临床研究与医疗政策部门
卫生保健服务部 (DHCS) 福利部 (BD) 的四个分支机构之一是临床研究和医疗政策分支机构，负责研究、制定、实施和监督 Medi-Cal 提供的大多数医疗保健服务的医疗保险和报销政策。
概述
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.
Medi-Cal 福利申请流程
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.
提交 MBR 时，外部方必须完整解决表格中列出的第 1-9 项，并确保提交所有所需的支持文件或信息。 请注意，支持文档或信息必须以超链接形式提交和/或作为单独文件附加，并通过电子邮件与 MBR 表格一起提交给 BD。请注意，未能提交或完整填写 MBR 以及任何必要的支持文档或信息可能会导致 MBR 被退回，并且请求不会被评估。
根据覆盖请求的性质，BD 可能需要咨询其他 DHCS 部门，这可能会增加完成审查所需的时间；但是，平均而言，BD 需要大约一 (1) 个月的时间来完成对 MBR 上提供的信息的全面分析，并进行自己的独立研究，然后通过电子邮件回复。
投稿说明：
- 已完成的 MBR 和任何支持文件或信息必须通过电子邮件dhcsmedicalpolicy@dhcs.ca.gov 以电子方式提交给 BD。
- 请注意，MBR 和任何提交的支持文件均须根据 PRA 的规定进行披露（参见政府法典第 6250 节及以下条款）。
- 因此，BD 建议请求者不要提交任何机密或专有信息。
- For more information on the PRA, please see DHCS’ Public Records Act website.
资源
联系信息
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:
卫生保健服务部-福利科
收件人：临床研究和医疗政策部门
女士4601
邮局 信箱 997417
萨克拉门托，加利福尼亚州 95899-7417
笔记
- 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).
- 此外，请注意，如果承保请求需要 BD 获得额外的州和/或联邦政府的批准才能实施（例如，特定设备、测试/程序或服务不属于现有的福利承保类别），BD 可能无法发布最终的福利承保决定，您将通过电子邮件收到通知。