CMS Net Provider EDI (Children’s Medical Services Network Provider Electronic Data Interchange)
CMS Net Provider EDI is a web-based tool that enables approved CCS and GHPP providers and Medi-Cal Managed Care Plans to electronically access the status of Requests for Services/Authorizations. Providers and plans have access to view service authorizations, have the ability to print service authorizations, denial and Notices of Action letters. In addition, for providers approved as a Trading Partner, have the ability to submit electronic Service Authorization Requests (eSARs) to the CCS or GHPP Programs through the PEDI web portal.
- The information obtained through the CMS Net PEDI is real time.
- Each provider or plan shall have a minimum of one, designated PEDI liaison(s) that shall be responsible for all communication with the State Information Technology Section (ITS) for coordination of users within the organization and dissemination of PEDI id’s and passwords. The PEDI liaison(s) shall also be responsible for submitting staffing changes (provider separation, user modification, new users, etc.) including status of their position, via the CMS Net PEDI web portal.
Each provider or plan must have internal agreements at their site between services including, but not limited to: Inpatient Services, Outpatient Clinics, Emergency Services, CCS and GHPP approved Special Care Centers regarding the internal distribution of CCS and GHPP service authorization information.
- Each provider or plan must assure that they have written permission from the providers within their domain to access the providers’ individual authorizations. (This requirement is not applicable to health plans.)
- If the provider/plan is approved for PEDI, the County and or/Regional Office will not provide hard copies of SARs, NOAs or other correspondence related to cases. Exceptions to this rule may be made for newborns using mom’s Medi-Cal eligibility and technical malfunctions.
- For Managed Care Plans (MCP) that subcontract with another Health Care Provider or Plan, the PEDI enrolled Plan is responsible for providing the SARs, NOAs or other applicable information to the subcontracted plan.
- Where feasible each provider or plan must be willing to enter into reciprocal agreements with State and local CCS programs permitting electronic access to medical information regarding CCS and GHPP beneficiaries.
Pharmacy Providers – Pharmacy providers are approved on a case-by-case basis. Pharmacy providers will have access to SARs issued to their specific National Provider Identifier (NPI), which includes CCS-restricted drugs, enteral nutrition products, and certain medical supplies. Pharmacy providers will not have access to view SARs issued to Physicians or Special Care Centers with Service Code Groupings (SCG 01, 02, etc.).