Medi-Cal Update

Part 1 - Program and Eligibility | July 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. 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 20, 2019, will be held until July 5, 2019. 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 27, 2019, will be held until July 5, 2019. 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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3. RAD Code and Correlation Table Updates

The following Remittance Advice Details (RAD) messages have been added to help reconcile provider accounts:

Additions Code Message
9914 DPP (Diabetes Prevention Program) code not payable more than once in rolling 24 months, any provider.
9915 DPP (Diabetes Prevention Program) code not payable more than once in rolling 24 months, same provider.
9916 DPP (Diabetes Prevention Program) code not payable if other code has been paid in rolling 24 months.
9917 DPP (Diabetes Prevention Program) services not payable for limited scope members unless pregnant.

Additionally, national Claim Adjustment Reason Codes (CARC), Claim Adjustment Group Codes (CAGC), Remittance Advice Remark Codes (RARC) and description updates have been added to the Remittance Advice Details (RAD) Electronic Correlation Table to National Codes sections in the Part 1 manual.

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

Provider Manual(s) Page(s) Updated
Part 1 remit cd9000 (55); remit elect corr9900 (3); remit elect corr rarc (1, 2)
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4. AEVS: Carrier Codes for Other Health Coverage: July 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.

Addition(s)
Code Carrier    
A500 AHMC HEALTHCARE    

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5. 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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6. 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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7. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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