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LEA Claims Billed with CPT Code 96130 Erroneously Denied

January 30, 2019

The Department of Health Care Services (DHCS) has identified a claims processing issue causing claims with CPT code 96130 (psychological testing evaluation services by physician or other qualified health care professional; first hour) to be erroneously denied with Remittance Advice Details (RAD) Code 0037: Health Care Plan enrollee, capitated service not billable to Medi-Cal. The issue affects Local Educational Agency (LEA) Medi-Cal Billing Option Program claims for dates of service on or after January 1, 2019.

No action is required of providers. DHCS and the California MMIS Fiscal Intermediary are working to resolve this issue. Providers should continue to submit claims in a timely manner and are encouraged to check the Medi-Cal website regularly for updates regarding this issue.