Medi-Cal Update

Part 1 - Program and Eligibility | March 2017

Print Medi-Cal Update
 

1. Remittance Advice Detail Code 010: Denials for Duplicate Claims

A frequent cause of claim denials by Medi-Cal is due to incorrect recipient admission and discharge dates and/or incorrect patient status codes submitted by providers. Erroneous “from-through” dates or patient status billed by one provider and paid by Medi-Cal can result in the denial of correct claims billed by another provider. This often occurs between hospitals and nursing homes during the transfer of the recipient. Providers see this on their Remittance Advice Details (RADs) as a claim denied by RAD code 010.

Should the denied provider choose to dispute the claim and there is no resolution between the two providers regarding the dates in question, Medi-Cal could recoup the full reimbursement of the original erroneously paid claim, and will not make an adjustment without a correction request from that provider.

Incorrectly paid and denied claims can also create incorrect provider reimbursement data and inaccuracies in the health service records that may impact beneficiary share of cost, access to services and estate recovery.

For assistance in resolving these issues, providers are advised to write to the Correspondence Specialist Unit at:

Correspondence Specialist Unit
P.O. Box 13029
Sacramento, CA 95813-4029

For information about proper claim form completion, refer to the claim completion section in the appropriate Part 2 manual.

Print Article | Return to Top
 

2. TSC Phone Prompt Menu Updates

The Telephone Service Center (TSC) has recently updated the prompt menu for the interactive voice response system to include more direct access to Every Woman Counts (EWC) system and billing inquiries.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Part 1 provrelfrm1ref (1)
Print Article | Return to Top
 

3. ORP related RAD Code and Correlation Table Updates

Effective April 1, 2017, the mappings for national Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC) will change for Ordering, Referring and Prescribing (ORP) related Remittance Advice Details (RAD) codes 0558, 9253, 9254 and 9255.

In addition, the following ORP related RAD messages are added to help reconcile provider accounts:

Addition Code Message
9275 ORP ID not found on the NPPES Master File.
9276 The ORP not an individual (Type 1) Provider on the NPPES Master File.
9277 The ORP ID is not active within the status effective dates on the NPPES Master File.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Part 1 remit cd 9000 (24); remit elect corr 500 (11); remit elect corr 9200 (7, 8, 10, 11); remit elect corr rarc (3, 5)
Print Article | Return to Top
 

4. AEVS: Carrier Codes for Other Health Coverage: March 2017 Update

The AEVS: Carrier Codes for Other Health Coverage list has been updated. These codes are updated monthly. Additions and changes are shown in bold and underlined type on the updated provider manual pages. Updates are listed below.

Addition(s)
Code Carrier    
B019 BLUE SHIELD OF CALIFORNIA    
H101 HEALTH EDGE    
U119 UNIFIED HEALTH ONE    
       

Print Article | Return to Top
 

5. Aid Codes for the Medi-Cal County Inmate Program

Effective for dates of service on or after April 1, 2017, providers may submit claims for the Medi-Cal County Inmate Program (MCIP) with the following aid codes:

MCIP Program Aid Codes
Adult County Inmate Program (ACIP) F3, F4, G3, G4, N7, N8, N0
Juvenile County Ward Program (JCWP) G5, G6, G7, G8
County Compassionate Release Program (CCRP) and County Medical Probation Program (CMPP) J1, J2, J3, J4, J5, J6, J7, J8, K6, K7, K8, K9

The county may reimburse a Medi-Cal provider to the extent required or otherwise permitted by state and federal law to arrange for services for the MCIP-eligible inmate. Additional amounts will be paid entirely with county funds, and will not be matched with federal financial participation.

For additional information, providers can submit questions via email to DHCSIMCU@dhcs.ca.gov.

For eligibility-related questions regarding ACIP, JCWP, CCRP or CMPP, providers can contact the Medi-Cal Eligibility Division at MCIEP@dhcs.ca.gov.

For all mental health and psychiatric service-related questions regarding ACIP, JCWP, CCRP or CMPP, providers can contact the County Customer Services Section at MedCCC@dhcs.ca.gov.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
CHDP
Part 1
aid codes (6–9, 11, 12)
Print Article | Return to Top
 

6. Medi-Cal Suspended and Ineligible Provider List is Updated

The monthly-updated Medi-Cal Suspended and Ineligible Provider List (S&I List) is available on the Suspended and Ineligible Provider List page of the Medi-Cal website.

Always refer to the S&I List when verifying ineligibility. Eligibility or ineligibility must also be verified through the Health and Human Services (HHS) Federal Office of Inspector General (OIG) List of Excluded Individuals/Entities.

Suspension of Entities Submitting Claims for Suspended Providers
Entities submitting claims for services rendered by a health care provider suspended from Medi-Cal or excluded from Medicare or Medicaid by the OIG are subject to Medi-Cal suspension.

Welfare and Institutions Code (W&I Code), section 14043.61, subdivision (a), states, in relevant part, that “a provider shall be subject to suspension if claims for payment are submitted under any provider number used by the provider to obtain reimbursement from Medi-Cal for the services, goods, supplies or merchandise provided, directly or indirectly, to a Medi-Cal recipient by an individual or entity that is suspended, excluded, or otherwise ineligible because of a sanction to receive, directly or indirectly, reimbursement from Medi-Cal and the individual or entity is listed on either the Medi-Cal Suspended and Ineligible Provider List or any list published by the Federal Office of Inspector General regarding the suspension or exclusion of individuals or entities from the Federal Medicare and Medicaid programs, to identify suspended, excluded, or otherwise ineligible providers.”

Print Article | Return to Top
 

7. Medi-Cal Hotlines


Medi-Cal Hotlines  
Border Providers (916) 636-1200
DHCS Medi-Cal Fraud Hotline 1-800-822-6222
Telephone Service Center (TSC) 1-800-541-5555
Provider Telecommunications Network (PTN) 1-800-786-4346

For a complete listing of specialty programs and hours of operation, please refer to the Medi-Cal Directory in the provider manual.

Mailing Address:
Xerox State Healthcare, LLC
PO Box 13029
Sacramento, CA 95813-4029

Medi-Cal Fraud is Against the Law
Medi-Cal fraud costs taxpayers million each year and can endanger the health of Californians. Help protect Medi-Cal and yourself by reporting violations today.

DHCS Medi-Cal Fraud Hotline: 1-800-822-6222

The call is free and you can remain anonymous. Knowingly participating in fraudulent activities can result in prosecution and jail time. Help prevent Medi-Cal fraud.

Stop Illegal Tobacco Sales
The simplest way to stop illegal tobacco sales to minors is for merchants to check ID and verify the age of the tobacco purchasers. Report illegal tobacco sales to 1-800-5-ASK-4-ID.

For more information, see the California Department of Public Health – California Tobacco Control website.

Print Article | Return to Top
 

8. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



Note:

If you cannot view the MS Word or PDF (Portable Document Format) documents correctly, please visit the Web Tool Box to link to a download site for the appropriate reader.