Lub Ib Hlis 8, 2025 (supersedes Kaum Ob Hlis Ntuj 23, 2024 version)​​ 

The Department of Health Care Services (DHCS) created this Pediatric Integration Q&A document based upon stakeholder feedback received during recent meetings and via email. Updated language from the prior version of this Q&A document is bolded and bracketed for ease of review. DHCS recognizes that not all questions and/or scenarios may be addressed in this Q&A document but will work to incorporate additional information into a forthcoming Frequently Asked Questions (FAQ) document that will be released and published on DHCS’ Medi-Cal Rx website in mid-January. To this end, should you have any additional questions, please submit them to DHCS via email at RxCarveout@dhcs.ca.gov or to the Medi-Cal Rx Education and Outreach team via email at MediCalRxEducationOutreach@primetherapeutics.com so they can be included in the forthcoming FAQ document.​​ 

Cov Lus Nug​​ 

1. Pediatric Integration yog dab tsi?​​ 

Pediatric Integration refers to the ending of the Medi-Cal Rx Transition Policy and reinstatement of utilization management (UM) edits/controls, including, but not limited to, quantity and frequency limitations and prior authorization (PA) request requirements for Medi-Cal members 21 years of age and younger. Pediatric Integration applies to both pediatric Medi-Cal and California Children’s Services (CCS) eligible members receiving services through Medi-Cal and CCS. [Effective January 31, 2025, the following will occur:]​​ 

» Rau kev pib kho tshiab/cov ntawv sau tshuaj tshiab, txhua daim ntawv thov hauv tsev muag tshuaj yuav rov ua raws li UM kho/tswj thiab PA cov cai, raws li tau teev tseg hauv Medi-Cal Rx thiab CCS cov kev pab cuam lub tsev muag tshuaj.​​ 

» Rau kev kho mob txuas ntxiv / tshuaj noj, rau lub sijhawm tsis pub tsawg tshaj 60 hnub, yog tias qhov kev thov yuav tsis kam lees nrog Reject 75 (PA xav tau) tab sis tus tswv cuab ntawm Medi-Cal muaj keeb kwm thov tsis ntev los no (15-hli saib rov qab), daim ntawv thov yuav them yam tsis tas yuav muaj PA ntxiv. Txoj hauv kev no yog npaj los muab sijhawm rau cov kws kho mob thiab cov kws kho mob ntxiv sijhawm los kho lawv cov txheej txheem sab hauv thiab cov phiaj xwm zoo dua rau PI cov cai, nrog rau xa cov PAs zoo.​​ 

• Please note that continuing therapies/prescriptions for a Medi-Cal member will still be subject to all other Medi-Cal Rx policy requirements, including but not limited to UM edits for quantity and frequency limits. These may result in a claim reject for a different reason or a PA request being needed to establish medical necessity.​​ 
• Tag nrho cov PAs tau pom zoo tam sim no yuav nyob twj ywm; cov hnub uas tau pom zoo thiab ua haujlwm PA yuav tsis raug hloov.​​ 
• Thov nco ntsoov tias DHCS yuav tshaj tawm tsab ntawv ceeb toom 30-hnub ua ntej kev rov ua haujlwm ntawm Kev Tsis lees paub 75 (PA xav tau) rau kev kho mob txuas ntxiv / tshuaj, uas yuav tshwm sim tsis pub dhau lub Peb Hlis 31, 2025.​​ 

2. CCS Panel Provider Authority Policy yog dab tsi?​​ 

Raws li ib feem ntawm Pediatric Integration dag zog, DHCS tau tsim CCS Vaj Huam Sib Luag Tus Tswv Cuab Txoj Cai. Txoj cai no lees paub cov kws tshaj lij thiab kev lees paub ntxiv uas yuav tsum tau muaj los ntawm CCS Panel Providers, ua rau cov kws kho mob uas yog kws kho mob lossis Certified Nurse Practitioners (CNPs) sau ntawv rau txhua tus menyuam yaus Medi-Cal lossis CCS-cov tswvcuab uas muaj hnub nyoog 20 xyoo thiab yau dua yam tsis tau xa daim ntawv PA rau cov tshuaj them, nrog rau cov khoom noj khoom haus, tshwj tsis yog cov khoom noj khoom haus, thiab cov khoom noj khoom haus. Txoj cai no yog npaj los txo qis kev tswj hwm lub nra uas tsis tsim nyog thiab txhim kho kev nkag mus tau raws sijhawm rau cov txiaj ntsig tshuaj.​​ 

3. DHCS tau npaj li cas rau qhov nce PA ntim, thov tsis lees txais, thiab hu rau lub chaw ntim uas cuam tshuam nrog Pediatric Integration?​​ 

Zoo ib yam li cov neeg laus rov qab los, qhov kev tsim ntawm Pediatric Integration yog ib qho kev siv zog ntawm cov ntaub ntawv uas tau pib nrog kev txheeb xyuas cov ntaub ntawv keeb kwm thiab cov ntaub ntawv PA. Hauv kev koom tes nrog cov neeg muaj feem cuam tshuam, DHCS tau txheeb xyuas cov hauv kev los txo cov kev tswj hwm kev ua haujlwm cuam tshuam nrog PA kev xa tawm los ntawm kev ntxiv cov tshuaj tsom rau menyuam yaus thiab cov khoom lag luam rau Daim Ntawv Cog Lus Tshuaj (CDL) thiab Cov Khoom Muag Khoom Muag; ua raws Medi-Cal thiab CCS cov txheej txheem kho mob; thiab pib txoj cai CCS Panel Provider Authority. [Lub Ib Hlis Ntuj thaum ntxov, DHCS tau kho nws txoj cai txoj hauv kev rau kev siv PI, raws li tau piav qhia ntau ntxiv hauv nqe lus nug #1 saum toj no.]​​ 

4. DHCS tau npaj li cas rau cov kws kho mob thiab cov khw muag tshuaj rau Pediatric Integration hloov pauv tshwm sim rau lub Ib Hlis 31, 2025?​​ 

Zoo ib yam li cov neeg laus rov qab los, DHCS tau ua ntau txoj hauv kev rau Pediatric Integration nthuav tawm thiab kev kawm, uas suav nrog cov hauv qab no:​​ 

• Tshaj tawm peb tsab ntawv ceeb toom ua ntej, raws li hauv qab no:​​ 
  • 90-hnub ceeb toom rau Lub Kaum Hli 31, 2024​​ 
  • 60-hnub ceeb toom rau lub Kaum Ib Hlis 27, 2024​​ 
  • 30-hnub ceeb toom rau lub Kaum Ob Hlis 31, 2024​​ 
• Posting Pediatric Integration resource materials on DHCS’ Medi-Cal Rx website under “Education and Outreach”.​​ 

• Delivering live, interactive presentations starting in November and continuing through January to key stakeholder groups and associations within the pediatric community representing children’s hospitals, managed care plans, physician organizations, advocates, and those who serve this population.​​ 
  • Thov nco ntsoov tias cov lus tawm tswv yim los ntawm cov koom nrog hauv webinars tau siv los ntawm DHCS los qhia txog kev txhim kho cov peev txheej kev kawm.​​ 

• Kev npaj rau lub webinars txhua lub limtiam uas tuav los ntawm Medi-Cal Rx, pib thaum nruab nrab Lub Ib Hlis, los tshuaj xyuas cov cai thiab cov txheej txheem rau kev xa daim ntawv thov tshuaj thiab PA thov rau cov tswvcuab menyuam yaus.​​ 
• Npaj los tuav lub sijhawm ua haujlwm rau Medi-Cal Rx Pediatric Integration thaum Lub Ib Hlis 2025 los teb cov lus nug tshwj xeeb uas ua rau mus nyob.​​ 
• Muab los npaj thiab teem caij rau kev pab cuam/kev txhawb nqa rau tus kheej raws li qhov kev thov ntawm pawg neeg koom tes.​​ 
• Siv Medi-Cal Rx Cov Neeg Siv Khoom Hauv Chaw Pabcuam (CSC) cov neeg sawv cev ntxiv los pab daws qhov kev hu xov tooj ntau ntxiv thiab teb cov lus nug.​​ 

5. Kuv tuaj yeem kawm ntxiv txog Rx Pediatric Integration nyob qhov twg?​​ 

To learn out more about Pediatric Integration, including how to obtain individualized technical assistance/support, please visit DHCS’ Medi-Cal Rx website. Under the Education and Outreach page, you will find a Pediatric Integration tab with links to key documents and information about webinars, video recordings, and other support materials.​​ 

6. Yuav ua li cas cov chaw muag tshuaj yuav them nqi rau Medi-Cal thiab CCS-cov tswv cuab tsim nyog (cov menyuam yug tshiab) uas tseem tsis tau muaj lawv tus kheej Medi-Cal tus lej ID (ID)?​​ 

For Medi-Cal and CCS-eligible members (newborns) who do not have their own Medi-Cal member ID, pharmacy providers should submit claims for any Medi-Cal Rx pharmacy benefits under the Medi-Cal member’s (newborn’s) mother’s ID number. This can occur for up to 60 days following birth, and thereafter any claims will need to be submitted with the Medi-Cal member’s (newborn’s) own Medi-Cal member ID number.  Claims for newborns will be identified via the Relationship Code and PA Type Code (PATC). A submitted value of ’03’ – Dependent and a PATC value of ‘8’ will identify the member as a newborn on the claim. If the pharmacy appropriately identifies the claim as a newborn, the CCS Panel Provider Authority policy will apply and the claim will be processed with an age under one (1) year of age. If the claim is not appropriately identified as a newborn, the claim will be processed using the mother’s age.​​ 

Yuav Tsum Tau Tso Cai Ua Ntej​​ 

7. Thaum twg cov chaw muab tshuaj thiab cov kws kho mob tuaj yeem pib xa PAs rau Medi-Cal thiab CCS-cov tswv cuab tsim nyog uas muaj hnub nyoog qis dua 22 xyoos rau Medi-Cal Rx?​​  

Pib txij Lub Ib Hlis 31, cov chaw muag tshuaj tuaj yeem xa tuaj PAs ua haujlwm, txog li 100-hnub ua ntej hnub pib ntawm daim ntawv tshuaj tshiab lossis hnub sau ntawm daim ntawv tshuaj kho dua lossis rov ua dua uas yuav tsum tau muaj PA, tshwj tsis yog rau Medi-Cal thiab CCS-cov tswvcuab tsim nyog muaj hnub nyoog qis dua ib (1) xyoo.​​ 

8. Yog vim li cas PAs proactive thiaj tsis raug txais rau Medi-Cal thiab CCS-cov tswvcuab tsim nyog muaj hnub nyoog qis dua (ib tug) 1 xyoos?​​ 

Due to potentially rapid changes in a Medi-Cal or CCS-eligible member’s health status, PA requests for medications, enteral nutrition products, and medical supplies for Medi-Cal or CCS-eligible members younger than one (1) year of age should be submitted at the time prescription is needed. CCS-paneled Physicians and CNPs are not subject to this age limitation and may prescribe for Medi-Cal and CCS-eligible members under one (1) year of age without submitting a PA, in accordance with the CCS Panel Provider Authority policy. Please note that drugs and products excluded from CCS Panel Provider Authority will require a PA, regardless of member age.​​ 

9. Vim li cas PA cov lus thov thiab UM kho/tswj yuav tsum muaj rau CCS cov tswv cuab tsim nyog yog tias kev kho mob tau tso cai rau CCS qhov tsim nyog?​​ 

UM kev tswj hwm, suav nrog PAs, yog qhov tsim nyog rau Medi-Cal thiab CCS-tsim nyog cov tswv cuab kev nyab xeeb thiab kev ncaj ncees.  DHCS tau mob siab ua haujlwm los txhim kho kev sib koom tes thiab txo cov nra hnyav ntawm kev tswj hwm los ntawm kev ua raws Medi-Cal thiab CCS cov txheej txheem kho mob, ntxiv cov khoom tsom rau menyuam yaus rau CDL thiab Cov Khoom Muag Khoom Muag, thiab ua tiav CCS Vaj Huam Sib Luag Muab Tswv Yim. PA saib xyuas cov tshuaj, khoom siv kho mob thiab cov khoom siv nkag tau muab cov txheej txheem ntxiv ntawm kev nyab xeeb, kev ua tau zoo, kev xav tau tseem ceeb, nqi, thiab kev siv tsis raug, raws li tau teev tseg hauv Welfare and Institutions Code section 14105.39 thiab Title 22, California Code of Regulations, Seem 51313.6, nyob rau hauv cov xwm txheej uas txwv tsis pub siv nrog rau kev poob rau sab nraud, tab sis tsis xav tau kev tswj hwm. cov qauv kev coj ua hauv zej zog.​​ 

10. Yog tias ib tug menyuam yaus Medi-Cal lossis CCS-tus tswvcuab tsim nyog raug tshem tawm hauv tsev kho mob, cov tshuaj puas yuav tsum tau xa daim ntawv PA?​​ 

PA submission requirements for pediatric Medi-Cal and CCS-eligible members are driven by several factors including, but not limited to, whether the prescriber has CCS Panel Provider Authority, whether the medications are included under that Authority, and program scope of coverage. Additional factors such as UM edits/controls including quantity and frequency limits could also impact whether a PA is required. [Please see response #1 above for more information about DHCS’ adjusted policy approach for continued therapies/prescriptions that may not require a PA as of January 31, 2025.]​​ 

11. Daim ntawv teev cov tshuaj thiab cov khoom uas tsis suav nrog CCS Panel Provider Authority nyob qhov twg?​​ 

Cov tshuaj thiab cov khoom uas tsis suav nrog CCS Pawg Neeg Muab Kev Pabcuam raug txheeb xyuas nyob rau hauv Medi-Cal Rx Pom Zoo Cov Tshuaj Hauv Tebchaws (NDC) Daim Ntawv Teev Npe. Thawj qhov kev tshaj tawm nrog cov ntaub ntawv no yuav muaj ua ntej Lub Ib Hlis 31, 2025, nrog cov kev hloov tshiab txhua hli luam tawm thaum pib ntawm txhua lub hlis pib thaum Lub Ob Hlis.​​ 

Qhia​​ 

12. DHCS qhia tias yuav muaj kev saib xyuas sab hauv peb lub hlis twg. DHCS puas tuaj yeem thov qhia meej txog lub hom phiaj thiab tsom mus ntxiv thiab seb cov ntaub ntawv no puas raug tshaj tawm?​​ 

The intent of DHCS’ additional quarterly monitoring, which will be internal-only and not publicly released, is to regularly gather claims and PA data. This data will be used by DHCS to glean information and make data-driven changes, if necessary, to the Medi-Cal Rx pharmacy benefits and CCS Panel Provider Authority policy.​​ 

13. Puas yog DHCS puas yuav tshaj tawm cov ntaub ntawv qhia txog kev cuam tshuam ntawm Pediatric Integration?​​ 

Zoo ib yam li kev tshaj tawm tawm tom qab txhua qhov kev ua tiav rau cov neeg laus rov qab los, DHCS yuav tshaj tawm tsab ntawv tshaj tawm txhua lub limtiam uas suav nrog cov ntaub ntawv ntawm qhov ntim ntawm kev thov, PAs, thiab hu rau Medi-Cal Rx CSC. DHCS txhawb kev pom meej hauv cov txheej txheem no thiab tau cog lus ua haujlwm ze nrog cov neeg muaj feem cuam tshuam uas muaj lus nug tshwj xeeb thiab / lossis kev txhawj xeeb.​​ 

Kev Noj Qab Haus Huv​​ 

14. Pediatric Integration puas cuam tshuam rau cov khoom noj khoom haus?​​ 

Yog lawm, qhov rov qab kho dua ntawm UM kho / tswj, suav nrog kev hloov kho kom muaj nuj nqis thiab PA cov cai, nyob rau hauv Pediatric Integration siv rau txhua qhov kev pab cuam hauv khw muag tshuaj Medi-Cal Rx.​​ 

15. Puas yog CCS Panel Provider Authority siv rau cov khoom noj khoom haus nkag mus?​​ 

CCS Panel Provider Authority siv rau tag nrho cov khoom noj khoom haus uas tau cog lus hauv cov khoom noj uas muaj calorie ntau tshaj txhua hnub. Cov khoom noj khoom haus uas tsis tau cog lus nkag mus rau hauv cov khoom noj khoom haus thiab cov khoom noj khoom haus nkag mus rau sab nraud uas tsim los siv tsis suav nrog Txoj Cai no.​​ 

16. Puas yog tus neeg muab kev pabcuam yuav tsum tau txais PA hloov tshiab rau kev hloov pauv khoom noj khoom haus tsw qab thaum lub tsw qab hauv PA rov qab txiav txim thiab nws yog tib yam khoom?​​ 

Txoj cai tswjfwm kev noj zaub mov nkag mus tso cai rau kev sib pauv ntawm cov khoom noj khoom haus uas tau cog lus rau hauv tib yam khoom / hom. Yog xav paub ntxiv txog cov khoom lag luam tsis txaus thiab kev hloov pauv ntawm cov khoom lag luam, thov mus rau Medi-Cal Rx Tus Kws Kho Mob Phau Ntawv Qhia Ntu 12.8 thiab Medi-Cal Rx Cov Lus Nug Nug Txog Cov Khoom Noj Khoom Noj.​​ 

17. DHCS tau tsim qhov txwv kom muaj nuj nqis rau cov khoom noj khoom haus nkag mus li cas?​​ 

The enteral nutrition quantity limits are based on published guidelines, including national Food and Nutrition recommendations, which were reviewed by DHCS and are included in published Medi-Cal Rx policy. Claims submitted for quantities that exceed published policy limitations can be approved with a PA request demonstrating medical necessity. PA requests are reviewed by Medi-Cal Rx and responses sent to the submitter within 24 hours. If medical necessity cannot be established for the quantity requested, Medi-Cal Rx will have the ability to approve the request with modifications that reflect the pediatric Medi-Cal or CCS-eligible member’s daily caloric needs and other pertinent clinical considerations that may apply. In the meantime, the pediatric Medi-Cal or CCS-eligible member may obtain the needed formula within caloric limits. Additional information on Enteral Nutrition Dispensing Quantity Limitations can be found in Section 12.6 of the Medi-Cal Rx Provider Manual. Maximum Quantity limits for each product for a 31-day supply are published on the List of Contracted Enteral Nutrition Products.​​ 

thov​​ 

18. Puas yog 14-hnub kev tshaj tawm xwm txheej kub ntxhov tseem yuav siv tau thaum lub sijhawm Medi-Cal Rx Pediatric Integration?​​ 

Yog lawm, cov chaw muab tshuaj muaj peev xwm siv 14-hnub kev kho mob xwm txheej ceev los xyuas kom meej tias cov neeg mob Medi-Cal lossis CCS-cov tswv cuab tsim nyog tau txais cov nyiaj pab hauv tsev muag tshuaj raws sijhawm. Medi-Cal Rx Pediatric Integration tsis muaj kev cuam tshuam rau txoj cai no.​​ 

CCS Panel Provider Enrollment​​ 

19. Kuv yog CNP thiab CCS Vaj Huam Sib Luag. Kuv tau hais tias kuv yuav tsum xa daim PA rau cov tshuaj uas yuav tsum tsis txhob xav tau PA rau CCS Paneled Providers. Vim li cas thiaj yuav yog li ntawd?​​ 

Yog tias koj tau thov los ua CCS Paneled Provider ua ntej Lub Kaum Hli 2023, koj raug xaiv los ua Tus Kws Saib Xyuas Neeg Mob (RN) thaum lub sijhawm ntawd. Yuav kom tsim nyog rau CCS Vaj Huam Sib Luag Muab Kev Tso Cai ua CNP, koj yuav tsum tau sau npe ua CNP. Txhawm rau txheeb xyuas tus neeg muab kev pabcuam thiab/lossis xa daim ntawv thov CCS tshiab, thov mus saib ntawm CCS Panel Application webpage.​​ 

20. Kuv yog Medi-Cal tus kws kho mob tab sis tam sim no tsis yog CCS Panel Provider.  Kuv puas tuaj yeem thov rau CCS Vaj Huam Sib Luag?​​ 

Yog lawm, cov kws kho mob uas kho CCS cov tswv cuab tsim nyog tau raug txhawb kom thov rau CCS Panel Status. Cov lus nug txog kev tsim nyog thiab cov txheej txheem thov tuaj yeem xa mus rau ProviderPaneling@dhcs.ca.gov. CCS Panel raws li txoj cai tsis txwv rau cov kws kho mob thiab CNPs; Txawm li cas los xij, CCS Pawg Neeg Saib Xyuas Kev Ua Haujlwm uas tso cai rau cov kws sau ntawv sau ntawv rau feem ntau cov tshuaj thiab cov khoom muag tshuaj rau menyuam yaus Medi-Cal lossis CCS cov tswvcuab tsim nyog yam tsis tau xa daim PA yog txwv rau cov kws kho mob thiab CNPs. Yog xav paub ntxiv txog CCS Paneling, thov mus saib ntawm DHCS lub vev xaib Ua Tus Muab CCS.​​ 

21. Kuv puas tuaj yeem tsim nyog rau CCS Panel Provider Authority yog kuv tsis yog CCS Panel Provider?​​ 

Yuav kom tsim nyog rau CCS Panel Provider Authority, cov kws kho mob yuav tsum yog Medi-Cal tus kws kho mob sau npe thiab sau npe CCS Panel Provider. Tam sim no, tsuas yog cov kws kho mob thiab CNPs tsim nyog rau CCS Panel Provider Authority.​​ 

22. Vim li cas CCS Pan Provider Authority tsuas siv tau rau cov neeg mob uas muaj hnub nyoog 20 thiab qis dua?​​ 

Cov neeg laus rov qab los siv rau Medi-Cal cov tswv cuab hnub nyoog 22 xyoos thiab laus dua. Pediatric Integration siv rau menyuam yaus Medi-Cal thiab CCS-cov tswv cuab tsim nyog 21 thiab qis dua. Thaum lub sij hawm rov qab los rau cov neeg laus, lub xyoo kev tshav ntuj ntxiv ib ntus tau ntxiv rau UM kho/tswj rau cov menyuam yaus rau Medi-Cal thiab CCS-cov tswv cuab tsim nyog uas muaj hnub nyoog 21 xyoos. Cov menyuam yaus uas tau teev tseg rau Medi-Cal thiab CCS-cov tswvcuab tsim nyog muaj hnub nyoog qis dua 21 xyoos, ua raws li tsoomfwv cov cai kuaj ntxov ntxov thiab sijhawm sijhawm, kuaj mob, thiab kho (EPSDT).​​