Medi-Cal Update

Part 1 - Program and Eligibility | May 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. A New Way to Subscribe – Contact Medi-Cal Subscription Service Representatives

Medi-Cal is committed to keeping you up-to-date on the latest Medi-Cal news and policy updates.

The Medi-Cal Subscription Service (MCSS) is a free service that provides subscribers with personalized email notifications for urgent, high-impact announcements and monthly news/policy updates as they post to the Medi-Cal website.

Providers can now contact MCSS representatives directly at MCSSCalifornia@conduent.com to subscribe and for assistance with managing subscriptions. Subscribing is simple and free!

If you have not yet subscribed to MCSS, Medi-Cal encourages you to utilize one of the following two methods to subscribe.

To subscribe by email:

  1. Download the linked MCSS Subscriber Form

  2. Enter your name, email address, ZIP code and subscriber type in the appropriate fields

  3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

  4. Attach your completed form to an email and send to MCSSCalifornia@conduent.com

To subscribe online:

  1. Go to the MCSS Subscriber Form page on the Medi-Cal website

  2. Enter your email address and ZIP code, and select a subscriber type from the drop-down menu

  3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

  4. Click “Subscribe Now” at the bottom of the page

After the form has been received, a welcome email will be sent to the provided email address. If you are unable to locate the welcome email in your inbox, check your junk email folder.

For more information about MCSS, visit the MCSS Help page.

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3. Instructions on Submitting an eTAR for a Non-Benefit Procedure Code

Medi-Cal may provide reimbursement for a non-benefit with an approved Treatment Authorization Request (TAR) if medical necessity is established.

When submitting an electronic TAR (eTAR) for a non-benefit, the provider must select the special handling description “Service is a non-benefit and no TAR requirement on procedure file – REVIEW” on the Patient Information section of the eTAR application.

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

Provider Manual(s) Page(s) Updated
Part 1 tar (8)
Clinics and Hospitals
General Medicine
Inpatient Services
Obstetrics
hcpcs (1); tar and non (1)
Acupuncture
Adult Day Health Care Centers
AIDS Waiver Program
Audiology and Hearing Aids
Chiropractic
Chronic Dialysis Clinics
Durable Medical Equipment
Expanded Access to Primary Care Program
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Local Educational Agency
Medical Transportation
Multipurpose Senior Services Program
Orthotics and Prosthetics
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
hcpcs (1)
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4. Symfi Lo Available as Noncapitated Service for Select MCPs

Effective for dates of service on or after February 5, 2018, efavirenz/lamivudine/tenofovir disoproxil fumarate (Symfi Lo) is added as a noncapitated service for the treatment of HIV-1 infection in all Managed Care Plans (MCPs) except:

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. 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 P/DCL 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
Nguyen, Hung Van, MD A42303 2/19/18 – 8/19/19 CPT-4 codes, Breast Mammography: 77051, 77052, 77053, 77054, 77055, 77056, 77057, 77058, 77059, 77061, 77062 and 77063 with or without modifiers/HCPCS codes, Mammography: G0202, G0204 and G0206 with and without modifiers.
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6. Documentation Requirements When Contacting the Correspondence Specialist Unit

Providers may write directly to the Correspondence Specialist Unit (CSU) for clarification about recurring billing issues that have not been resolved through either the Claims Inquiry Form (CIF) or appeal process and have resulted in claim denials or potential unsatisfactory payments.

When writing to the CSU for assistance, providers should enclose up to three examples of Claim Control Numbers (CCNs) for the billing issue and include as much of the following documentation as possible with the letter of inquiry:

A lack of necessary records may delay research.

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

Provider Manual(s) Page(s) Updated
Family PACT
Part 1
prov rel (4)
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7. AEVS: Carrier Codes for Other Health Coverage: May 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    
H333 HEALTH NET    
O231 OSCAR PLATINUM EPO    

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8. 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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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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