This document provides an overview of the California Children's Services (CCS) Program and the Genetically Handicapped Persons Program (GHPP). It discusses eligibility requirements, covered services, referral processes, billing statuses, and the roles of providers. Key points include that CCS serves children with certain medical conditions who meet residential, financial, and medical eligibility, while GHPP serves adults with specified genetic diseases. Referrals are made to local CCS county offices or the state GHPP office by submitting a Service Authorization Request form. Providers must be paneled and authorized to provide services to CCS and GHPP clients.

1. California Children’s Services (CCS) Genetically
Handicapped Persons Program (GHPP) Authorization
and Claims Enhancement
Class #: 22
Presenter: Harry Chang/Barbara Sasaki
ID: U

2. Purpose and Objectives

3. The purpose of this module is to provide an
overview of the California Children’s Services
(CCS) Program and the Genetically
Handicapped Person Program (GHPP) and
highlight important program requirements
required from Providers and Beneficiaries.
Purpose

4.  Understand the CCS
& GHPP Program
requirements
 Identify important
CCS & GHPP contact
information
Objectives

5. Resources

6. Medi-Cal Subscription Service (MCSS)
MCSS is a free subscription service
that enables providers and others
interested in Medi-Cal to receive
subject-specific links to Medi-Cal news,
Medi-Cal Update bulletins, urgent
announcements and/or System Status
Alerts via email.
For more information and subscription
instructions, visit the MCSS Subscriber
Form at (www.medi-cal.ca.gov/mcss).

7. Provider Manual References – Part 2
California Children’s Services
(CCS) Program (cal child)
California Children’s Services
(CCS) Program Eligibility (cal
child elig)
California Children’s Services
(CCS) Program County Office
Directory (cal child county)
California Children’s Services
(CCS) Program Special Care
Centers (cal child spec)
Genetically Handicapped
Persons Program (GHPP)
(genetic)

8. Department of Health Care Services
Systems of Care Division

9. The Systems of Care Division (SCD) of the Department of Health Care
Services (DHCS) is responsible for the administration and oversight of
programs that focus on children and adults with special health care needs.
SCD focuses on high-risk, high-cost child and adult populations and
programs:
• California Children’s Services (CCS)
• High-Risk Infant Follow-up Program (HRIF)
• Medical Therapy Program (MTP)
• Child Health and Disability Prevention (CHDP) Program
• Health Care Program for Children in Foster Care (HCPCFC)
• Newborn Hearing Screening Program (NHSP)
• Genetically Handicapped Person Program (GHPP)
• Palliative Care Waiver Program
The mission of SCD is to assure access to health care services for children
and adults with special health care needs.
http://www.dhcs.ca.gov/Pages/default.aspx

10. California Children’s Services (CCS)
Health and Safety Code, Section 123800 et seq. is the enabling statute for the
CCS program and is governed by the Welfare and Institutions Code Section
14094-14094.3 and the California Code of Regulations (Title 22, Section 51013)

11.  Program providing healthcare services for children that meet 1)
residential, 2) financial, & 3) medical eligibility requirements and are
between birth and up to 21 years of age.
• Residential: Must be residing in the county that they are seeking
services for
• Financial: Must have an Adjusted Gross Income (AGI) < $40,000 or
related medical costs of 20% of AGI
• Medical: Full description of all CCS Program eligible conditions can be
found here:
http://www.dhcs.ca.gov/services/ccs/Pages/medicaleligibility.aspx
• MTP/MTU: Sub program that provides OT/PT and other related
services that are delivered in public school settings
• Inquiries/Questions: Refer to pg. 9 for County contact information and
statuses or found online (http://www.dhcs.ca.gov/services/medi-
cal/Pages/CountyOffices.aspx)
 SAR and client inquiries should be directed to county offices
What is CCS?

12. Affordable Care Act (ACA)/Managed Care
Plans (MCPs)
• Many Medi-Cal eligible children with CCS
Program-eligible medical conditions are
enrolled in Medi-Cal managed care
plans. Services to treat a child’s CCS
Program-eligible medical condition are
“carved out” of the plan’s fiscal
responsibilities.
• The Medi-Cal MCPs in these six counties
are responsible to pay for primary AND
preventative care AS WELL AS the CCS
eligible medical condition diagnosis and
treatment.
CCS and ACA
County Organized Health
Systems (COHS)
Santa Barbara CenCal Health
San Mateo Health Plan of San
Mateo
Solano Partnership Health Plan
Marin Partnership Health Plan
Napa Partnership Health Plan
Yolo Partnership Health Plan

13. CCS Billing Statuses
OHC Medi-Cal OTLICP *CCS
Private Federal Federal State
*Except for those counties where
CCS services are carved in.
Client statuses:
• CCS/Medi-Cal, Full Scope: CCS clients who are eligible for full-scope no Share of
Cost (SOC) Medi-Cal.
• CCS/Medi-Cal, Share of Cost: CCS clients who must pay a determined portion of
the medical costs prior to Medi-Cal coverage.
• CCS Only: CCS clients who are not eligible for Medi-Cal.
• CCS/OTLICP: CCS Clients who prior to 2014 were, or would have been, enrolled
in California’s State Children’s Health Insurance Program (SCHIP).
Commercial Health Insurance/Other Health Coverage (OHC):
• Providers must submit an Explanation of Benefits (EOB) or a valid denial letter
from the OHC with every claim.
Payer of last resort:

14. GHPP Health Care
Services
GHPP provides authorization for health care services
for adults with genetic diseases specified in the
California Code of Regulations (CCR), Title 17,
Section 2932.

15. GHPP Referral Requirements
 Residential: Must be a resident of California
 Financial: No income limits
• Clients between 200% – 299% of Federal Poverty Level
(FPL) are required to pay a fee of 1.5% of their AGI.
• Clients at or above 300% of FPL are required to pay a fee of
3% of their AGI.
 Medical: Full description of all GHPP Program eligible
conditions can be found here:
http://www.dhcs.ca.gov/services/ghpp/Pages/MedicalEli
gibility.aspx
 Over the age of 21 years

16. Affordable Care Act (ACA)/Managed Care Plans (MCPs)
• Some GHPP clients are also Medi-Cal eligible and are enrolled in Medi-Cal’s MCPs. In such
cases the plans are capitated and are responsible for providing comprehensive health care to
these GHPP clients, including services to treat their GHPP-eligible conditions.
• Providers must submit claims for authorized services rendered to the GHPP/Medi-Cal clients
enrolled in these plans to the plan directly.
GHPP & ACA
GHPP Billing Statuses
Client statuses:
• GHPP/Medi-Cal: GHPP clients enrolled in Medi-Cal MCPs
• GHPP/Other Health Coverage (OHC): GHPP clients with other health coverage either Medi-Cal,
Commercial or Private.
• Providers must submit an Explanation of Benefits (EOB) or a valid denial letter from the OHC
with every claim.
Payer of last resort:
OHC Medi-Cal GHPP
Private Federal Federal

17. GHPP Contact Info
Inquiries/Questions/Referrals:
P: 916-327-0470
P: 800-639-0597 (Toll-Free)
F: 916-440-5318
Genetically Handicapped Persons Program
1515 K Street, Suite 400
MS 8100, P.O. Box 997413
Sacramento, CA 95899-7413

18. Referral Process

19. Service Authorization Requests (SARs)
Requests for authorization of services
 CCS requests are submitted to the local CCS county office
where the child resides. (See pg 10-17)
 Independent Counties: have delegated authority to approve
Financial, Residential, and Medical eligibility; population
greater than 200,000
 Dependent Counties: have delegated authority to approve
Financial, Residential eligibility, the state is responsible for
Medical eligibility; population less than 200,000
 GHPP requests are submitted to the State office.
Fax: (916) 440-5318
 Type of SARs - New Referral & Established

20. Referral Process
Who can make a referral to the GHPP or CCS Program?
• Anyone can make a referral to the GHPP or CCS Program
• Family Doctor
• Physician Specialist
• Public Health Nurse
• Family
• School
Minimum requirements:
• Applicant Info: First & Last Name, DOB, Address, & Contact
Number
• Parent or Legal Guardian: First & Last Name
• Services requested: A statement listing the services requested
for the applicant
• Person/Agency requesting services: Name and address of
individual or agency requesting services
• Related medical documentation

21. Referral Process
 CCS and GHPP referrals should be made to the CCS Program or GHPP
as early as possible.
 CCS and GHPP does not pay for services provided before the date of
referral, unless the applicant is full-scope Medi-Cal, no share of cost.
 Once all eligibility is verified, the case will remain open for a maximum of
365 days before being reconsidered for eligibility.
Diagnostic and Treatment
Services
 A case may be temporarily opened to confirm CCS or GHPP medical
eligibility of the client; no other services may be authorized during this period.
 Only services related to the CCS-eligible or GHPP-eligible condition will be
covered

22. Provider Electronic Data
Interchange

23. Provider Electronic Data Interchange (PEDI)
Is an on-line interface application for approved
Providers, Hospitals and Managed Care Plans
to search for California Children Services
(CCS) and Genetically Handicapped Persons
Program (GHPP) Service Authorization
Requests (SARs).
SARs for all counties and GHPP are included.
PEDI is accessed via a secure Department of
Health Care Services (DHCS) website, and
encompasses security measures for access.

24. Provider Electronic Data Interchange (PEDI)
https://cmsprovider.cahwnet.gov/PEDI/piplogin.jsp

25. Provider Electronic Data Interchange (PEDI)
PEDI will allow you to:
 Determine if the CCS Independent County, Regional Office or GHPP has entered
your Request for Service.
 Determine the status of your Request for Service (i.e. authorized, denied,
modified, or cancelled).
 Print copies of SAR’s, Notices of Action, or Denial letters.
 Search CCS and GHPP Client Eligibility and generate various Activity and Client
Reports.
 Information obtained through PEDI is real time.
For additional information or an Application, please contact the DHCS CMS Net
Help Desk at (866) 685-8449.

26. Provider Paneling

27. Provider Paneling
What is Paneling?
 Paneling is a process that the CCS program uses to
determine if a provider meets the advanced
education, training and/or experience requirements
for his or her provider type in order to render services
to provide services for CCS clients or applicants with
special health care needs.
 Must be a Medi-Cal Provider before
becoming a CCS Provider
 Providers are not required to be paneled with
GHPP.
 If there are any questions regarding the submission
of the application please contact the Provider
Services Unit at (916) 322-8702.

28. Paneling Requirements
 A National Provider Identifier (NPI) OR the facility/employer’s NPI:
 For some Allied Health Providers
 For physicians of a Rural Health Clinic (RHC) or Federally
Qualified Health Center (FQHC)
 National Provider Identifier (NPI) registered with the DHCS Medi-Cal.
 Current Medical License
 Must Be Board Certified
 Current Board Certificate in Specialty or Subspecialty
Specialty Physicians
 Current medical license from the Medical Board of California or from
the Osteopathic Medical Board of California
 Must be board certified by the American Board of Medical Specialties
 Physicians who are not board certified, but who are board
eligible by training and experience for the certifying examination,
may participate in the CCS Program for no more than three
years.
28

29. Paneling Requirements
Family Practice Physicians
 Be currently licensed as a physician by the California Board of
Medical Quality Assurance
 Be certified by the American Board of Family Practice
 Be approved for participation in the Child Health and Disability
Prevention (CHDP) Program.
 Providers not working for a CHDP-approved facility must
have documented experience treating children with CCS
Program-eligible medical conditions for at least five years,
or have treated 100 or more such children.
Podiatrists
 Podiatrists must be licensed to practice podiatric medicine by the
California Board of Podiatric Medicine
 Be certified by the American Board of Podiatric Surgery or the
American Board of Podiatric Orthopedics
 Have documented experience treating children with CCS
Program-eligible medical conditions for at least five years, or
have treated 100 or more such children

30. Allied Health Provider Paneling
 SCD requires that all physicians and some Allied Health Professionals be CCS
paneled in order to be issued an authorization to provide services to CCS clients.
 Refer to the workbook for special requirements for Allied Health Provider
Paneling.
The following provider types require paneling:
* Provider types
with program
participation
limitations
Occupational Therapists Physical Therapists Respiratory Care Practitioners
Orthotists & Prosthetists Podiatrists Social Workers
Audiologists Pediatric Nurse Practitioners * Psychologists Speech-Language Pathologists
Dietitians Physicians Registered Nurses

31. Paneling Categories for Physicians
Full Approval Status
 Physician applicants who meet all criteria required for
paneling.
Provisional Status
 If the physician is board eligible for the American Board
of Medical Specialties, provisional paneling status will
be given to the physician for three years upon
completion of residency or fellowship training.
Exceptional Status
 The provider does not qualify for either status above
and requires CCS Medical Director review.

32. Web-Based Paneling Application
Submission
 This application allows providers to apply on-line for
California Children's Services (CCS) Paneling and
immediately view the status of the submitted application.
 Providers may track their application status on line with a
unique tracking number.
 Providers will receive an immediate on-line approval or
requested to submit additional documentation necessary
to process their paneling applications.
 Web Paneling URL:
https://cmsprovider.cahwnet.gov/PANEL/index.jsp
 For questions related to CCS paneling, please contact the
Provider Services Unit at 916-322-8702.

33. Hospital & Special Care Centers
Standards
 The CCS Program approves and assigns various types of hospital approval levels
 Tertiary, Pediatric Community, General Community, Special Hospital, and Limited
Hospital
 Hospital standards can be found at the following link:
http://www.dhcs.ca.gov/services/ccs/Pages/ProviderStandards.aspx
Special Care Centers
 SCCs provide comprehensive, coordinated health care organized around a specific
condition or system. SCCs are comprised of multi-disciplinary, multi-specialty
providers who evaluate the client's medical condition and develop a family-centered
health care plan to facilitate the provision of timely, coordinated treatment.
 CCS Special Care Centers and Standards can be found at:
http://www.dhcs.ca.gov/services/ccs/Pages/providerstandards.aspx
 GHPP Special Care Centers and Standards can be found at:
http://www.dhcs.ca.gov/services/ghpp/Pages/SpecialCareCenters.aspx

34. Approved CCS Providers
 "Approved Hospital" means a facility which has been determined
by the CCS program to meet the requirements in order to render
services to a CCS applicant or client.
 "Approved Prosthetic/Orthotic Facility" means a facility which
has been determined by the CCS program to meet the requirements
in order to render services to a CCS applicant or client.
 "Paneled Non-PMF Provider" means providers required to be
paneled but not required to obtain a Medi-Cal provider number.
 "Paneled Provider" means an individual who has been determined
by the CCS program to meet the advanced education, training,
and/or experience requirements for his/her provider type in order to
render services to a CCS applicant or client.
This site contains a list of approved Providers:
http://www.dhcs.ca.gov/services/ccs/Pages/CCSProviders.aspx

35. SARs & SCGs

36. Authorization
 The GHPP and CCS Program requires prior authorization for health
care services related to a CCS or GHPP client’s eligible medical
condition.
 Services may be authorized for varying lengths of time during
the client’s program eligibility period.
 SARs should be submitted to client’s County CCS office.
 Service Authorization Requests (SARs) are used:
 To refer/enroll new clients into the Program.
 By providers to request services for eligible clients.
 To approve requested services for eligible clients.
o Should be accompanied by supporting medical documentation
 Fillable forms can be found here:
 New Referral SAR
http://www.dhcs.ca.gov/formsandpubs/forms/Forms/ChildMedSv
cForms/dhcs4488.pdf
 Established Client SAR
http://www.dhcs.ca.gov/formsandpubs/forms/Forms/ChildMedSv
cForms/dhcs4509.pdf

37. Service Code Groupings (SCGs)
What are service code groupings?
 SCGs are groups of reimbursable codes that are authorized to
CCS Program-paneled or approved providers for the care of a
client’s CCS Program or GHPP-eligible medical condition.
 A SCG SAR enables the provider to render care to a CCS client
without needing to obtain repeated single authorizations for
services.
 Currently there are 12 SCGs, as indicated in the list below:
01 – Physician 05 – Cochlear Implant Centers 09 – Chronic Dialysis Clinics
02 – Special Care Center 06 – High Risk Infant Follow-up 10 – Ophthalmology
03 – Transplant 07 – Orthopedic Surgeon 11 – Medical Therapy
04 – Communication
Disorder Center
08 – Rural Health Clinic/Federally
Qualified Health Center
12 – Podiatry

38. SCG Descriptions
 01-Physician
A list of procedure codes specifically for physicians.
 02- Special Care Center
Special Care Centers (SCCs) includes all procedure codes available in preceding physician SCG 01
in addition to procedure codes for diagnostic studies relative to SCC-unique services.
 03-Transplant
The Transplant Center SCG includes all procedure codes available in preceding physician SCG 01
and Special Care Centers SCG 02 in addition to procedure codes for diagnostic studies relative to
Transplant Center unique services.
 04-Communiation Disorder Center
A list of procedure codes specifically for Communication Disorder Centers.
 05-Cochlear Implant Centers
A list of procedure codes specifically for Cochlear Implant Centers.
 06-High Risk Infant
A list of procedure codes specifically for High Risk Infant Follow-Up services

39.  07-Orthopedic
The orthopedic surgeon SCG includes all codes available in preceding physician SCG 01 in addition
to procedure codes for diagnostic studies relative to CCS-eligible orthopedic services.
 08-FQHC/RHC
A list of procedure codes specifically for Rural Health Clinic (RHC) and Federally Qualified Health
Center Code Group 08 (FQHC) all-inclusive per visit codes.
 09-Chronic Dialysis Clinics
A list of procedure codes specifically for Chronic Dialysis Clinics.
 10-Ophthamology
A list of procedure codes specifically for Ophthalmologists diagnosis and treatment.
 11-Medical Therapy
A list of procedure codes specifically for Physical and occupational therapists diagnosis and
treatment.
 12-Podiatry
A list of procedure codes specifically for Podiatrists diagnosis and treatment.
SCG Descriptions

40. Sharing SARs – Physician Authorization
The physician’s authorization SCG 01 number is shared with other health care providers that the
physician has requested for diagnostic services, supplies or equipment, such as:
1. Physician Specialists- Initial referral consultation visits
2. Laboratory- Laboratory tests related to the client’s eligible medical condition and requested by the
authorized physician or physician designee if the service codes are listed in the physician SCG (01).
3. Radiology- Radiology tests related to the client’s eligible medical condition and requested by the
authorized physician or physician designee if the service codes are listed in the physician SCG (01).
4. Pharmacy- Drugs prescribed by the authorized physician or physician designee are covered in the
physician SCG and do not require a separate authorization. Specific drugs require authorization
when prescribed separately or included in a compound.
5. Medical Supplies- A separate SAR is required for medical supplies if the billing limits of the
product(s) (for example, quantity) are exceeded, in accordance with Medi-Cal policy, or there is
no specific code for the medical supply.

41. Durable Medical Equipment (DME)
The CCS Program requires that DME requests must be
requested by a CCS–paneled physician. The GHPP does not
require physicians to be paneled.
The provider prescribing the DME must have a SCG SAR that
includes the dates of service on which the DME is dispensed.
The “date of delivery” to the beneficiary is the “date of service”.
In addition to the Medi-Cal Provider Manual DME requirements,
the CCS Program and GHPP require the following information
with the SAR:
 Signed prescription
 Detailed description of DME
 Rental or purchase
 Appropriate HCPCS code
 List of any additional billable accessory (description, HCPCS
code, and quantity of each)

42. Durable Medical Equipment (DME)
The CCS and GHPP Program requires that the
appropriate modifier be included on the request for DME
items:
 NU- New equipment, purchase
 RR- Rental
 RA – Replacement - Used to indicate replacement
vision care frames and lenses.
 RB - Replacement as part of a repair - Used to
indicate replacement parts during repair of Durable
Medical Equipment (DME), including parts of
eyeglass frames.

43. Inpatient Hospital Authorizations
There are two components to authorizations for an inpatient hospital stay:
 Physician Authorization
 Hospital Authorization
 Designated Public Hospital Authorization - # of per diem days
requested for inpatient episode
o The anticipated inpatient admission
o The number of per diem days approved for the inpatient episode
 Private Hospital Authorization – Diagnosis Related Group (DRG);
authorization for 1 day, typically admission date
The paneled physician with primary (Admitting/Attending) responsibility for
the CCS client while hospitalized requires an authorization from the CCS
Program.
 If the admitting physician already has an existing SCG SAR for the
client, a separate SAR is not required.
 The admitting physician’s authorization may be shared with other
physicians as requested by the authorized physician.

44. Surgery Authorizations
A separate SAR from the Inpatient Hospital Authorizations.
Is composed of two components:
 Physician: Authorization from the Program for all related surgical
procedures.
o The SAR must include all specific procedure codes anticipated for
the surgery.
 Facility authorization: Hospitals must submit a separate SAR for the
number of inpatient days required for the surgical procedure and
postoperative care.
o If the CCS client requires additional time in the hospital, the
hospital must request a modification of the authorization to include
the additional days. (Does not apply for DRG facilities.)

45. Outpatient Surgery Authorizations
CCS/GHPP Program: Physician Authorization
The paneled physician must request authorization for surgery
with all specific anticipated procedure codes and an SCG 01
code. Surgery authorizations for elective surgery may be
requested for a specified time period during which the surgery
can take place.
Note: An SCG 51 code authorization for surgery may be issued when
requested and there is confirmation that there is a CCS Program-eligible
medical condition requiring surgery and all CCS Program eligibility
requirements are met.
Outpatient Surgery Facility Authorization
The physician’s authorization must be shared with the
outpatient surgery facility. The outpatient surgery facility must
bill utilizing the physician’s authorization and indicate the
authorized physician’s provider number as the referring
provider.
Note: Outpatient facilities are not required to be CCS or GHPP approved.

46. Physical, Occupational, and Speech Therapy
Authorizations
 SARs for physical, occupational and speech therapy services must be
submitted to the local CCS County Program or the State SCD GHPP office.
 The requested therapy must be for the treatment of the client’s CCS Program-
or GHPP-eligible medical condition.
 Requests must include:
1. procedure codes
2. number of therapy visits
3. time period
4. physician prescription
5. medical necessity
6. current therapy report
Note: The CCS Program’s therapy SARs will only be accepted for review from CCS-paneled
therapists. GHPP therapy providers are not required to be paneled.

47. Home Health Agency Service Authorizations
Home Health Agencies (HHA) services, related to the client’s CCS
Program- or GHPP-eligible medical condition and requested by the
authorized physician for the CCS Program or GHPP client, may be
requested by submitting a SAR to the appropriate program.
An authorized physician treating client as an inpatient may proactively
request authorization for anticipated post-discharge HHA services at
the same time as the inpatient request.
 The physician may request HHA services using the CCS/GHPP
New Referral SAR form.
 The CCS Program or the GHPP may authorize the initial home
assessment and up to three additional visits if requested by the
discharging physician at the time of the CCS Program or the
GHPP client’s discharge from the inpatient stay. For additional,
medically necessary HHA visits, a SAR and the signed plan of
treatment must be submitted for authorization.
 HHA services not prior requested by the physician, must be
submitted within three working days of the date the services
started.

48. SAR Status Notification
Once a SAR has been received and processed by the
GHPP or CCS Program, the provider will receive written
notification from the GHPP or CCS Program regarding the
status of the submitted SAR. There are four types of SAR
status a provider may receive:
 Authorized (Example located within your
workbook)
 Denied
 Modified
 Cancelled
If a SAR is denied, the family will receive a denial letter
from the GHPP or CCS Program with instructions on how to
appeal. This denial may be used as documentation for
follow up.

49. Modifying a SAR
 Begin date (may only be back-dated)
 End date (may only be extended)
 Units (may only be increased)
 Quantity (may only be increased)
 Inpatient Number of Days (Now tied to
DRGs)
 Additional codes/service code
groupings may be added (additions
only, codes may not be changed)
 Authorized By, Primary and
Secondary DX may be modified
 Special Instructions may be deleted
or changed
SARs may by modified for one or more of the following reasons:

50. Cancelled SARs
 Once a SAR has been “Authorized,” or “Modified” the
SAR may only be “Cancelled”.
 Cancelled SARs are still valid for the specific date
range of the cancelled SAR.
For example: If the SAR status is Cancelled and the
effective date range of the SAR is January 1, 2013 –
January 15, 2013, providers are authorized to bill for those
dates of service.

51. Objectives Met
• Identified CCS program and GHPP
requirements
• Identified important SCD, CCS, GHPP,
DHCS and DHCS FI contact information

52. California Children’s Services (CCS) Genetically
Handicapped Persons Program (GHPP) Authorization
and Claims Enhancement
Class #: 22
Presenter: Harry Chang/Barbara Sasaki
ID: U

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