The California Pharmacists Association (CPhA) advocates for pharmacists being reimbursed for patient care beyond dispensing. In 2021, Medi-Cal began covering Medication Therapy Management (MTM) services for chronic conditions. CPhA has supported these efforts and is now providing a guide for members to become Medi-Cal MTM providers.
In order to participate in the program, a pharmacy must first be an approved Medi-Cal provider. If your pharmacy is not a Medi-Cal provider, you must submit an application through DHCS’s Provider Application and Validation for Enrollment (PAVE) portal for your pharmacy. Individual pharmacists are currently not eligible providers who can sign up to be Medi-Cal providers through PAVE.
In PAVE, a pharmacy must also choose a pharmacist to become an Ordering, Referring and Prescribing (ORP) provider. This is necessary because all pharmacist services, including MTM, require that the entity providing the service be enrolled as an ORP in order for the pharmacy to properly bill the claim.
Pharmacies must enroll as soon as possible. Currently, the entire process is averaging about six months to complete, depending on deficiencies in their application.
Once your pharmacy has become a Medi-Cal provider and you enroll your pharmacist(s) as ORP providers, you are now eligible to sign up as an MTM provider. The 2021 Budget Act requires pharmacy providers who wish to become MTM providers to sign individual contracts with DHCS. These contracts are between the provider and DHCS. The contract contains the various obligations and requirements in order to become MTM providers. The contract also contains the list of eligible drugs that may be considered for MTM services as well as payment provisions that you may bill Medi-Cal for MTM services that have been provided.
In order to participate in the program, a pharmacy must first be an approved Medi-Cal provider. If your pharmacy is not a Medi-Cal provider, you must submit an application through DHCS’s Provider Application and Validation for Enrollment (PAVE) portal for your pharmacy. Individual pharmacists are currently not eligible providers who can sign up to be Medi-Cal providers through PAVE.
In PAVE, a pharmacy must also choose a pharmacist to become an Ordering, Referring and Prescribing (ORP) provider. This is necessary because all pharmacist services, including MTM, require that the entity providing the service be enrolled as an ORP in order for the pharmacy to properly bill the claim.
Pharmacies must enroll as soon as possible. Currently, the entire process is averaging about six months to complete, depending on deficiencies in their application.
Medi-Cal permits MTM services via telehealth if compliant with California’s Business and Professions Code 2290.5 or equivalent licensing requirements, while adhering to patient rights and privacy laws. Documentation for telehealth services must match in-person standards for billed CPT codes. Services requiring onsite labs, vital signs, or direct visualization are not eligible for telehealth. Providers must obtain and document patient consent prior to telehealth services.
Telehealth MTM must meet DHCS standards for equipment, privacy, and billing, including real-time, high-quality video with a minimum speed of 4 Mbps and HIPAA compliance. Providers must use place of service code 02 for telehealth and submit a one-time telehealth policy report and annual beneficiary reports. Additional restrictions apply to services through FQHCs, RHCs, or Indian Health Services agreements.
Pharmacists will use HIPAA-compliant CPT codes to bill for eligible MTM services, with the following codes and rates:
99605
Medication therapy management service(s) provided by pharmacist, individual, face-to- face with patient, with assessment and intervention if provided; new patient visit, initial 15 minutes
$43
99606
$43
99607
$43
Telehealth services are billed as face-to-face encounters in 15-minute increments, capped at one hour per session. Providers must use the “02” code in the Place of Services field.
Providers will be expected to submit various reports to DHCS regarding MTM services that will be outlined in the provider contract. Formats of the reports, where to send those reports and what information needs to be included in those reports will be detailed in Exhibit C of your contract. Failure to submit these reports in a timely manner may result in the termination of your contract with DHCS. Additionally, DHCS may request a patient specific report with specified information in the request. These patient-specific reports are due upon request but no later than 30 days after receipt of the request.
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