Medi-Cal Update

Part 1 - Program and Eligibility | December 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. Electronic Health Care Claim Payment/Advice Receiver Agreement Form Updated

The form, Electronic Health Care Claim Payment/Advice Receiver Agreement (ANSI ASC X12N 835 Transaction) (DHCS 6246),has been updated. Providers are encouraged to use the updated form, which can be downloaded from the Forms page of the Medi-Cal website.

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

Provider Manual(s) Page(s) Updated
Part 1 remit elect (4)
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4. New GMC Plans for Sacramento and San Diego Counties: Aetna

Effective for dates of service on or after January 1, 2018, new Geographic Managed Care (GMC) Health Care Plans (HCPs) will begin operation in Sacramento and San Diego counties.

Aetna Better Health of California (HCP 015) will join existing GMC plans in Sacramento County.

Aetna Better Health of California (HCP 016) will join existing GMC plans in San Diego County.

Medi-Cal recipients in both counties have received notices explaining how these changes could affect them. Providers may contact Aetna Better Health of California at 1-855-772-9076 for more information.

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

Provider Manual(s) Page(s) Updated
Part 1 mcp code dir (14, 16); mcp gmc (3)
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5. Phase 1: RTD Generation to Be Discontinued

The Department of Health Care Services (DHCS) is phasing out the generation of Resubmission Turnaround Documents (RTDs) (Form 65-1). The discontinuation of RTDs will both increase claims processing efficiency and reduce costs.

RTDs will be discontinued in multiple phases. The first phase was implemented in November 2017 and the second phase will implement in the first quarter of 2018. The third phase is expected to implement in the second quarter of 2018. The new process will deny claims submitted with questionable or missing information instead of generating an RTD. As DHCS transitions from the use of RTDs to claim denials, providers can expect to receive fewer RTDs. When the project is completed, the use of RTDs will be completely discontinued.

The implementation of each RTD phase-out period will be announced in a future monthly bulletin. Providers are encouraged to routinely check the Medi-Cal website for more information.

In addition, the following Remittance Advice Details (RAD) codes are added to help reconcile provider accounts:

Addition Code Message
9282 Patient sex code missing or invalid.
9283 Attending, referring, or prescribing provider number missing or invalid.
9284 Patient liability information missing or invalid.
9285 Accommodation code missing or invalid.
9286 Cost center code missing/invalid.
9287 Admission date or hour missing or invalid.
9288 Admission date chronologically out of sequence with discharge date.
9289 Discharge date or hour missing or invalid.
9290 Medicare EOMB date billed missing or invalid.
9291 Total charges billed invalid.
9292 Medicare disallowed amount invalid.

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

Provider Manual(s) Page(s) Updated
Part 1 remit cd 9000 (25); remit elect corr 9200 (12–14); remit elect corr rarc (1–4)
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6. Aid Codes for the Medi-Cal State Inmate Program

Effective retroactively for dates of service on or after November 1, 2016, providers may submit claims for the Medi-Cal State Inmate Program (MSIP) with the following aid codes:

MSIP Program Aid Codes
State Medical Parole K2, K3, K4, K5

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

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

Provider Manual(s) Page(s) Updated
CHDP
Part 1
aid codes (9)
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7. Billing Assistance

Providers may call the Telephone Service Center (TSC) at 1-800-541-5555, 8 a.m. to 5 p.m., Monday through Friday, except holidays.

What items are needed when calling in for billing assistance?
Providers should call the TSC with a brief description of the billing issue or training request. Details should include the Claim Control Number (CCN), ID, name and Date of Service (DOS) for the issue about which the provider is inquiring.

Where can you find more help?
The Provider Relations Organization (PRO) is the primary liaison between the provider community and the Medi-Cal program. PRO provides billing and training assistance to providers.

Correspondence Specialist Unit (CSU)
Providers may write directly to the CSU for clarification about recurring or complex billing issues that have not been resolved through either the Claims Inquiry Form (CIF) or appeal process.

Regional Representatives
Provider inquiries that cannot be handled by the TSC or CSU are referred to a regional representative. Regional representatives provide education services that are outlined on the Outreach & Education page of the Medi-Cal website and are geared toward assisting providers on how to efficiently submit their Medi-Cal claims for payment. Regional representatives are located throughout the state and are available to visit providers in their office or facility for one-on-one billing assistance and tailored workshops free of charge. To request a referral for a regional representative in your area, call the TSC at 1-800-541-5555.

For more information regarding the PRO, providers may refer to the Provider Relations Directory section of the Part 1 manual.

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8. AEVS: Carrier Codes for Other Health Coverage: December 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
D022 DENTAL BLUE PPO
N138 NX HEALTH NETWORK
V012 BLUE VIEW VISION
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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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