Medi-Cal Update

Part 1 - Program and Eligibility | August 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. Update: Capitation of Select Psychiatric Drugs for AIDS MCP

An article titled “Postponement of AIDS MCP Psychiatric Drug Changes” published in the March 2019 Medi-Cal Update informed providers that changes regarding the capitation of a select list of psychiatric drugs were postponed. This issue has been resolved and effective for dates of service on or after July 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 (Health Care Plan [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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3. Capitation of Antivirals for AIDS Managed Care Plan (MCP)

Effective for dates of service on or after July 1, 2019, providers should no longer bill Medi-Cal fee-for-service for FDA-approved antiviral drugs for recipients enrolled in Positive Healthcare. Providers should bill all FDA-approved antiviral drugs directly to Positive Healthcare. For assistance with filling antiviral prescriptions, providers may call Positive Healthcare Pharmacy Technical Help at 1-888-554-1334, 24 hours a day, seven days a week.

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

Provider Manual(s) Page(s) Updated
Part 1 mcp prim (4, 5)
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4. RAD Code and Correlation Table Update

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

Added  
Code Message
9997 Medicare deductible maximum exceeded.
9998 Medicare co-insurance maximum exceeded.
   
Updated  
Code Message
375 EOB is not attached.  Bill Medicare.

Additionally, national Claim Adjustment Reason Codes (CARC), Claim Adjustment Group Codes (CAGC), Remittance Advice Remark Codes (RARC) and description updates have been made 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 cd300 (10); remit cd9000 (60); remit elect corr300 (13); remit elect corr9900 (11); remit elect corr rarc (4)
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5. AEVS: Carrier Codes and Other Health Coverage: August 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
A031 ALLWAYS HEALTH PARTNERS PPO
B023 BLUE SHIELD OF CA - FEP DENTAL
B025 BLUE SHIELD OF CA - PED DENTAL
B417 BLUE SHIELD OF CA - EXTERNAL RX
B668 BLUE SHIELD OF CA - FEP HMO
C634 CIGNA PART C
H231 THE HEALTH PLAN
S049 SANFORD HEALTH PLAN
S070 SIHO

Change(s)
Code Carrier
A030 ALLWAYS HEALTH PARTNERS
B020 BLUE SHIELD OF CA - PED VISION
B027 BLUE SHIELD OF CA - DENTAL HMO
B032 BLUE SHIELD OF CA - FEP DENTAL
B319 BLUE SHIELD OF CA - MEDIGAP-RX
B320 BLUE SHIELD OF CA - MEDIGAP-RX
B418 BLUE SHIELD OF CA - 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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