Medi-Cal Update

Part 1 - Program and Eligibility | September 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. New Aid Code 2C: County Children's Health Initiative Program

Effective for dates of service on or after October 1, 2019, aid code 2C (County Children's Health Initiative Program [CCHIP]) provides county-specific, full-scope, no Share of Cost (SOC) medical, dental, mental health and vision benefits to CCHIP children. CCHIP children must be 18 years of age or younger with a modified adjusted gross income above 266 percent and up to and including 322 percent of the U.S. Department of Health & Human Services (HHS) poverty guidelines.

This aid code is not eligible for Local Educational Agency (LEA) services, Child Health and Disability Prevention (CHDP) services or for an infant using the mother's ID.

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

Provider Manual(s) Page(s) Updated
CHDP
Part 1
aid codes (21)
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3. CHDP Gateway Aid Code Update

Effective for dates of service on or after July 1, 2019, Child Health and Disability Prevention (CHDP) Gateway applicants with unsatisfactory immigration status who would have been enrolled in aid code 8Y, for CHDP services only, will now be enrolled in aid code 8W or 8X, for full-scope Medi-Cal benefits. Pursuant to Welfare and Institutions Code (W&I Code), Section 14007.8, individuals under age 19 who do not have satisfactory immigration status or are unable to establish satisfactory immigration status may receive full-scope Medi-Cal benefits, including temporary full-scope Presumptive Eligibility (PE).

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

Provider Manual(s) Page(s) Updated
CHDP
Part 1
aid codes (32)
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4. Antihemophilic Factor Jivi Added as Noncapitated Benefit for Select MCPs

Effective for dates of service on or after October 1, 2019, HCPCS code J7208 (injection, factor VIII, [antihemophilic factor, recombinant], pegylated-aucl, [Jivi], 1 i.u.) is a noncapitated benefit for all Managed Care Plans (MCPs) except for the following:

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

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5. Address Change for Kern Health Systems

Effective September 23, 2019, the address for Kern Health Systems is updated to the following:

Kern Health Systems
  dba Kern Family Health Care
2900 Buck Owens Boulevard
Bakersfield, CA  93308-6316

For assistance and more information, providers may contact Kern Family Health Care at 1-800-391-2000 or at (661) 632-1590.

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

Provider Manual(s) Page(s) Updated
Part 1 mcp code dir (5)
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6. Reminder: Recipient Eligibility Verification

The Department of Health Care Services (DHCS) would like to remind providers that they are advised to verify eligibility for Medi-Cal recipients on the date of service, even if eligibility was previously verified for the month. Certain programs require eligibility to be verified on the date of service, such as the Medi-Cal County Inmate Program (MCIP).

For more information about recipient eligibility verification, providers may refer to the “Recipient Eligibility Verification” heading on the Frequently Asked Questions (FAQ) page of the Medi-Cal website. The FAQs page can be found under the References tab or under the Featured Links section on the home page of the Medi-Cal website.

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7. AEVS: Carrier Codes for Other Health Coverage: Month year 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
M111 MEDI-CAL MANAGED CARE
M222 MEDICARE ADVANTAGE

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8. 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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9. 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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10. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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