DHCS announces prior authorization flexibilities and emergency coverage for Medi-Cal patients

April 28, 2020
Area(s) of Interest: Practice Management 

The California Department of Health Care Services (DHCS) recently made important changes to the prior authorization process and billing for COVID-19-related emergency services to ensure that all Medi-Cal patients will have access to medically necessary COVID-19 testing and treatment.

Coverage of Emergency COVID-19 Related Services

Emergency services are covered for all Medi-Cal patients, including undocumented beneficiaries, when necessary to treat an emergency medical condition.

During the ongoing public health emergency, DHCS is deeming COVID-19 testing and related medically necessary treatment services to be emergency services. There is no copay for emergency services including testing, evaluation and treatment for COVID-19.

When billing emergency COVID-19 testing and treatment service in an office/outpatient setting physicians should:

  1. Report Emergency Indicator=Y in field 24C of the CMS-1500 form
  2. Report Emergency indicator=81 on the UB 04 form
  3. Indicate emergency treatment on the claim and include “PATIENT IMPACTED BY COVID-19” in box 19 of the claim form
  4. Use ICD-10 U07.1 as the primary diagnosis code.
  5. Include relevant clinical information about the patient condition and why the emergency services rendered were considered immediately necessary. 

CMA asked DHCS for clarity on how physicians can comply with the requirement to include relevant clinical information about the patient’s condition and why the emergency services were immediately necessary. DHCS advised that including the appropriate COVID-19 diagnosis code, documenting the emergency condition in the medical record and complying with existing signature requirements on the claim form will ensure compliance. 

Treatment Authorization Flexibilities

Although Treatment Authorization Requests (TAR) are still required during the public health emergency, TARs can be submitted after services have been rendered. Providers should put “PATEINT IMPACTED BY COVID-19” in the “miscellaneous information” field on the TAR. TARs with this designation will be expedited and approved as appropriate. Physicians must still submit supporting documentation to justify the need or medical necessity and maintain documentation of medical necessity in the patient’s medical file.

For TARs that are already authorized, providers can extend the “through date” if needed through the eTAR system. Physicians should put “PATIENT IMPACTED BY COVID-19” the “miscellaneous information” field.

Questions regarding COVID-19 billing can be directed to DHCS at (800) 541-5555.




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