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20-668 Learn When to Coordinate Care with California Children's Services

Date: 09/04/20

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

For Medi-Cal, this information applies to Fresno, Kings, and Madera counties.

Help reduce member concerns and denied claims

After a member has established eligibility in the California Children’s Services (CCS), the CCS program assumes case management responsibilities. This includes prior authorization and payment for all services related to the CCS-eligible medical condition and care for newborn stabilization prior to transfer to a CCS-approved neonatal intensive care unit (NICU).

All care in the CCS program must be given by CCS-paneled providers and in a CCS-approved facility for CCS to make payment, with the exception of certain trauma care.

Get a prior authorization

The CCS program issues an authorization after it reviews the request for services and determines medical eligibility. All services, except emergency and after-hour services, require prior authorization. The participating physician group (PPG) continues to provide all medically necessary covered services to the member until CCS eligibility is confirmed.

CCS-eligible NICU patients

Authorization for a CCS-approved NICU facility also authorizes related NICU physician services and fees. A separate authorization process for NICU physician services is not needed. This does not apply to a CCS-paneled surgeon who performs surgery on an infant in a CCS-approved NICU.

What care does the PCP give CCS-eligible members?

The primary care physician (PCP) remains responsible for providing primary care services to the member and care for medical conditions not eligible for or covered by the CCS program. This includes coordinating with CCS and CCS-paneled specialists to ensure continuity of care for those conditions that are covered by the CCS program.

When is the PPG involved?

The PPG continues to provide all medically necessary covered services to the member until CCS eligibility is confirmed.

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.

  • Referrals for the emergency inpatient admission must be made to the county CCS program on the next business day and must include documents proving the need for emergency care.
  • Once the member is stabilized, the PPG must ensure the member is transferred to a CCS-approved hospital. 

How to reach the County CCS Program

The county CCS program telephone and fax numbers are:

County

Telephone number

Fax number

Fresno

(559) 600-3300

(559) 455-4789

Kings

(559) 852-4693

(559) 582-6803

Madera

(559) 675-4945

(559) 675-7803

Please visit California Children's Services website for more information.

Request assistance, training and more information

  • Participating providers and care managers can contact CalViva Health at 1-888-893-1569 to request assistance with Service Authorization Request (SAR) referrals and CCS training.
  • More information about coverage, SAR forms, referrals, and claims billing is found in provider update 20-523, distributed on July 8, 2020.

Online resources

You can also use the following links and references:

Access the Provider Library

Use either option below to access the library:

Option 1 – Access the provider website

1     Log in to the Health Net Provider website.

2     From the home page, scroll to the bottom and select the Provider Library tile.

Option 2 – Go directly to the Health Net Provider Library.

Then select Medi-Cal > Provider Manual > Public Programs > California Children’s Services. SAR forms are found under Forms and References.

If you have additional questions regarding the information contained in this update, contact CalViva Health at 1-888-893-1569.



Last Updated: 09/03/2020