Pediatric Integration Question & Answer (Q&A) Document
January 8, 2025 (supersedes December 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.
General Questions
1. What is Pediatric Integration?
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:]
» For new start therapies/prescriptions, all pharmacy claims will again be subject to UM edits/controls and PA requirements, as outlined in Medi-Cal Rx and CCS pharmacy benefit policies.
» For continuing therapies/prescriptions, for a period of no less than 60 days, if a claim would otherwise reject with Reject 75 (PA required) but the Medi-Cal member has recent claims history (15-month lookback period), the claim will pay without the need for additional PA. This approach is intended to give providers and prescribers additional time to adjust their internal processes and better plan for PI requirements, as well as submit proactive PAs.
- 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.
- All currently approved PAs will remain active; approved and active PA dates will not be modified.
- Please note that DHCS will issue a 30-day notice prior to the reinstatement of Reject 75 (PA required) for continuing therapies/prescriptions, which will occur no sooner than March 31, 2025.
2. What is the CCS Panel Provider Authority Policy?
As part of the Pediatric Integration effort, DHCS developed the CCS Panel Provider Authority Policy. This policy recognizes the expertise and additional credentialing required of CCS Panel Providers, enabling paneled providers who are physicians or Certified Nurse Practitioners (CNPs) to prescribe for all pediatric Medi-Cal or CCS-eligible members 20 years of age and younger without submitting a PA for covered drugs, enteral nutrition products, and disposable medical supplies, with some exceptions. This policy is intended to reduce unnecessary administrative burden and improve timely access to pharmacy benefits.
3. How has DHCS prepared for the increased PA volume, claim rejections, and call center volume associated with Pediatric Integration?
Similar to adult reinstatement, the design of Pediatric Integration was a data-driven effort that began with analysis of historical claims and PA data. In collaboration with stakeholders, DHCS identified opportunities to reduce the administrative workload associated with PA submission by adding pediatric-focused medications and products to the Contract Drugs List (CDL) and Covered Products Lists; aligning Medi-Cal and CCS clinical criteria; and initiating the CCS Panel Provider Authority Policy. [In early January, DHCS adjusted its policy approach for implementation of PI, as described in more detail in question #1 above.]
4. How has DHCS prepared prescribers and pharmacies for Pediatric Integration changes occurring on January 31, 2025?
Similar to adult reinstatement, DHCS has taken a multi-step approach to Pediatric Integration outreach and education, which includes the following:
- Releasing three advance notice alerts, as follows:
- 90-day alert on October 31, 2024
- 60-day alert on November 27, 2024
- 30-day alert on December 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.
- Please note that feedback from stakeholder webinars has been used by DHCS to inform the development of educational resources.
- Planning for weekly webinars hosted by Medi-Cal Rx, beginning mid-January, to review policies and procedures for submission of pharmacy claims and PA requests for pediatric members.
- Planning to hold dedicated office hours for Medi-Cal Rx Pediatric Integration in January 2025 to address specific questions leading up to go-live.
- Offering to arrange and schedule individual technical assistance/support sessions at the request of stakeholder groups.
- Deploying additional Medi-Cal Rx Customer Service Center (CSC) representatives to help address increased call volume and answer questions.
5. Where can I learn more about Rx Pediatric Integration?
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. How should pharmacy providers bill for Medi-Cal and CCS-eligible members (newborns) who do not yet have their own Medi-Cal member identification (ID) number?
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.
Prior Authorization Requirements
7. When can pharmacy providers and prescribers start submitting PAs for Medi-Cal and CCS-eligible members under the age of 22 to Medi-Cal Rx?
Beginning January 31, pharmacy providers may submit PAs proactively, up to 100-days in advance of the start date of a new prescription or the fill date of a renewed or refilled prescription requiring a PA, except for Medi-Cal and CCS-eligible members younger than one (1) year of age.
8. Why are proactive PAs not accepted for Medi-Cal and CCS-eligible members younger than (one) 1 year of age?
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. Why are PA requests and UM edits/controls necessary for CCS eligible members if treatment has been authorized for the CCS eligible condition?
UM controls, including PAs, are necessary for Medi-Cal and CCS-eligible member safety and program integrity. DHCS has worked diligently to improve coordination and reduce administrative burdens by aligning Medi-Cal and CCS clinical criteria, adding pediatric-focused products to the CDL and Covered Products Lists, and executing CCS Panel Provider Authority. PA oversight of prescribed medications, medical supplies and enteral products provides an added layer of safety, efficacy, essential need, cost, and misuse potential, as outlined in Welfare and Institutions Code section 14105.39 and Title 22, California Code of Regulations, section 51313.6, in cases where use falls outside expected parameters including, but not limited to Federal Food and Drug Administration guidelines and community practice standards.
10. If a pediatric Medi-Cal or CCS-eligible member is being discharged from a hospital, will the medications require a PA submission?
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. Where is the list of drugs and products excluded from CCS Panel Provider Authority located?
Drugs and products excluded from the CCS Panel Provider Authority are identified on the Medi-Cal Rx Approved National Drug Codes (NDC) List. The first publication with this information will be available prior to January 31, 2025, with monthly updates published at the start of each month beginning in February.
Reporting
12. DHCS shared that there will be internal quarterly monitoring. Could DHCS please clarify the purpose and focus as well as whether this information be publicly released?
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. Will DHCS publicly release any data to report the impact of Pediatric Integration?
Similar to reporting released after each implementation phase for adult reinstatement, DHCS will publish a weekly summary report that includes data on the volume of claims, PAs, and calls to the Medi-Cal Rx CSC. DHCS supports transparency in this process and is committed to working closely with stakeholders who have specific questions and/or concerns.
Enteral Nutrition
14. Does Pediatric Integration impact enteral nutrition products?
Yes, the reinstatement of UM edits/controls, including edits for quantity and PA requirements, under Pediatric Integration applies to all covered Medi-Cal Rx pharmacy benefits.
15. Does the CCS Panel Provider Authority apply to enteral nutrition products?
CCS Panel Provider Authority applies to all contracted enteral nutrition products within the established daily calorie maximum. Non-contracted enteral nutrition products and enteral nutrition products prescribed outside established use parameters are excluded from this Authority.
16. Does the provider need to get an updated PA for an alternate enteral nutrition flavor when the flavor under PA is on back order and it is the same product?
Enteral nutrition coverage policy allows for interchangeability among contracted enteral nutrition products within the same product categories/types. For additional information on product shortages and product interchangeability please refer to the Medi-Cal Rx Provider Manual Section 12.8 and Medi-Cal Rx Enteral Nutrition Frequently Asked Questions.
17. How did DHCS establish the quantity limits for enteral nutrition products?
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.
Claims
18. Will the 14-day emergency override still be applicable during Medi-Cal Rx Pediatric Integration?
Yes, pharmacy providers can use the 14-day emergency override to ensure that pediatric Medi-Cal or CCS-eligible members receive pharmacy benefits in a timely manner. Medi-Cal Rx Pediatric Integration has no impact on this policy.
CCS Panel Provider Enrollment
19. I am a CNP and CCS Panel Provider. I was told I need to submit a PA for a medication that should not require a PA for CCS Paneled Providers. Why would that be the case?
If you applied to be a CCS Paneled Provider prior to October 2023, you were designated as a Registered Nurse (RN) at that time. To be eligible for the CCS Panel Provider Authority as a CNP, you will need to be registered as a CNP. To verify provider status and/or submit a new CCS application, please visit the CCS Panel Application webpage.
20. I am a Medi-Cal enrolled physician but am not currently a CCS Panel Provider. Can I apply for CCS Panel status?
Yes, health care providers who treat CCS-eligible members are encouraged to apply for CCS Panel Status. Questions regarding qualifications and application process may be submitted to ProviderPaneling@dhcs.ca.gov. CCS Panel status is not limited to physicians and CNPs; however, CCS Panel Authority that enables prescribers to write scripts for most medications and pharmacy products for pediatric Medi-Cal or CCS-eligible members without submitting a PA is restricted to physicians and CNPs. For more information on CCS Paneling, please visit the DHCS webpage Becoming a CCS Provider.
21. Can I qualify for CCS Panel Provider Authority if I am not a CCS Panel Provider?
To qualify for CCS Panel Provider Authority, health care providers must be a Medi-Cal enrolled clinician and registered CCS Panel Provider. Currently, only physicians and CNPs qualify for CCS Panel Provider Authority.
22. Why does the CCS Pan Provider Authority only apply to pediatric members 20 and younger?
Adult reinstatement applied to Medi-Cal members ages 22 and older. Pediatric Integration applies to pediatric Medi-Cal and CCS-eligible members 21 and younger. During adult reinstatement, a temporary additional grace year was added to the UM edits/controls for the pediatric population for Medi-Cal and CCS-eligible members who are 21 years of age. The defined pediatric population for Medi-Cal and CCS-eligible members is younger than 21 years of age, pursuant to federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements.
