Resources from dhcs.ca.gov

Medi-Cal Managed Care Plans Mandatory or Voluntary Enrollment and Medi-Cal Aid Codes (dated January 8, 2019)

Learn about different Medi-Cal eligibility aid codes, which aid codes require mandatory enrollment in a Medi-Cal Managed Care Plan and which Medi-Cal Managed Care model is available in which County.

Manual of Criteria for Medi-Cal Authorization (revise date April 15, 2004)

A compilation of criteria which apply to some services provided by the Medi-Cal program, such as long term care, acute administrative days, inpatient rehab, home health. etc.  

PLEASE NOTE: Criteria in this manual, such as those for surgical procedures may no longer be the standard of practice. As appropriate, defer to your organization's protocol.

Provider Preventable Conditions (PPC)

Learn about the two classifications of PPCs and view a list for each type. PPCs consist of health care-acquired conditions (HCAC) when they occur in acute inpatient hospital settings only and other provider-preventable conditions (OPPC) when they occur in any health care settings.  Federal regulations and state law prohibits payment for treatment of PPCs.  

Medi-Cal References This link takes the user to the Medi-Cal References library. The Table of Content provides link to an assortment of helpful materials, listings and announcements to facilitate participation in the Medi-Cal program.  

Medi-Cal Provider Manual  

This link takes the user to the Provider Manual's Table of Content. This manual contains a wealth of information for Medi-Cal providers and Managed Care Plans on a variety of topics, such as billing, reimbursement, authorization guidelines, etc.  Below are some helpful links to criteria/guidelines from this manual to perform UR activities:

• Billing Codes and Reimbursement Rate for DME 
• Frequency Limits for DME 

• Durable Medical Equipment (DME): Infusion Equipment, including Insulin Pump 

• Durable Medical Equipment (DME): Oxygen and Respiratory Equipment Coverage Criteria 

• Durable Medical Equipment (DME): Wheelchair and Wheelchair Accessories Guidelines 

• Durable Medical Equipment (DME): Speech Generating Devices (SGD)

• Durable Medical Equipment (DME): Therapeutic Anti-Decubitus Mattresses and Bed Products 

• Enteral Nutrition Products Medical Criteria

• Criteria for Authorization and Reimbursement for Orthotics 
• Frequency Limits for Orthotics                

• Criteria for Authorization and Reimbursement for Prosthetics  
• Frequency Limits for Prosthetics    

•  Medical Transportation – Ground Guidelines for NEMT & NMT

•  Subacute Care Programs: Adult Eligibility and Treatment Criteria
•  Subacute Care Programs: Pediatric Eligibility and Treatment Criteria   

•  Home Health Agencies (HHA) Billing Codes and Reimbursement Rates 

CCS Program Overview 

An overview of the CCS program, independent and dependent counties, and the role of Medi-Cal Managed Care plans

California Children’s Services (CCS) Program Eligibility 

Explains the specific eligibility requirements and medical eligibility criteria to participate in the California Children’s Services (CCS) program. 

CCS Medical Therapy Program (MTP)

Learn about CCS’s, Medical Therapy Program and the medical eligibility criteria for children who can access PT and OT services located in Medical Therapy Units located in schools and stand-only locations.

California Children’s Services (CCS) Program County Office Directory 

A directory that identifies the CCS county offices as dependent or independent, and the addresses of offices responsible for the county providing their administrative oversight. 

California Code of Regulations (CCR) Title 22 Social Security, Division 3- Health Care Services, Subdivision 1-California Medical Assistance Program

View an index of "Chapters" that pertain to the California Medical Assistance Program, which is the Medi-Cal program.   

California Code of Regulations (CCR) Title 22, Social Security, Division 3- Health Care Services, Determination of Eligibility and Share of Cost 

View regulations and terminology used to determine Medi-Cal program eligibility.  

California Code of Regulations (CCR) Title 22 Social Security, Division 3- Health Care Services, Definitions of Provider Types Look up definitions used in the Medi-Cal program, such as emergency services, experimental services, homebound patient, skilled nursing facility level of care, subacute level of care, etc. 

California Code of Regulations (CCR) Title 22, Social Security, Division 3- Health Care Services, Determination of Eligibility and Share of Cost 

View regulations and terminology used to determine Medi-Cal program eligibility.  

California Code of Regulations, Title 22, Social Security, Division 3- Section 51321. Durable Medical Equipment 

Learn about what items are not covered by Medi-Cal.  View citations for: (1) authorization shall not be granted for medical equipment when a household or furniture item will adequately serve the patient's medical needs and (2) DME shall be limited to the lowest cost item that meets the patient's medical needs

California Code of Regulations, Title 22, Social Security, Division 3- § 51003. Treatment Authorization Requests (TARs) 

View PDF file regarding authorization and reauthorization requests; and, citation that only allows authorization to be granted for the lowest cost item or service covered by the Medi-Cal program.