Medi-Cal Update

Part 1 - Program and Eligibility | January 2018

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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. Identification of Medi-Cal Recipients When Picking Up Prescriptions

The Department of Health Care Services (DHCS) has recently been notified of issues related to acceptable forms of Medi-Cal recipient identification when picking up prescriptions at pharmacies. The Welfare and Institutions Code (W&I Code) 14018.2(c), and the Eligibility: Recipient Identification section of the Part 1 Medi-Cal provider manual, currently direct providers to accept a valid California driver’s license, ID card issued by the Department of Motor Vehicles (DMV), another type of picture identification card or other credible document of identification to establish identity when a recipient does not have a state-issued California ID.

The purpose of the policy clarification is to assist pharmacy providers in identifying appropriate forms of identification for Medi-Cal recipients when picking up prescriptions from a pharmacy. Pharmacy providers are reminded that alternative forms of credible identification are acceptable to prevent recipients being denied of picking up prescriptions. This is particularly important when providing services to the homeless population and/or disaster victims.

The policy for acceptable documentation for identification is listed in the Eligibility: Recipient Identification Cards section of the Part 1 Medi-Cal provider manual. Unless state or federal law requires specific forms of identification when obtaining an over-the-counter (OTC) or prescription drug, the documents listed below meet the requirement of W&I Code, Section 14018.2(c), and should be accepted as documentation of identification when dispensing a medication to a recipient or recipient’s representative:

*  Provision of pseudoephedrine requires that recipients (or representative for recipient) present identification compliant with the requirements of the Combat Methamphetamine Epidemic Act of 2005 (CMEA).

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3. Age Restriction for Aid Codes in the Medi-Cal County Inmate Program

Effective retroactively for dates of service on or after November 1, 2016, the following aid codes for the Medi-Cal County Inmate Program (MCIP) have updated age restrictions:

MCIP Program Aid Codes
County Compassionate Release Program (CCRP) and County Medical Probation Program (CMPP) K6, K7, K8, K9

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 (10)
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4. AEVS: Carrier Codes for Other Health Coverage: January 2018 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
S100 SAN JOAQUIN COUNTY HEALTH PLAN

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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 Program website.

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7. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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