Cal. Code Regs. tit. 17 § 6868

Current through Register 2024 Notice Reg. No. 45, November 8, 2024

Section 6868 - Schedule of Maximum Allowances

(a) Health screening procedures. Reimbursement for the procedures listed in this subsection, when billed in accordance with this subchapter, shall be the amount billed by the provider for the procedures performed, up to the maximum allowances specified in this subsection. For purposes of this subsection: new patient means a person who has not previously received a health assessment from the examiner, and there is no health assessment record for the person established with the provider; extended visit means a visit in which the patient requires as much or more time to be given a health assessment as does a new patient; routine visit means a visit in which the patient requires less time than ordinarily needed with a new patient or an extended visit.

HEALTH SCREENING PROCEDURE	MAXIMUM ALLOWANCE
History and Physical Examination by Comprehensive Care Provider
	New Patient or Extended Visit
		Adolescent	..........................(age 12 through 20 years)	..........................$49.51
		Late childhood	..........................(age 5 through 11 years)	..........................43.32
		Early childhood	..........................(age 1 through 4 years)	..........................40.84
		Infant	..........................(birth through 11 months)	..........................38.37
	Routine Visit
		Adolescent	..........................(age 12 through 20 years)	..........................39.60
		Late childhood	..........................(age 5 through 11 years)	..........................33.43
		Early childhood	..........................(age 1 through 4 years)	..........................30.95
		Infant	..........................(birth through 11 months)	..........................28.46
By Health Assessment--Only Provider
	New Patient or Extended Visit
		Adolescent	..........................(age 12 through 20 years)	..........................43.32
		Late childhood	..........................(age 5 through 11 years)	..........................37.13
		Early childhood	..........................(age 1 through 4 years)	..........................34.65
		Infant	..........................(birth through 11 months)	..........................32.18
	Routine Visit
		Adolescent	..........................(age 12 through 20 years)	..........................37.13
		Late childhood	..........................(age 5 through 11 years)	..........................30.95
		Early childhood	..........................(age 1 through 4 years)	..........................28.46
		Infant	..........................(birth through 11 months)	..........................25.99
Pelvic Exam..........................				..........................10.00
Vision Screening
	Snellen eye test or equivalent visual acuity test
		..........................Age 7 years and older		..........................$ 2.02
		..........................Age 3 through 6 years		..........................4.00
Hearing Screening
	..........................Pure Tone Audiometry	..........................9.21
Tuberculin Testing
	..........................Multiple Puncture			..........................4.54
	..........................Mantoux (intracutaneous)			..........................7.53

(b) Laboratory Tests. For laboratory tests listed in this subsection that the provider performs, reimbursement shall be either the provider's usual charge to the general public for the test or the maximum allowance specified in this subsection, whichever is less. If a laboratory test is performed by other than the screening provider, for instance by an outside laboratory, the screening provider may bill the Department's Child Health and Disability Prevention Program for the charge made to the provider by the laboratory (except for cytologic examination of a gynecologic slide as described below), plus a charge not to exceed $4.63 for the provider's collection and handling of the specimen. The total shall not exceed the maximum allowance specified in this subsection for the laboratory test.

If a clinical laboratory performs a cytologic examination of a gynecologic slide taken during the course of a CHDP health assessment, or other laboratory services resulting from a CHDP health assessment, the clinical laboratory may bill the Department's Child Health and Disability Prevention Program the clinical laboratory's usual charge to the general public not to exceed the maximum allowance specified in this subsection. The health assessment provider may bill the program a charge not to exceed $4.63 for the provider's collection and handling of the specimen. The total charge from the clinical laboratory and the health assessment provider shall not exceed the maximum allowance specified in this subsection for cytologic tests. Clinical laboratory tests shall be performed in the manner and by persons and laboratories that meet the relevant standards established in the Health and Safety Code, the Business and Professions Code and Title 17 of the California Code of Regulations.

LABORATORY TEST		MAXIMUM ALLOWANCE
Blood Tests
	Hematocrit..........................	..........................$3.01
	Hemoglobin..........................	..........................3.01
	Sickle Cell Status (Electrophoresis)..........................	..........................30.11
	Blood Lead Screening Blood Lead Level Determination..........................	..........................22.45
Phenylalanine (PKU) Blood..........................		..........................4.54
Urine Tests
	Urinalysis, routine, complete..........................	..........................4.54
	Urine "Dipstick"..........................	..........................2.87
Tests for Microorganisms
	Culture for Neisseria Gonorrhea..........................	..........................6.02
Cytologic Tests
	Papanicolaou (Pap) Smear..........................	..........................11.22
Ova and Parasites, direct smears, concentration and identification..........................		..........................12.39
VDRL, RPR or ART..........................		..........................4.56
Chlamydia Test..........................		..........................19.25

(c) Immunizations. Reimbursement for the immunizations listed in this subsection, when billed in accordance with this subchapter, shall be the amount billed by the provider for the immunizations given, up to the maximum allowances specified in this subsection. However, if the provider uses vaccine supplied at no cost to the provider by the Department's Immunization Assistance Program, the maximum reimbursement for administration of the vaccine shall be the amount determined by the Department rather than the amount specified in this subsection. The maximum reimbursement rate for the professional component of administering an immunization under this subsection shall be $4.52. The maximum allowable reimbursement for the ingredient component of an immunization shall be based on prevailing market acquisition costs as determined by the Department's fiscal intermediary.

IMMUNIZATION

DPT (diphtheria and tetanus toxoids with pertussis vaccine) First, second, third of series; booster.

Td (combined tetanus and diphtheria toxoids, adult type)

Dd (combined tetanus and diphtheria toxoids, pediatric type)

Hib (Haemophillus Influenza Type b) vaccine

Hib (Haemophillus Influenza Type b) conjugate vaccine

HibTITER

Polio: IPV (inactivated trivalent poliovirus vaccine)

First, second, third of series, or booster

TOPV (trivalent oral polio virus vaccine) First, second, third of series; booster.

Measles vaccine

Rubella vaccine

Mumps vaccine

MR (measles, rubella) vaccine

MMR (measles, mumps, rubella) vaccine

MuR (mumps, rubella) vaccine

HBVAC (hepatitis B vaccine) (Pre-exposure)

HBIG (hepatitis B immune globulin) (Post exposure)

Cal. Code Regs. Tit. 17, § 6868

1. Amendment filed 8-1-84 as an emergency; effective upon filing (Register 84, No. 31). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 11-29-84. For prior history, see Register 81, No. 52.
2. Certificate of Compliance transmitted to OAL 11-27-84 and filed 12-27-84 (Register 84, No. 52).
3. Amendment filed 8-1-85 as an emergency; effective on filing (Register 85, No. 32). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 11-29-85.
4. Certificate of Compliance transmitted to OAL 11-20-85 and filed 12-27-85 (Register 85, No. 52).
5. Amendment of section and NOTE filed 2-23-93; operative 3-25-93 (Register 93, No. 9).

Note: Authority cited: Sections 208 and 321, Health and Safety Code, and Sections 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 323 and 323.2 (a), Health and Safety Code; and Section 14105, Welfare and Institutions Code; Items 4260-111-001, Chapter 258, Statutes of 1984, and Statutes of 1985, Chapter 111, Items 4260-111-001 and 890; and Section 655.6, Business and Professions Code.

1. Amendment filed 8-1-84 as an emergency; effective upon filing (Register 84, No. 31). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 11-29-84. For prior history, see Register 81, No. 52.
2. Certificate of Compliance transmitted to OAL 11-27-84 and filed 12-27-84 (Register 84, No. 52).
3. Amendment filed 8-1-85 as an emergency; effective on filing (Register 85, No. 32). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 11-29-85.
4. Certificate of Compliance transmitted to OAL 11-20-85 and filed 12-27-85 (Register 85, No. 52).
5. Amendment of section and Note filed 2-23-93; operative 3-25-93 (Register 93, No. 9).