For example:  97123456780)

 

 

Where claims are submitted for CCS-authorized services

Medi-Cal Fiscal Intermediary (FI)

Medi-Cal Fiscal Intermediary (FI)

(If a CCS client resides in Napa, San Mateo, Santa Barbara, Solano or Yolo County, submit claims per CCS county office policy)

Submit claims per CCS county office policy

Submit claims per CCS county office policy