Medi-Cal Update

Part 1 - Program and Eligibility | July 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. Accelerated Enrollment Aid Code Restricted to Children

Effective for dates of service on or after August 1, 2017, aid code 8E restricts benefits to include only children under 19 years of age. The complete description for aid code 8E is now: Accelerated Enrollment. Provides immediate, temporary, fee-for-service, full-scope Medi-Cal benefits for children under 19 years of age.

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

Provider Manual(s) Page(s) Updated
Part 1
CHDP Provider Manual
aid codes (29)
Print Article | Return to Top
 

3. RAD Code 0558 Turned Off for LTC and Inpatient Claims

Current claim submission standards for long term care (LTC) and inpatient claim types do not fully support Patient Protection and Affordable Care Act ordering, referring and prescribing (ORP) provider requirements. Medi-Cal will defer implementation and enforcement of ORP requirements for LTC and inpatient claim types until a fully supported solution is designed.

Until further notice, Remittance Advice Details (RAD) for these claim types will not use RAD code 0558: Ordering/Referring/Prescribing NPI not enrolled or eligible for the service billed on date of service. Future claims may deny.

Providers should watch for updates on implementation and enforcement of ORP requirements in Medi-Cal Update bulletins and the Ordering, Referring and Prescribing (ORP) page on the Medi-Cal website.

Print Article | Return to Top
 

4. AEVS: Carrier Codes for Other Health Coverage: July 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 Code Carrier
C020 CAREMORE HEALTH PLAN D104 ANTHEM BLUE CROSS DENTAL HMO
C021 CAREMORE HEALTH PLAN M013 MOLINA HEALTHCARE OF CA INC
C022 CAREMORE HEALTH PLAN U052 XNITED HEALTHCARE
D103 ANTHEM BLUE CROSS DENTAL PPO    

Print Article | Return to Top
 

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.”

Print Article | Return to Top
 

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 Program website.

Print Article | Return to Top


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.