Medi-Cal Update

Part 1 - Program and Eligibility | April 2017

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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.

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2. Recipient Share of Cost/Spend Down Field Messages Clarified

The provider manual has been updated to clarify eligibility messages received for Medi-Cal recipients with a Share of Cost (SOC), also known as spend down amounts. These reminders were published previously in the November 2016 Medi-Cal Update.

In some instances, a Medi-Cal recipient will have an SOC amount in one or more spend down fields on the Medi-Cal provider’s eligibility messages. These circumstances are:

Providers should read the eligibility message carefully. If the recipient has no SOC Medi-Cal, but still has an SOC amount in the “Remaining Spend Down Amount,” “Spend Down Amount Case Balance” and/or “Spend Down Obligation Amount” field, several elements may appear in the eligibility message. An Eligibility Verification Confirmation (EVC) number will appear in the message along with a statement regarding the recipient’s lack of SOC coverage.

Based on the settlement in the Sneede v. Kizer lawsuit, if the SOC amount is due to the possibility that the recipient’s medical expenses can be applied to another Medi-Cal case, the end of the message will state the Medi-Cal case number(s) and the SOC amount remaining in the cases for which the recipient can choose to apply their medical expenses.

If the recipient can choose to use their medical expenses to meet a family SOC in the same case, there will be no Medi-Cal case numbers. The message will state that the recipient can choose to use their medical expenses to meet the family SOC. In this case, providers should inform recipients that they may choose to apply their medical expenses to either the family SOC or to the SOC of another case. Providers should not charge the recipient any SOC amount if the recipient does not choose to apply their expenses to the family’s SOC or the SOC of another case.

When the SOC amount in the “Spend Down Obligation Amount” field is due to the 250 percent Working Disabled Program, the message will state that the recipient is eligible for full-scope Medi-Cal under aid code 6G with no SOC. An EVC number will also appear. The SOC amount is a premium that the recipient pays directly to the Department of Health Care Services (DHCS). Providers are not to collect this amount from 250 percent Working Disabled Program recipients.

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

Provider Manual(s) Page(s) Updated
Part 1 share (12, 13)
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3. Tenofovir Alafenamide Fumarate Identified as Noncapitated for Select MCPs

Effective for dates of service on or after November 10, 2016, tenofovir alafenamide fumarate is identified as noncapitated in select managed care plans (MCPs) for the treatment of chronic hepatitis B virus infection in adults with compensated liver disease.

Providers are encouraged to visit the Medi-Cal website regularly for updates to the list of contract drugs and MCP policy.

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

Provider Manual(s) Page(s) Updated
Part 1 mcp cohs (6); mcp gmc (8); mcp imperial (6); mcp prim (5); mcp two plan (7)
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4. AEVS: Carrier Codes for Other Health Coverage: April 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
A810 ANTHEM BLUE CROSS BLUE SHIELD
O122 OPTUM RX

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5. 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.”

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6. 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, refer to the Medi-Cal Directory in the provider manual.

Mailing Address:
Conduent
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.

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7. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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