Medi-Cal Update

Part 1 - Program and Eligibility | June 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. Medi-Cal Checkwrite Schedule Update for Fiscal Year 2018 – 2019

Effective July 1, 2018, the checkwrite schedule is updated for fiscal year 2018 – 2019. The schedule reflects warrant release dates and Electronic Fund Transfer (EFT) dates of deposit for all programs including the following:

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

Provider Manual(s) Page(s) Updated
Part 1 check (1–3)
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3. Fiscal Year Two-Week Checkwrite Hold for Specific Provider Payments

Specific checkwrites scheduled for the last two weeks of each fiscal year will be delayed until the start of the next fiscal year.

Checkwrite Hold for Fee-for-Service Provider Payments
Medi-Cal funded fee-for-service programs scheduled with a warrant date of June 21, 2018, will be held until July 6, 2018. Checkwrites and payments to the following programs will be held during this time period:

Checkwrite Hold for Fee-for-Service Provider Payments Including State-Only Programs
Medi-Cal funded fee-for-service and state-funded programs scheduled for June 28, 2018, will be held until July 6, 2018. Checkwrites and payments to the following programs will be held during this time period:

Payments to the Every Woman Counts (EWC) program will be excluded from the checkwrite hold.

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4. CCS Capitated for Managed Care Plans in Certain Counties

Effective for dates of service on or after July 1, 2018, California Children's Services (CCS) is a capitated service for recipients receiving health care services through Medi-Cal Managed Care Plans (MCPs) in Merced, Monterey, San Luis Obispo and Santa Cruz counties.

These counties participate in the Whole-Child Model (WCM) program, under which responsibility for services provided to CCS-eligible recipients is transferred from the county CCS program to Medi-Cal MCPs. Partners for Children/Pediatric Palliative Care Waiver (PFC/PPCW) services submitted with an approved CCS Service Authorization Request (SAR), however, remains noncapitated.

For more information, providers in Merced, Monterey and Santa Cruz counties may contact Central California Alliance for Health at 1-800-700-3874.

Providers in San Luis Obispo County may contact CenCal Health at 1-800-421-2560.

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

Provider Manual(s) Page(s) Updated
Part 1 mcp cohs (2)
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5. Cimduo: New Noncapitated Antiviral for Select Managed Care Plans

Effective for dates of service on or after February 28, 2018, the antiviral drug lamivudine and tenofovir disoproxil fumarate (Cimduo) is added as a non-capitated service for the treatment of HIV-1 infection for all Managed Care Plans (MCPs) except the following:

Cimduo is a noncapitated service for Primary Care Case Management (PCCM) health care plan 915, AIDS Healthcare Centers – Los Angeles, for dates of service on February 28, 2018, through June 30, 2018. This information will not be added to the provider manual because the chart of antiviral drugs is being removed from the PCCM manual section this month. Providers may wish to reserve this article as policy for these dates of service.

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

Provider Manual(s) Page(s) Updated
Part 1 mcp cohs (6, 7); mcp gmc (8); mcp imperial (6); mcp two plan (7)
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6. New PACE Managed Care Plans in San Joaquin and Stanislaus Counties

Effective for dates of service on or after July 1, 2018, Stockton Program of All-Inclusive Care for the Elderly (PACE) will open PACE Managed Care Plans (MCPs) in San Joaquin and Stanislaus Counties.

PACE is an all-inclusive capitated program designed to coordinate and provide comprehensive medical, social and rehabilitative services needed to restore or preserve the independence of frail elderly individuals. PACE aims to help recipients live in their communities for as long as medically possible.

Enrollment is voluntary and recipients qualify for plan services if they meet the following criteria:

For more information regarding eligibility, requirements, PACE services or contracting with Stockton PACE, call (650) 741-0743.

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

Provider Manual(s) Page(s) Updated
Part 1 mcp code dir (18, 21); mcp spec (1)
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7. AEVS: Carrier Codes for Other Health Coverage: June 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    
A302 ASI    

Deletion(s)
Code Carrier    
G999 CDCR MEDICAL PAROLEE PLAN    

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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. 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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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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