Medi-Cal Update

Part 1 - Program and Eligibility | December 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. ESRD Pilot Project Extended for VillageHealth

The End Stage Renal Disease (ESRD) Pilot Project for VillageHealth has been extended through December 31, 2019. All existing billing instructions remain the same and are applicable to the participating provider.

The ESRD Special Claims Processing Pilot Project was established to accept and process claims for participating providers who meet the State Plan criteria for Medi-Cal secondary payments. This allows for payment of coinsurance and deductibles for dual-eligible recipients in a Medicare Advantage Plan (MAP). VillageHealth is the only MAP for which its providers meet the State Plan criteria for Medi-Cal secondary payments.

An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

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

Provider Manual(s) Page(s) Updated
Part 1 mcp spec (7); medicare (3)
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3. Capitation of Select Psychiatric Drugs for AIDS MCP

Effective for dates of service on or after January 1, 2019, providers should no longer bill Medi-Cal fee-for-service for the following psychiatric drugs for recipients enrolled in AIDS Healthcare Foundation's Managed Care Plan (MCP) in Los Angeles County (HCP 915):

Providers should bill the listed psychiatric drugs directly to Positive Healthcare California. For assistance with filling psychiatric drug prescriptions, providers may call Positive Healthcare Pharmacy Technical Help at 1-888-554-1334, 24 hours a day, seven days a week.

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4. Gary and Mary West PACE Opens in San Diego County

Effective for dates of service on or after January 1, 2019, Gary and Mary West PACE of Northern San Diego will open a Program of All-Inclusive Care for the Elderly (PACE) plan in San Diego County.

PACE is an all-inclusive capitated program designed to coordinate and provide all needed preventative, primary, acute, long term care and social and rehabilitative services through one comprehensive program and to help participants live in the community for as long as medically possible. PACE is a voluntary program. To qualify for enrollment into PACE, a Medi-Cal recipient must meet the following criteria:

For more information regarding eligibility, requirements, PACE services or contracting with Gary and Mary West PACE, call (858) 412-8759.

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

Provider Manual(s) Page(s) Updated
Part 1 mcp code dir (17); mcp spec (1)
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5. AEVS: Carrier Codes for Other Health Coverage: December 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 Code Carrier
D591 MUTUAL OF OMAHA RX D592 UNITED HEALTHCARE

Changes(s)
Code Carrier Code Carrier
P610 PMI/DELTACARE USA W140 UMR PPO
S448 WELLCARE PART D W141 UMR HMO
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6. 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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7. 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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8. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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