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California Health & Wellness is no longer a Medi-Cal plan starting January 1, 2024. Regardless of the county you live in, your Medi-Cal service and benefits will not be impacted by the health plan changes since you will be assigned to a new health plan. The county you live in determines your new health plan. Learn more

20-027 Prop 56 Rates for SFY 2019-2021

Date: 01/28/20

Same rates used for SFY 2018–2019 will be paid

Supplemental rates for dates of service from July 1, 2019, through December 31, 2021, are the same as the state fiscal year (SFY) 2018–2019 rates. This was approved by the Department of Health Care Services (DHCS) All Plan Letter (APL) 19-015 on December 24, 2019. Attachment A shows the qualifying CPT codes and their rates. Supplemental payments for specific physician services are in addition to:

  • Base provider compensation under the Provider Participation Agreement (PPA).
  • Contracting rates with primary care physicians (PCPs) or independent practice associations (IPAs).

Review minimum requirements to qualify

Payment amounts in Attachment A apply to participating providers who are eligible to offer and bill claims with the listed CPT codes during the SFY period. A current W-9 must be on file.

  • Submit a clean claim or encounter with one of the qualifying CPT codes.
  • Ensure the IPA submits your encounters timely and accurately, if contracted through an IPA.

Supplemental payments are made within 90 days of receiving a clean claim or accepted encounter.

Excluded from Prop 56 supplemental payments

The following are not eligible for Prop 56 payments for physician services:

  • Federally Qualified Health Centers
  • Rural Health Clinics
  • American Indian Health Programs
  • Cost-based Reimbursement Clinics
  • Dually eligible members with Medi-Cal and Medicare Part B

Update your W-9 form

If you have not submitted a W-9 in the past 12 months or if your information has changed, submit a new form by fax or email (see Send in your W-9 form by email or fax below). The W-9 form must include the physician’s:

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

Send in your W-9 form by email or fax

You can download the most current form from the Internal Revenue Service (IRS) website at www.irs.gov/pub/irs-pdf/fw9.pdf with complete instructions.

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

Include the provider’s:

  • Last name
  • Office address
  • TIN
  • First name
  • Email address
  • NPI

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

EMAIL

HNCA_W9_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.”)

Additional information

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 California Health & Wellness Plan (CHWP) at 1-877-658-0305.    

Attachment A: Directed payment amounts from July 31, 2017, through December 31, 2021

CPT

Description

Supplemental rates for SFY1

2019–2021

2018–2019

2017–2018

90791

Psychiatric diagnostic evaluation

$35

$35

$35

90792

Psychiatric diagnostic evaluation with medical services

$35

$35

$35

90863

Pharmacologic management

$5

$5

$5

99201

Office/outpatient visit new

$18

$18

$10

99202

Office/outpatient visit new

$35

$35

$15

99203

Office/outpatient visit new

$43

$43

$25

99204

Office/outpatient visit new

$83

$83

$25

99205

Office/outpatient visit new

$107

$107

$50

99211

Office/outpatient visit established

$10

$10

$10

99212

Office/outpatient visit established

$23

$23

$15

99213

Office/outpatient visit established

$44

$44

$15

99214

Office/outpatient visit established

$62

$62

$25

99215

Office/outpatient visit established

$76

$76

$25

99381

Initial comprehensive preventive medicine E&M2 (age < 1)

$77

$77

No rates

for SFY 2017–2018

99382

Initial comprehensive preventive medicine E&M (ages 1–4)

$80

$80

99383

Initial comprehensive preventive medicine E&M (ages 5–11)

$77

$77

99384

Initial comprehensive preventive medicine E&M (ages 12–17)

$83

$83

99385

Initial comprehensive preventive medicine E&M (ages 18–39)

$30

$30

99391

Periodic comprehensive preventive medicine E&M (age < 1)

$75

$75

99392

Periodic comprehensive preventive medicine E&M (ages 1–4)

$79

$79

99393

Periodic comprehensive preventive medicine E&M (ages 5–11)

$72

$72

99394

Periodic comprehensive preventive medicine E&M (ages 12–17)

$72

$72

99395

Periodic comprehensive preventive medicine E&M (ages 18–39)

$27

$27

1SFY – state fiscal year

2E&M – evaluation and management