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Streamlined Procedure for ACA-Related Appeals

February 23, 2016

The streamlined appeals procedure and waiver of normal timeliness requirements discussed in this article are available for a limited period only and apply only to certain Patient Protection and Affordable Care Act (ACA) related appeals. This will be the last opportunity for providers to appeal payment or lack of payment for ACA-eligible services.

Note: This article only deals with appeals of ACA payments for Medi-Cal services. Providers with concerns about ACA payments for Child Health and Disability Prevention (CHDP) program services are referred to the November 9, 2015, NewsFlash article on the Medi-Cal website titled, “Important Notices about ACA Payments to CHDP Providers.”

The ACA required increases in the rates potentially payable to specified primary care providers. Providers were given the opportunity to attest their eligibility and to potentially receive additional ACA payments for services.

The Medi-Cal program has already paid most providers the full ACA amounts they were due, but is currently implementing an Erroneous Payment Correction (EPC) (estimated to occur January through March 2016, in phases) which will include paying remaining providers who have not yet received their full ACA amounts due.

In an effort to assist providers who successfully attested for ACA in the past and who believe an error has occurred in any of their ACA payments, the Department of Health Care Services (DHCS) is offering a streamlined procedure for providers to appeal their payments.

Eligible Providers/Claims
This special procedure only applies to appeals from providers who have already successfully attested. Note that attestation is closed. It also only applies to claims for services that are ACA-eligible and only to the following classes of claims:

  • Previously paid Medi-Cal claims, or
  • Medi-Cal crossover claims paid $0.00 with Remittance Advice Details (RAD) code 0442: Medicare payment meets or exceeds Medi-Cal maximum reimbursement.

DHCS will waive timeliness requirements for appeals of such claims if the appeals are submitted in accordance with the submission requirements discussed below and are received during the period from March 1, 2016, through June 30, 2016.

Whether to Submit an Appeal
Before submitting an appeal, providers should consider the following information to determine whether an appeal would be beneficial:

  • All providers considering an appeal should read, in its entirety, the soon to be published NewsFlash article titled, “Important Notices about ACA Payments for Medi-Cal Services.” This article can assist providers in determining whether or not they have already received the full ACA payment allowable under law on their claims.
  • In some cases ACA reprocessed claims were paid at a lower amount than a provider might have expected. This was frequently due to the provider’s original claim containing a billed amount for a given service that was actually less than the ACA payment rate for the service. Payment by Medi-Cal of the lesser billed amount on such claims was correct. This is because the law requires that DHCS not pay more than the amount a provider billed on a claim, even if the ACA would have allowed an increased payment had the provider billed a larger amount. Note that the law requires that providers bill Medi-Cal no more than their “usual and customary” fees.
  • If a provider had mistakenly billed less on a claim than their actual usual and customary amount, the provider can submit an appeal with a corrected claim attached showing their usual and customary rate as the billed amount. Increased ACA payment will be considered; however, the appeal submission requirements listed below must also be satisfied.
  • Some ACA payment amounts were slightly less than a provider might have expected due to differences in claim amounts payable based on geographic pricing. For example, a provider in one area might have received a larger payment than a provider in another area due to the fact that the ACA regulations require payments to be based on the Medicare rates in effect for each specific geographical area. Payments in such cases were correct even though providers in different areas were paid at a different rate for the same procedure.
  • For physicians whose services qualified for ACA increased payments based on the specialty they practice, ACA increased amounts were payable only for claims with dates of service within the period in which the physician was board certified, as indicated by the dates on the self-attestation information the physician had submitted.
  • For some services, the amount Medi-Cal had previously paid on an original claim was equal to or larger than the ACA payable amount. In such cases, no further ACA payment is due to the provider.

ACA Appeal Submission Requirements
In order to qualify for the streamlined appeals procedure and limited timeliness waiver, submitted appeals must meet the following requirements. Note that a provider can submit up to 14 claims with each appeal as long as all the claims are for the same recipient. If multiple claims are submitted with one appeal, ensure that all necessary documents for each claim are also attached.

  • The appeal must be received by Xerox State Healthcare, LLC during the period of March 1, 2016, through June 30, 2016.
  • Use standard Appeal Form (90-1)
  • Write or type “ACA” at the top of the Reason for Appeal field (Box 13)
  • Attach a copy of the original claim or corrected claim if corrections are needed
  • Attach all documentation which the original claim required
  • Helpful Hint: Processing of an appeal involves voiding out (i.e., recouping) the amount paid on the original claim from the provider and reprocessing (and potentially paying) the original or corrected claim that is attached to the appeal. When the appealed claim is reprocessed, it will be denied unless all the documentation that was required when the original claim was submitted is submitted with the appeal. To reduce the chances of recoupment of the original claim payment combined with a denial (rather than payment) of the reprocessed claim, it is suggested that providers attach to the appeal all the documentation that the provider sent with the original claim submission.

    Note: The Medi-Cal provider manual frequently lists required medical justification, Explanation of Medicare Benefits (EOMBs), Other Health Coverage Explanation of Benefits and other documents needed when a claim is originally submitted. Consult the provider manual for requirements.

  • For each claim, attach a copy of the most recent RAD which shows that the claim was either previously paid or was a crossover claim paid $0.00 with RAD code 0442: Medicare payment meets or exceeds Medi-Cal maximum reimbursement.

Providers with questions may call the Telephone Service Center (TSC) at 1-800-541-5555.