Medi-Cal Update

Part 1 - Program and Eligibility | June 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. Fiscal Year Two-Week Checkwrite Hold for Specific Provider Payments

Specific checkwrites scheduled for the last two weeks of each fiscal year (FY) will be delayed until the start of the next FY.

Checkwrite Hold for Fee-for-Service Provider Payments
Medi-Cal funded fee-for-service programs scheduled with a warrant date of June 22, 2017, will be held until July 7, 2017. Checkwrites and payments to the following programs will be held during this time period:

Checkwrite Hold for Fee-for-Service Provider Payments Including State-Only Programs
Medi-Cal funded fee-for-service and state-funded programs scheduled for June 29, 2017, will be held until July 7, 2017. Checkwrites and payments to the following programs will be held during this time period:

Payments to the Every Woman Counts (EWC) program will be excluded from the checkwrite hold.

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3. Medi-Cal Checkwrite Schedule Update for Fiscal Year 2017 – 2018

Effective July 1, 2017, the checkwrite schedule is updated for fiscal year 2017 – 2018. The schedule reflects warrant release dates and Electronic Fund Transfer (EFT) dates of deposit for all programs including the following:

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

Provider Manual(s) Page(s) Updated
Part 1 check (2, 3)
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4. Deactivation of Non-Participating Providers

Effective July 22, 2017, non-participating providers will be deactivated pursuant to Welfare and Institutions Code (W&I Code), Section 14043.62. A non-participating provider is one who has been enrolled for more than 12 months and has not submitted a claim or rendered services reported on a claim in the last 12 months.

The status for select providers, including physicians and psychologists, may change from active to rendering.

Providers who enrolled in Medi-Cal solely to render services to dual-eligible recipients and a select number of local educational agencies will be excluded from the deactivation.

Deactivated providers will be notified by letter.

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5. ORP Provider Validation Lookup Tool Beta Release

Medi-Cal is in the process of implementing the Patient Protection and Affordable Care Act (ACA) Ordering, Referring and Prescribing (ORP) requirements. To support billing providers’ compliance with these requirements, Medi-Cal has created the ORP Provider Validation Lookup Tool. The web-based tool gives billing providers the ability to verify an ORP provider. This is done using the ORP provider Type 1 (individual) National Provider Identifier (NPI) to verify that an ORP provider is known to Medi-Cal and if the ORP provider is active for the specified date of service in advance of billing Medi-Cal. This will allow the billing provider to resolve any issues with invalid NPIs or non-enrolled ORP providers before submitting a claim.

A beta version of the ORP Enrollment Validation Lookup Tool has been released. Please use the beta version of the tool to set up processes and procedures for validating ORP provider enrollment when fulfilling/billing a service. Medi-Cal will release a final version of the tool prior to enforcing ORP requirements on claims (that is, denying claims for failure to provide a valid Type 1 [individual] NPI for an enrolled ORP provider).

The tool will validate ORP provider enrollment and display a response along with a transaction number. Users should record the transaction number in the event of a discrepancy between the ORP Enrollment Validation Lookup Tool response and claim adjudication.

The ORP Provider Validation Lookup Tool can be accessed from the Ordering, Referring and Prescribing (ORP) Web page on the Medi-Cal website along with more information and frequently asked questions about ORP requirements.

Click on the ORP Enrollment Validation Lookup link to verify ORP Medi-Cal enrollment status. For instructions on how to use the tool, refer to the ORP Provider Enrollment Validation Lookup Tool Guide.

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

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6. MCIP Claims Denied with RAD code 9996

Medi-Cal County Inmate Program (MCIP) claims billed to the DHCS Fiscal Intermediary for dates of service prior to April 1, 2017, are denied with Remittance Advice Details (RAD) code 9996: The County does not have a signed MCIP Agreement in effect. This RAD message has been added to help reconcile provider accounts.

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

Provider Manual(s) Page(s) Updated
Part 1 remit cd9000 (59); remit elect corr9900 (11); remit elect corr rarc (5)
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7. Reminders Regarding Third-Party Liability Billing

Medi-Cal Eligible Recipients
The Welfare and Institutions Code (W&I Code), Section 14019.3, requires that when Medi-Cal eligibility has been verified (by presentation of a Benefits Identification Card or by other proof of eligibility), a Medi-Cal provider seeking reimbursement from Medi-Cal shall submit a claim subject to the rules and regulations of the Medi-Cal program. Payment received from the state in accordance with Medi-Cal fee structures shall constitute payment in full. Medi-Cal providers must not attempt to obtain payment from Medi-Cal recipients for the cost of Medi-Cal covered health care services (see W&I Code, Sections 14019.4 and 14452.6).

Other Health Coverage/Balance Billing Prohibitions
W&I Code, Sections 14124.795 and 14124.90, provide that Medi-Cal is the payer of last resort. Generally, when known, a provider must bill a recipient’s Other Health Coverage before billing Medi-Cal. A Medi-Cal provider must not bill a third party after billing Medi-Cal because the Medi-Cal payment constitutes payment in full (regardless of the percentage of the provider’s billed amount).

The California Supreme Court in Olszweski v. Scripps Health (2003) 30 Cal. 4th 798 invalidated W&I Code, Section 14124.791, because it directly conflicted with federal law prohibiting “balance billing” of recipients. A provider billing Medi-Cal for services rendered to a Medi-Cal recipient may not assert a lien against a settlement, judgment or award obtained by a recipient.

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8. RAD Code and Correlation Table Updates

The following Remittance Advice Details (RAD) messages have been updated to help reconcile provider accounts:

Code Message
0558 Ordering/Referring/Prescribing NPI not enrolled or eligible for the svc billed on date of svc. Future claims may deny.
9252 Ordering/Referring/Prescribing NPI is unknown or is not eligible for the svc billed on the date of svc.
9253 Ordering/Referring/Prescribing NPI is not eligible for the svc billed on the date of svc.
9254 Ordering/Referring/Prescribing NPI is not eligible for the svc billed on the date of svc.
9255 Ordering/Referring/Prescribing NPI is not eligible for the svc billed on the date of svc.
9275 Ordering/Referring/Prescribing NPI is unknown in the NPPES Registry.
9276 Ordering/Referring/Prescribing NPI is not a Type 1-Individual according to the NPPES Registry.
9277 Ordering/Referring/Prescribing NPI not eligible for the svc billed on the date of svc according to the NPPES Registry.

Also, national Claim Adjustment Reason Codes (CARC), Claim Adjustment Group Codes (CAGC), Remittance Advice Remark Codes (RARC) and description updates have been added to the Remittance Advice Details (RAD) Electronic Correlation Table to National Codes sections in the Part 1 manual.

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

Provider Manual(s) Page(s) Updated
Part 1 remit cd500 (5); remit cd9000 (23, 24); remit elect corr500 (11); remit elect corr9200 (7, 8, 10, 11)
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9. 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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10. 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 Program website.

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11. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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