Medi-Cal Update

Part 1 - Program and Eligibility | March 2019

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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. Claims for Noncapitated Antivirals for HCP 915 Erroneously Denied

From January 1, 2019, through January 15, 2019, claims for noncapitated antiviral drugs for recipients enrolled in AIDS Healthcare Foundation's Managed Care Plan (MCP) in Los Angeles County (HCP 915) for dates of services on or after January 1, 2019, erroneously denied with Remittance Advice Details (RAD) code 0037: Health Care Plan enrollee, capitated service not billable to Medi-Cal.

Treatment Authorization Requests (TARs) for these services submitted to Medi-Cal from January 1, 2019, through January 15, 2019, may also have erroneously denied. Providers should resubmit denied TARs.

The claims processing issue has been resolved. An Erroneous Payment Correction (EPC) will be implemented to reprocess erroneously denied claims.

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3. Name Change for Select HCPs in Los Angeles and San Diego Counties

Effective for dates of service on or after January 1, 2019, the names of select Managed Care Plan (MCP) Health Care Plans (HCPs) are changed.

The Caremore Cal MediConnect plan in Los Angeles County (HCP 818) is now known as Anthem Blue Cross Cal MediConnect.

The Care 1st Partner Plan, LLC Cal MediConnect plans in Los Angeles County (HCP 817) and San Diego County (HCP 803) are now known as Blue Shield of California Promise Cal MediConnect.

The Geographic Managed Care (GMC) plan in San Diego County (HCP 167) is now known as Blue Shield of California Promise Plan.

Addresses and telephone numbers for these plans have not changed. Providers may contact the HCPs for assistance and information at the following numbers:

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

Provider Manual(s) Page(s) Updated
Part 1 mcp code dir (7, 16); mcp gmc (3)
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4. Certain Paper Enrollment Applications Removed from the Medi-Cal Website

As specified in a previous Provider Enrollment Division (PED) provider bulletin published January 4, 2019, on November 18, 2016, the Department of Health Care Services (DHCS) instituted a web-based Medi-Cal provider enrollment system entitled Provider Application and Validation for Enrollment (PAVE) 2.0 and on September 4, 2018, instituted PAVE 3.0. PAVE provides a new mode of submitting provider enrollment applications and required documentation to DHCS by means of an electronic form, the Medi-Cal Provider e-Form Application (e-Form).

With the implementation of the PAVE provider portal, the following paper enrollment applications are removed from the Medi-Cal website:

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

Provider Manual(s) Page(s) Updated
Part 1 prog (11); prov guide (3 – 7)
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Centers
non ph (3, 8, 20)
Medical Transportation mc tran gnd (21)
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5. Postponement of AIDS MCP Psychiatric Drug Changes

This article corrects information published in the December 2018 Medi-Cal Update, titled “Capitation of Select Psychiatric Drugs for AIDS MCP.” The previous article announced that changes regarding the capitation of the following psychiatric drugs for AIDS Healthcare Foundation’s Managed Care Plan (MCP) in Los Angeles County (HCP 915) would be effective for dates of service on or after January 1, 2019:

These changes have been postponed. No changes to the capitation of psychiatric drugs for Health Care Plan (HCP) 915 have occurred. These, therefore, remain non-capitated. The date on which these policy changes will become effective will be announced at a later date. Providers are encouraged to routinely check for updates on the Medi-Cal website for the forthcoming notice of implementation.

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6. Rebinyn Added as Noncapitated Benefit for Select MCPs

Effective for dates of service on or after April 1, 2019, Injection Factor IX (antihemophilic factor, recombinant), glycopegylated, (Rebinyn), 1 IU is a noncapitated benefit for select Managed Care Plans (MCPs). This coagulation factor is indicated for the treatment of hemophilia B in children and adults and is used for:

Providers should follow billing instructions as specified in the Blood and Blood Derivatives section in the appropriate Part 2 manual.

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

Provider Manual(s) Page(s) Updated
Part 1 mcp cohs (10); mcp gmc (10); mcp imperial (8); mcp prim (6); mcp two plan (9)
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7. Disulfiram Available as Noncapitated Benefit for Select MCPs

Effective for dates of service on or after April 1, 2019, disulfiram is available as a noncapitated benefit for the treatment of alcoholism for all Managed Care Plans (MCPs) except for the following Health Care Plans (HCPs):

Providers are encouraged to check the Medi-Cal website regularly for updates to the current 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 (9); mcp gmc (9); mcp imperial (7); mcp two plan (8)
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8. AEVS: Carrier Codes for Other Health Coverage: March 2019 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.

Change(s)
Code Carrier
D035 MODA/DELTA DENTAL OF OREGON
H183 HUMANA VALUE/GOLD PLUS

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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:
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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