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Frequently Asked Questions for Referral Providers Newly added


Eligibility Questions

How do we verify patient eligibility for EWC?

Before providing services, referral providers should verify that: (1) the patient's identification number is active; (2) the patient is age-eligible for the indicated procedure; and (3) the procedure is covered by EWC.

(1) The patient's identification number is active

In order to verify that the patient's EWC identification number is active, the referral provider should check the dates on her ID card.

(2) The patient is age-eligible for the indicated procedure

The patient must also be age-eligible for the service. Age criteria include:

  • Cervical Services: age 21 and over
  • Breast Cancer Screening Services: age 40 and over
  • Breast Cancer Diagnostic Services for Symptomatic: any age 

(3) The procedure is covered by EWC

Finally, the indicated procedure must be covered by EWC: Click here for a list of EWC provider covered procedures forms under "PDF Forms" on the EWC Provider Tools and Links section of this website.


Covered Procedures Questions

How do we know if a procedure is covered by EWC?

A full list of covered procedures can be found in the EvWoman section of the Medi-Cal Manual. Referral providers may bill EWC for all procedure codes marked with a dot (•) in the list under the approved procedures.

A full list of referral provider covered procedures form can be also found under "PDF Forms" on the EWC Provider Tools and Links section of this website

If a patient had a screening mammogram recently but now has symptoms, can we do a diagnostic mammogram or ultrasound?

Yes! EWC covers breast diagnostic testing for all eligible symptomatic individuals of any age.

Does EWC cover tomosynthesis or breast MRI?

At this time, EWC does not cover tomosynthesis or breast MRI. We are looking into the possibility of having tomosynthesis covered in the future.

Does EWC cover pelvic ultrasound?

No. EWC does not cover pelvic ultrasound under any circumstances.


Billing Questions

How do we bill EWC?

EWC claims should be submitted using the same process as Medi-Cal claims. Referral providers must have the recipient's 14 character ID number found on the EWC ID card (see Question "How do we know if a procedure is covered by EWC?" ). Click here for a "Covered Procedures and Diagnosis Code Look Up Tool ICD10 Version."

Remember, patients cannot be billed for EWC services. You must accept the EWC payment as payment in full. Patients cannot be billed directly for services not covered by EWC without a full disclosure of the cost and the patient's written authorization.

Claims can be submitted either by hard copy or electronically using CMS-1500 or UB-04. EWC billing examples for both forms are available on the Medi-Cal website under Provider Manuals. Providers who submit hard copy claims must send them to the appropriate address for their claim type as follows:

Medical Services (CMS-1500) Outpatient Services (UB-04)
Xerox State Healthcare, LLC
P. O. Box 15700
Sacramento, CA  95852-1700
Xerox State Healthcare, LLC
P. O. Box 15600
Sacramento, CA  95852-1600

How do we manage requests for prior authorization?

Prior authorization is not required for EWC patients. EWC is a fee-for-service program. However, in order to be reimbursed for a claim, the referral provider must ensure that the patient's identification number is active, that the patient is age-eligible for the service, and that the procedure is covered by EWC (see Question "How do we know if a procedure is covered by EWC?" ).

Why do we receive claim denials?

Here are some of the common denials you might receive:

The recipient is not eligible for benefits under the Medi-Cal program or other special programs.

  • You may receive this denial because the recipient's number has expired. It is important to check the dates on her card before providing services. Nevertheless, if a procedure has been performed on a woman with an expired card, she has 30 days of retroactive eligibility. Therefore, it is extremely important to refer her back to her PCP's office for recertification.

The recipient is not eligible for the special program billed and/or restricted services billed.

  • This usually means that the patient is eligible for EWC but the service is not covered by EWC – it is not on the list of covered procedures (e.g. breast MRI).

 The procedure is not consistent with the recipient's age

  • This denial is issued because the patient is not age-eligible for the service rendered (e.g. a screening mammogram on a 35 year old woman is not a covered procedure).

Invalid Cancer Detection Programs:  Every Woman Counts recipient ID

  • This denial is often caused by the recipient's ID being entered incorrectly. You may wish to double check that the ID number was entered correctly on the claims form.

How should we manage denied claims? Whom do we contact?

The first step is to follow the instructions above to double check the patient's recipient id number and expiration dates and to ensure that the service was an EWC-covered procedure for a woman of that age.

Second, you may call the Telephone Services Center at 1-800-541-5553 from 8 a.m. - 5 p.m. Monday through Friday. Click here for a link to the TSC main menu prompts. You may wish to ask for an issue number during this call.

You may also contact your Region's Clinical Coordinator for assistance. For your Region's contact information, click here. If you have spoken with the Telephone Services Center, please provide your Clinical Coordinator with the issue number provided during this call.

If a patient is being sent to collections for failing to pay a bill for a service that is covered by EWC, whom should we contact?

Clinical Coordinators cannot contact collection agencies. The facility that sent the patient's claims to collections must contact the collections agency and pull the request. The referral provider can then resubmit the EWC claim.


Breast and Cervical Cancer Treatment Program (BCCTP) Questions

Whom do we contact with questions about BCCTP?

BCCPT enrollment information is available from a BCCTP eligibility specialist at 1-800-824-0088 and on the Medi-Cal website. EWC and Family PACT PCPs may enroll patients who need treatment into BCCTP.

How do we know what is covered under BCCTP?

Coverage through BCCTP depends on whether the individual has qualified for federal BCCTP or state-funded BCCTP. Individuals who are approved for federal BCCTP may receive full scope Medi-Cal coverage while individuals who qualify for state-funded BCCTP may have limited scope Medi-Cal benefits. Once a patient is enrolled, however, she will be eligible for most services that are directly related to the individual's cancer treatment. For more information, call BCCTP at 1-800-824-0088.


Miscellaneous Questions

How can I become an EWC provider?

Referral providers do not need to enroll as EWC primary care providers but must be Medi-Cal providers in good standing. Providers who are interested in becoming an EWC PCP providers should contact the EWC Clinical Coordinator in their region. Clinical Coordinators can also provide links to support and advocacy groups as well as the latest information on what's happening in their communities. A list of EWC Clinical Coordinators for each region in California can be found here.

What services does FamilyPact (FPACT) cover?

FPACT provides family planning services, including all FDA-approved contraceptive methods and supplies, testing and treatment for sexually transmitted infections, HIV screening, cervical cancer screening, and limited infertility services.

A link to the procedures covered by FPACT can be found here on the FPACT website.


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Last updated: June 19, 2017

 
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