Clinical Research & Medical Policy Branch
Ib ntawm plaub ceg haujlwm hauv Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (DHCS), Kev Pabcuam Kev Pabcuam (BD) yog Lub Tsev Haujlwm Saib Xyuas Kev Tshawb Fawb & Kev Khomob Txoj Cai, uas yog lub luag haujlwm rau kev tshawb nrhiav, tsim, siv, thiab saib xyuas kev kho mob thiab kev them nyiaj rov qab rau feem ntau cov kev pabcuam khomob muab los ntawm Medi-Cal.
Txheej txheem cej luam
When BD is making determinations about medical coverage and reimbursement policy for Medi-Cal, BD’s clinical consultants – in partnership with other clinical consultants throughout DHCS – conduct an independent analysis and consider a myriad of factors, including, but not limited to: coverage determinations from other payors, including other state Medicaid programs; coverage determinations for federal Medicare, commercial insurance, etc.; guidance from federal oversight/policy bodies such as the Federal Food and Drug Administration, etc.; and evidence-based, nationally recognized clinical practice guidelines, and consensus statements; and peer-reviewed literature and randomized, controlled clinical studies/trials. Ultimately, BD’s clinical consultants must ensure that every device, test/procedure, service, and/or billing code added as a benefit under Medi-Cal meets appropriate “medical necessity” requirements and other threshold standards for coverage under a federal Medicaid program.
Pursuant to California Welfare and Institutions Code section 14059.5: (a) For individuals 21 years of age or older, a service is “medically necessary” or a “medical necessity” when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain. (b)(1) For individuals under 21 years of age, a service is “medically necessary” or a “medical necessity” if the service meets the standards set forth in Section 1396d(r)(5) of Title 42 of the United States Code. As specified in Medi-Cal policy, Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services are medically necessary or a medical necessity if they correct or ameliorate defects and physical and mental illnesses and conditions discovered through screening.
Cov txheej txheem thov nyiaj pab Medi-Cal
BD has created the Medi-Cal Benefit Request (MBR) (DHCS 8712), which must be completed by any external parties (e.g., providers, manufacturers, advocates, etc.) who are requesting BD’s consideration for adding a particular device, test/procedure, service, and/or billing code as a Medi-Cal benefit. BD will not be able to accept an MBR for coverage policies or programs outside of our defined areas. If BD receives an MBR for this purpose, BD will redirect the MBR to the appropriate DHCS team for follow-up.
Thaum xa daim MBR, tus neeg sab nrauv yuav tsum hais tag nrho cov khoom #1-9 raws li tau teev tseg hauv daim foos thiab tseem xyuas kom meej tias cov ntaub ntawv txhawb nqa lossis cov ntaub ntawv xa mus. Thov nco ntsoov tias cov ntaub ntawv txhawb nqa lossis cov ntaub ntawv yuav tsum raug xa mus ua qhov sib txuas thiab / lossis muab txuas ua ib daim ntawv cais thiab xa nrog MBR Daim Ntawv Thov ntawm email rau BD. Thov nco ntsoov tias tsis xa lossis ua tiav MBR nrog rau cov ntaub ntawv txhawb nqa lossis cov ntaub ntawv tsim nyog yuav ua rau MBR raug xa rov qab thiab qhov kev thov tsis raug tshuaj xyuas.
Raws li qhov xwm txheej ntawm qhov kev thov kev pab them nqi kho mob, BD yuav tsum tau sab laj nrog lwm qhov DHCS kev faib, uas tuaj yeem ua rau lub sijhawm xav tau los ua kom tiav peb qhov kev tshuaj xyuas; Txawm li cas los xij, qhov nruab nrab, BD yuav siv sijhawm kwv yees li ib (1) lub hlis los ua kom tiav nws cov kev ntsuam xyuas dav dav ntawm cov ntaub ntawv muab rau hauv MBR thiab ua nws txoj kev tshawb fawb ywj pheej ua ntej teb los ntawm email.
Cov lus qhia rau kev xa:
- Ua tiav MBRs thiab cov ntaub ntawv txhawb nqa lossis cov ntaub ntawv yuav tsum xa mus rau BD hauv hluav taws xob ntawm email ntawm dhcsmedicalpolicy@dhcs.ca.gov.
- Thov nco ntsoov tias MBR thiab cov ntaub ntawv txhawb nqa tau xa tuaj yuav raug nthuav tawm raws li PRA (saib Tsoom Fwv Txoj Cai Tshooj 6250 thiab lwm yam).
- Yog li ntawd, BD xav kom cov neeg thov tsis txhob xa cov ntaub ntawv tsis pub lwm tus paub lossis cov tswv cuab.
- For more information on the PRA, please see DHCS’ Public Records Act website.
Cov peev txheej
- Medi-Cal Daim Ntawv Thov Nyiaj Pab (MBR) (DHCS 8712)
- Med-Cal Benefit Request (MBR) Biomarker Pharmacogenetic Testing (DHCS 7106)
Cov ntaub ntawv tiv tauj
To contact the DHCS/BD’s Clinical Research & Medical Policy Branch, please call us at (916) 345-8134 or email us at dhcsmedicalpolicy@dhcs.ca.gov. You may also mail us at the following address:
Department of Health Care Services-Benefits Division
Attn: Clinical Research & Medical Policy Branch
TIAB SA 4601
PO ib 997417
Sacramento, CA 95899-7417
Sau ntawv
- Please note that BD is not primarily responsible for developing coverage policy for family planning benefits and services (except for abortion services), specialty mental health (SMH) and substance use disorder (SUD)/Drug Medi- Cal Organized Delivery System (DMC-ODS) services provided through the county behavioral health delivery system, outpatient drugs, including physician administered drugs (PADs), blood factors, optometry, enteral nutrition, eyeglasses/fabrication, or medical supplies. Additionally, BD does not oversee coverage policy for the following specialty programs: California Children’s Services (CCS) Program, Family Planning, Access, Care, and Treatment (FPACT) Program, Breast and Cervical Cancer Treatment Program (BCCTP), or Genetically Handicapped Persons Program (GHPP).
- Tsis tas li ntawd, thov nco ntsoov tias yog tias daim ntawv thov kev pab them nqi yuav xav tau ntxiv rau lub xeev thiab / lossis tsoomfwv kev pom zoo rau BD los siv (piv txwv li, cov cuab yeej tshwj xeeb, kev sim / txheej txheem, lossis kev pabcuam tsis poob rau hauv cov txiaj ntsig kev pabcuam uas twb muaj lawm), BD yuav tsis tuaj yeem muab qhov kev txiav txim siab them nyiaj zaum kawg thiab koj yuav raug ceeb toom los ntawm email.