24-649 Medi-Cal Covered Services Not Covered Under Medicare for DSNP Members in Exclusively Aligned Counties

Date: 11/25/24

Do not deny these services. Forward to Health Net instead.

Per the State Medicaid Agency Contract (SMAC) with the California Department of Health Care Services, Dual Special Needs Plan (DSNP) contractors are required to provide integrated organization determination for the DSNP members in Exclusively Aligned Enrollment (EAE) counties.¹ (PDF)

How this affects you

Participating physician groups (PPGs) should follow the instructions below to aid determining who is responsible for sending applicable decision letters and how to access the appropriate letter template.

Effective  October 28, 2024, for DSNP members in EAE counties, you must review both Medicare and Medi-Cal benefits to determine eligibility for the service requested. Do not deny prior authorization as “not a covered benefit” without checking both Medicare and Medi-Cal covered services (refer to the list of services below).

EAE counties in 2024

Wellcare by Health Net’s (Health Net’s) EAE counties in 2024 are:

• Fresno
• Kings
• Madera
• Los Angeles
• Sacramento
• Tulare

New timelines

Effective October 28, 2024, Health Net is requesting PPGs to forward prior authorizations for the services that are not covered under Medicare but that are covered under Medi-Cal to Health Net within the following new timelines:

• For standard requests, forward to Health Net within 1 business day upon receipt of the request.
• For expedited requests, forward to Health Net within 24 hours upon receipt of the request.

Fax authorizations to the Health Net Medi-Cal Prior Authorization Department fax number

Fax prior authorizations to the Medi-Cal fax number listed under Health Net Prior Authorization Department in the Provider Library’s Contacts section, 800-743-1655, and include:

• The date and time that the service request was initially received.
• The clinical decision that was used to make the initial determination.

Health Net will forward prior authorizations received directly from physicians and other providers to delegated PPGs

There are some instances in which physicians and other providers would submit a prior authorization for DSNP members directly to the Plan. In such cases, Health Net has requested physicians and other providers to resubmit the prior authorization to the delegated PPG for Medicare review first. However, under the new guidance, this is no longer allowed. Therefore, Health Net will be faxing the prior authorizations received directly from physicians and other providers to delegated PPGs to be reviewed under Medicare benefits. Delegated PPGs can then follow the same procedure for the integrated organization determination process.

Services not covered under Medicare but covered under Medi-Cal

• Asthma remediation
• Community Based Adult Services
• Community Supports
• Community transition services/nursing facility transition services to a home
• Day habilitation programs
• Durable medical equipment (DME) that is covered by Medi-Cal²
• Environmental accessibility adaptation (home modification)
• Housing deposit (up to $6,000)
• Housing tenancy and sustaining services
• Housing transition navigation
• Long-term care
• Medically tailored meals
• Nursing facility transition/diversion to assisted living facilities
• Personal care services and homemaker services
• Recuperative care
• Respite services
• Short-term post-hospitalization housing
• Sobering centers

Scenarios where PPGs would be responsible for sending out the Applicable Integrated Plan (AIP) Coverage Decision Letter

Please refer to the below table to see the scenarios where PPGs are responsible for sending out the AIP Coverage Decision Letter. This will help PPGs determine when to forward the authorizations to the Plan and when to send the Applicable Integrated Plan Coverage Decision Letter for DSNP members in EAE counties.

Scenario	Delegated PPG	Health Plan
Eligibility denial	Deny and send AIP coverage decision letter.	N/A
Medical necessity denial	Deny and send AIP coverage decision letter.	N/A

 

Scenarios where PPGs would be responsible for forwarding the request to the Health Plan

Scenario	Delegated PPG	Health Plan
Benefit denial	Forward to Health Plan with the Medicare clinical decision.	Deny and send AIP coverage decision letter.
Out of network	Forward to Health Plan with the Medicare clinical decision.	Deny and send AIP coverage decision letter.

 

The Applicable Integrated Plan Coverage Decision Letter can be found in the Delegation Oversight Interactive Tool (DOIT)/MetricStream.

Claims processing

If you are a PPG that is responsible for claims that are Medicare covered services, effective October 28, 2024, forward claims that have Medi-Cal covered services to Health Net within 10 business days for the Plan to process as a secondary claim. The secondary claim requires a copy of the Provider Explanation of Benefits (EOB) or Remittance Advice (RA) from the primary payer. Include the information that the claim was forwarded to the Plan in the EOB or RA. Do not deny the claim without checking both Medicare and Medi-Cal covered services.

You can submit the secondary claim to the Plan in one of three ways:

• Electronically using the HIPAA 5010 standard 837I (005010X223A2) and 837P (005010X222A1) transaction (preferred method)
• 837 files with attachment
• Paper claims. Send to:
  Health Net Medi-Cal Claims
  PO Box 9020
  Farmington, MO 63640-9020
  

Additional information

Relevant sections of Health Net’s provider operations manuals³ have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library on Health Net’s provider portal. If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by telephone at 800-929-9224 or through the Health Net provider portal.

¹ https://www.dhcs.ca.gov/provgovpart/Documents/2024-EAE-SMAC-Boilerplate.pdf.
² For more information on the list of Medi-Cal covered DME, refer to https://mcweb.apps.prd.cammis.medi-cal.ca.gov/publications/manual.
³ The provider operations manual(s) may apply to physicians, participating physician groups (PPGs), hospitals, and ancillary providers, as applicable.

 

This information applies to Participating Physician Groups (PPGs).