California Children’s Services. (CCS) Coordination. For dates of service up to CalOptima’s implementation of the WCM program, which will be no sooner than July 1, 2019, County agrees, for Members eligible for and/or receiving CCS Program benefits, to obtain authorization from and xxxx the CCS Program for all services eligible for CCS Program reimbursement regardless of time, effort and/or expense required in obtaining CCS Program authorization and/or reimbursement. County agrees to pursue authorization and/or reimbursement for services from the CCS Program fully and completely prior to seeking authorization and/or reimbursement from CalOptima. Pursuing CCS Program authorization and reimbursement shall include, but not be limited to, submitting clean and complete Claims in format(s) mandated by the CCS Program, submitting and/or resubmitting documentation required by the CCS Program in order to receive authorization and/or reimbursement, obtaining reconsideration in instances where the CCS Program has denied authorization and/or reimbursement, and the filing and pursuing of all applicable appeals and grievances with the CCS Program. As directed by DHCS, a separate WCM Memorandum of Understanding (WCM MOU) between CalOptima and County is effective July 1, 2019 or the date CalOptima’s Whole Child Model program becomes effective, whichever is later. Thereafter, County and CalOptima shall coordinate their CCS operations pursuant to that WCM MOU rather than pursuant to this Contract.
California Children’s Services. (CCS) County/California Children’s Services and CalOptima Responsibilities
California Children’s Services. “CCS”) Program - A state and county program providing Medically Necessary services to treat CCS-Eligible Conditions.
California Children’s Services. “CCS”)-Eligible Condition - means a medical condition that qualifies a Child to receive medical services under the CCS Program, as specified in 22 CCR section 41515.1 et seq. DRAFT
California Children’s Services. The SELPA shall assure that a Medical Treatment Unit shall be established as part of the Interagency Agreement with California Children’s Services (CCS) consistent with State law. Jointly, the member LEAs shall contribute to these costs via the LACOE unreimbursed cost provision of this agreement.
California Children’s Services. (CCS) Services provided by the CCS program are not covered under this Contract. Upon adequate diagnostic evidence that a Medi-Cal Member under 21 years of age may have a CCS-eligible condition, Contractor shall refer the Member to the local CCS office for determination of eligibility.
A. Contractor shall develop and implement written policies and procedures for identifying and referring children with CCS-eligible conditions to the local CCS program. The policies and procedures shall include, but not be limited, to those which:
1) Ensure that Contractor's providers perform appropriate baseline health assessments and diagnostic evaluations which provide sufficient clinical detail to establish, or raise a reasonable suspicion, that a Member has a CCS-eligible medical condition;
2) Assure that contracting providers understand that CCS reimburses only CCS-paneled providers and CCS-approved hospitals within Contractor's network; and only from the date of referral;
3) Enable initial referrals of Member’s with CCS-eligible conditions to be made to the local CCS program by telephone, same-day mail or fax, if available. The initial referral shall be followed by submission of supporting medical documentation sufficient to allow for eligibility determination by the local CCS program.
4) Ensure that Contractor continues to provide all Medically Necessary Covered Services to the Member until CCS eligibility is confirmed.
5) Ensure that, once eligibility for the CCS program is established for a Member, Contractor shall continue to provide all Medically Necessary Covered Services that are not authorized by CCS and shall ensure the coordination of services and joint case management between its Primary Care Providers, the CCS specialty providers, and the local CCS program.
6) If the local CCS program does not approve eligibility, Contractor remains responsible for the provision of all Medically Necessary Covered Services to the Member. If the local CCS program denies authorization for any service, Contractor remains responsible for obtaining the service, if it is Medically Necessary, and paying for the service if it has been provided.
B. Contractor shall execute a Memorandum of Understanding (MOU) with the local CCS program as stipulated in Exhibit A, Attachment 12, Provision 2, for the coordination of CCS services to Members.
C. The CCS program authorizes Medi-Cal payments to Contractor network physicians who currently are members of the CCS panel and to other providers...
California Children’s Services. Medical Eligibility for the Medical Therapy Program 22 CA ADC § 41517.5
