Medi-Cal Update

Part 1 - Program and Eligibility | November 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. Medi-Cal Services Rendered to Medicaid Eligible Natural Disaster Evacuees

Due to recent natural disasters across the United States, Medi-Cal providers may render Medicaid services to eligible natural disaster evacuees in various states and Medicaid programs, subject to certain requirements. Reimbursement for rendering Medicaid services takes place through the applicable state and Medicaid program. Information regarding these states and programs follows.

Texas Medicaid
Medi-Cal providers interested in providing Medicaid services to Texas Medicaid clients may verify Texas Medicaid client eligibility and information as follows:

Medi-Cal providers may access the Texas Medicaid Provider Procedures Manual on the Providers Texas Medicaid page of the TMHP website. Note that Volume 1, Section 6, “Claims Filing” contains claims filing and submission guidelines and that provider handbooks begin with Volume 2.

Florida Medicaid
Medi-Cal providers interested in providing Medicaid services to Florida Medicaid recipients may use the following resources:

Louisiana Medicaid
Medi-Cal providers interested in providing Medicaid services to Louisiana Medicaid recipients may use the following resources:

Other Contacts, Regions and Medicaid Programs
Medi-Cal providers interested in rendering services to natural disaster evacuees may also use the following list of references and program contacts:

State Contact Telephone Email
Alabama Anita G. Brown (334) 242-5346 Anita.Brown@medicaid.alabama.gov
Alabama DeeAnn White (334) 242-5347 Deeann.White@adph.state.al.us
Florida

Shawn McCauley Intake:
(850) 412-3429
User Admin:
(850) 412-3428
Shawn.Mccauley@ahca.myflorida.com
Florida Tamara Strayer (850) 412-3429 Tamara.Strayer@ahca.myflorida.com
Georgia Nichole Thompson (404) 651-5191 Nthompson1@dch.ga.gov
Louisiana Lois Harpole (225) 219-4284 Lois.Harpole@la.gov
Puerto Rico María del C. Rosario (787) 474-3300,
ext. 3110
MRosario@asespr.org
South Carolina Felicia Burkett (803) 898-2561 Burkett@scdhhs.gov
Texas Walter Sotillo (512) 206-5083 Walter.Sotillo@hhsc.state.texas.gov
U.S. Virgin Islands Renée Joseph Rhymer (340) 774-0930,
ext. 4398
Renee.JosephRhymer@dhs.vi.gov
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3. End Stage Renal Disease Pilot Project Extended

The End Stage Renal Disease (ESRD) Pilot Project for VillageHealth has been extended through December 31, 2018. All existing billing instructions remain the same and are applicable to the participating provider.

The ESRD Special Claims Processing Pilot Project was established to accept and process claims for participating providers who meet the criteria for Medi-Cal secondary payments. This allows for payment of coinsurance and deductibles for dual-eligible recipients in a Medicare Advantage Plan (MAP). VillageHealth is the only MAP for which its providers meet the criteria for Medi-Cal secondary payments.

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

Provider Manual(s) Page(s) Updated
Part 1 mcp spec (7); medicare (3)
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4. Medi-Cal Procedure/Drug Code Limitation List Update

The Medi-Cal Procedure/Drug Code Limitation List (P/DCL List) has been updated. Providers placed on the P/DCL List do not receive Medi-Cal reimbursement for services under restriction. In addition, providers who fill orders for lab tests, drugs, medical supplies or any other restricted services prescribed or ordered by a provider under restriction are not reimbursed by Medi-Cal. The limitation is effective after the Department of Health Care Services (DHCS) gives the provider notice of the proposed limitation and no appeal is submitted within 45 days, or following denial of an appeal. After 18 months, the P/DCL automatically ceases, except for those with “indefinite” time frames.

Additions and changes are shown in bold and underline type in the Medi-Cal Procedure/Drug Code Limitation List section of the Part 1 provider manual. Always refer to the P/DCL List when determining provider procedure/drug code limitation(s).

Provider Name License Number Time Frame Codes
Lehman, Kent W., MD G38595 9/9/17 – 3/9/19 Any controlled substances, except those listed in Schedule III drugs of Phendimetrizine and Testosterone, the Schedule IV drugs of Phentermine and Nuvigil/Provigil and Schedule V drugs
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5. AEVS: Carrier Codes for Other Health Coverage: November 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
M996 MAGELLAN RX
S010 SUTTER MEDICAL FOUNDATION
V011 MES VISION
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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.”

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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, 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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8. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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