Medi-Cal Update

Part 1 - Program and Eligibility | April 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. Buprenorphine Extended Release Injection Added as Benefit for MCPs

Effective for dates of service on or after November 30, 2017, the buprenorphine extended release injection is available as a noncapitated service for all Managed Care Plans (MCPs), except for the following:

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

Provider Manual(s) Page(s) Updated
Part 1 mcp cohs (7); mcp gmc (9); mcp imperial (7); mcp two plan (8)
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3. Biktarvy Identified as Noncapitated for Select MCPs

Effective for dates of service on or after February 7, 2018, bictegravir/emtricitabine/tenofovir alafenamide (Biktarvy) is identified as noncapitated for the treatment of HIV-1 infection in all managed care plans (MCPs) except the following:

Providers are encouraged to visit the Medi-Cal website regularly to view the list of contract drugs and MCP policy.

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

Provider Manual(s) Page(s) Updated
Part 1 mcp cohs (6); mcp gmc (8); mcp imperial (6); mcp prim (5); mcp two plan (7)
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4. Dolutegravir/Rilpivirine Added for Certain Managed Care Plans

Effective for dates of service on or after November 21, 2017, the antiviral drug combination dolutegravir/rilpivirine is added as noncapitated service for all Managed Care Plans (MCPs) except for the following:

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

Provider Manual(s) Page(s) Updated
Part 1 mcp cohs (6); mcp gmc (8); mcp imperial (6); mcp prim (5); mcp two plan (7)
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5. Coagulation Factors: Noncapitated Services Added to Select MCPs

Effective retroactively for dates of service on or after January 1, 2017, the following coagulation factors will be noncapitated benefits and not reimbursed by County Organized Health System (COHS), Geographical Managed Care (GMC), Imperial, Primary Care Case Management (PCCM), Regional, San Benito and Two-Plan Model Managed Care Plans (MCPs).

Coagulation Factors

Factor VIII (antihemophilic factor, recombinant) (Afstyla), per IU

Factor VIII (antihemophilic factor, recombinant) (Nuwiq), per IU

Factor VIII (antihemophilic factor, recombinant) PEGylated, per IU

Factor IX albumin fusion protein, (recombinant), (Idelvion) per IU

Factor X (human), per IU

Von Willebrand factor (recombinant) (Vonvendi), per IU

These drugs are listed under the subheading “Blood Factors: Coagulation Factors” in the Part 1 manual.

Providers should follow billing instructions for noncapitated services (fee-for-service Medi-Cal or special programs) as specified in the Blood and Blood Derivatives section of the Part 2 manual.

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

Provider Manual(s) Page(s) Updated
Part 1 mcp cohs (8); mcp gmc (9); mcp imperial (8); mcp prim (6); mcp two plan (9)
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6. New Cardiac Rehabilitation RAD Codes

The following Remittance Advice Details (RAD) codes have been added to help reconcile provider accounts for cardiac rehabilitation:

RAD Code Message
9295 Service limitation 24 sessions in 24 weeks exceeded
9296 Service limitation 72 sessions in 18 weeks exceeded
9297 Cardiac rehabilitations are not separately reimbursable in the same calendar month

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

Provider Manual(s) Page(s) Updated
Part 1 remit cd9000 (25); remit elect corr9200 (15); remit elect corr rarc (1, 3)
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7. Phase 2: 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 was implemented in February 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 Medi-Cal Update. 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
9293 Prescription number missing.
9294 Gross amount blank or invalid.
9298 Hospitalization “to” date 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 (14, 15); remit elect corr rarc (1, 4)
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8. AEVS: Carrier Codes for Other Health Coverage: April 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    
B455 LIFETIME BENEFIT SOLUTION    

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9. Reminder: Do Not Staple Paper Claim Forms

Providers are reminded to not staple paper claim forms as staples delay claims processing. For more general reminders about paper claim submission, providers are encouraged to check the Billing Tips: Paper Claims page of the Medi-Cal website.

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10. 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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11. 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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12. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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