Medi-Cal Update

Part 1 - Program and Eligibility | September 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. Split-Bill Modifiers Added for Infectious Agent Detection Code

Effective retroactively for dates of service on or after February 1, 2018, CPT-4 code 87634 (infectious agent detection by nucleic acid [DNA or RNA]; respiratory syncytial virus, amplified probe technique) is reimbursable with split-bill modifiers.

No action is required of providers. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

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3. Grievance Procedure for Recipient Claims of Discrimination

In accordance with Section 1557 of the Patient Protection and Affordable Care Act (ACA), a health care provider must refer a Medi-Cal recipient to the grievance coordinator, if applicable, and to the Department of Health Care Services’ (DHCS) Office of Civil Rights in the event that the recipient makes a claim that the provider has failed to provide covered Medi-Cal services or unlawfully discriminated in another way on the basis of any of the following characteristics:

The Office of Civil Rights may be contacted via phone, written or electronic communication. To access the appropriate contact information for recipient claims of discrimination, providers may refer to the Provider Regulations section of the Part 1 manual.

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

Provider Manual(s) Page(s) Updated
Part 1 prov reg (1–3)
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4. Lofexidine HCl Added as Noncapitated Service for Select MCPs

Effective for dates of service on or after May 16, 2018, the new heroin detoxification and dependency treatment drug Lofexidine HCl, used to treat and reduce the severity of opioid withdrawal symptoms, is a noncapitated service for select Managed Care Plans (MCPs).

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

Provider Manual(s) Page(s) Updated
Part 1 mcp cohs (9); mcp gmc (9); mcp imperial (7); mcp two plan (8)
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5. AEVS: Carrier Codes for Other Health Coverage: September 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    
E564 EMBLEM HEALTH HMO    
M107 MANHATTAN LIFE ASSURANCE    
M355 MUTUAL OF OMAHA DENTAL    
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6. 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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7. 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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8. 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:
California MMIS Fiscal Intermediary
PO Box 13029
Sacramento, CA 95813-4029

Medi-Cal Fraud is Against the Law
Medi-Cal fraud costs taxpayers millions 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 persons under the age of 21 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.

Free Smoking Cessation Resources
The California Smokers’ Helpline provides free help for quitting smoking in multiple languages. Services can be accessed via toll-free hotline 1-800-NO-BUTTS, text, online chat or mobile app. For more information, see the California Smokers’ Helpline website.

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9. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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