20-182 Prop 56 Payments for Developmental Screenings

Date: 04/30/20

Start screenings at age 9 months, with follow-up at ages 18, and 24 or 30 months

This update gives information from the Department of Health Care Services (DHCS) All Plan Letter (APL) 19-016, issued December 26, 2019. DHCS requires that the American Academy of Pediatrics (AAP)/Bright Futures periodicity schedule and guidelines for pediatric periodic health visits are followed. The periodicity schedule requires developmental surveillance during every well-child visit and is considered preventive care. Prior authorization is not required.

Developmental screenings beyond scoring and documentation occur when a problem is found during the developmental surveillance. A screening does not imply a diagnosis. It is a way to collect information on the patient.

Children enrolled in Medi-Cal can get developmental screenings as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.

Requirements to qualify

Supplemental payment applies to contracted providers who are eligible to offer and bill claims for each qualifying general developmental screening service as follows:

Dates of service are on or after January 1, 2020.
Adheres to the AAP/Bright Futures periodicity schedule.
Adds CPT code 96110 (without modifier KX) to the claim or encounter.

- Modifier KX is used for autism spectrum disorder (ASD) which does not qualify.

Uses a standardized tool for the screening that meets the Centers for Medicare & Medicaid Services (CMS) criteria.¹

- Includes the domains for motor, language, cognitive, and social-emotional.

- Scores about 0.70 or above for reliability, validity and sensitivity.

Additional screenings qualify for supplemental payment when medically necessary due to identified risk.
Federally Qualified Health Centers, Rural Health Clinics, American Indian Health Programs, and Cost-based Reimbursement Clinicsqualify for payments.
Dually eligible members with Medi-Cal and Medicare Part B (regardless of enrollment in Medicare Part A or Part D) do not qualifyfor payments.

¹A list of standardized tools is found at www.medicaid.gov/medicaid/quality-of-care/performance-measurement/adult-and-child-health-care-quality-measures/child-core-set-reporting-resources/index.html.

Documentation requirements

Providers must document all of the following: tool used for the screening; that the completed screen was reviewed; results of the screen; interpretation of results; discussion with the member and/or family; and any appropriate actions taken. This documentation must be kept in the member’s medical record and be available upon request.

Payments

Clean claims or accepted encounters must be received within one year from the date of service. Supplemental payments are made within 90 calendar days of receipt. The payments are in addition to:

Base provider compensation under the Provider Participation Agreement (PPA).
Contracting rates with primary care physicians (PCPs) or participating physician groups (PPGs).

Prop 56 direct payment amount:

CPT code	Description	Amount
96110 – without modifier KX	Developmental screening, with scoring and documentation, per standardized instrument	$59.90

Note: Supplemental payments for CPT code 96110 are paid for members under age 21.

Send in your W-9 form and contact information

To process supplemental payments, a current W-9 form must be on file. You can download the most current W-9 form from the Internal Revenue Service (IRS) website at www.irs.gov/pub/irs-pdf/fw9.pdf with complete instructions. The W-9 form must include the rendering physician’s:

Current address used to receive checks	Individual taxpayer identification number (TIN)
National Provider Identifier (NPI) – If two or more NPIs are used (individual and group), include both NPIs where space is available

Fill out the below contact information sheet. Return the completed W-9 form and the contact information sheet by email or fax.

Email:

HNCA_W9_Submissions@Centene.com

(Add the words “Prop 56 W9” in the subject line.)

Fax:

1-833-794-0423

(Include a cover sheet and clearly add the words “Prop 56 W9” and “PROTECTED HEALTH INFORMATION.”)

How to file a grievance

Contact the Direct Pay team by email or fax with the provider’s information.

Email:

HNCA_DirectPay@healthnet.com

(Add the words “Prop 56 Grievance” in the subject line.)

Fax:

1-844-929-0402

(Include a cover sheet and clearly add the words “PROTECTED HEALTH INFORMATION.”)

In your grievance correspondence, include the provider’s:

Last name	Office address	TIN
First name	Email address	NPI

For additional information on these services, refer to the DHCS website at www.dhcs.ca.gov. If you have questions about the status of your W-9, Prop 56 payments or requesting a Remittance Advice (RA), contact the Health Net Medi-Cal Provider Services Center within 60 days at 1-800-675-6110.

Please return this section with your completed and signed W-9 form.

Email:

HNCA_W9_Submissions@healthnet.com

(Please note this is a document procurement email only, and is not monitored by an individual.)

Fax:

1-833-794-0423

Providers with same TIN and their individual NPI information can be listed here.