Medi-Cal Update

Part 1 - Program and Eligibility | October 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 Hours of Operation for POS/Internet Help Desk

Effective October 1, 2019, the hours of operation for the Point of Service (POS)/Internet Help Desk is 8 a.m. to 5 p.m., Monday through Friday, except holidays. Providers and submitters may need to update business or operational practices to align with this change.

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

Provider Manual(s) Page(s) Updated
Family PACT
Part 1
prov rel (6, 9)
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3. Medi-Cal Procedure/Drug Code Limitation List Update

The Medi-Cal Procedure/Drug Code Limitation List section of the Part 1 provider manual (proc list) has been updated. Always refer to the Procedure/Drug Code Limitation (P/DCL) list when determining provider procedure/drug code limitations.

Providers placed on the P/DCL list do not receive Medi-Cal reimbursement for services under restriction. In addition, providers who fill orders for lab tests, drugs, medical supplies or any other restricted services prescribed or ordered by a provider under restriction are not reimbursed by Medi-Cal.

The limitation is effective after the Department of Health Care Services (DHCS) gives the provider notice of the proposed limitation and no appeal is submitted within 45 days, or following denial of an appeal. Limitations automatically cease after 18 months, except for those with “indefinite” time frames.

List of Codes covered by providers placed on Procedure/Drug Code Limitation can be found separately on the Medi-Cal website.

No action is required of providers. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

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4. Billing Reminder: Do Not Use Non-Standard Claim Forms

This is a reminder to all providers who submit paper claims: all submitted forms must be on standard paper claim forms. Standard claim forms can be purchased from authorized vendors or requested from the Medi-Cal program. Accuracy, completeness and clarity of the form are necessary to ensure that the information is scanned correctly into the system.

For more information and tips about submitting paper claims, visit the Billing Tips: Paper Claims page on the Medi-Cal website.

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

Provider Manual(s) Page(s) Updated
Part 1 claim sub (3)
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5. PT/OT Services for CCS Recipients are Noncapitated for Certain Providers

Effective retroactively for dates of service on or after July 1, 2018, physical therapy/occupational therapy (PT/OT) services provided by designated, CCS-certified outpatient rehabilitation centers are noncapitated benefits in the following counties:

Humboldt Monterey San Luis Obispo Santa Cruz Sonoma
Marin Napa San Mateo Shasta Yolo
Merced Orange Santa Barbara Solano

These outpatient rehabilitation centers are CCS facilities that provide PT/OT services to California Children’s Services (CCS) Medical Therapy Program (MTP) recipients who receive healthcare services through Medi-Cal Managed Care Plans (MCPs).

For MCPs in the above counties where CCS services are capitated, PT/OT services by designated, CCS-certified outpatient rehabilitation centers are noncapitated. PT/OT services remain capitated for other providers.

For more information, providers may contact the following MCPs:

County MCP
Orange CalOptima
1-888-587-8088
San Luis Obispo and Santa Barbara CenCal Health
1-800-421-2560
Merced, Monterey and Santa Cruz Central California Alliance for Health
1-800-700-3874
San Mateo Health Plan of San Mateo
(650) 616-2106
Humboldt, Marin, Napa, Shasta, Solano, Sonoma and Yolo Partnership HealthPlan of California
1-800-863-4155

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

Provider Manual(s) Page(s) Updated
Part 1 mcp cohs (2)
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6. AEVS: Carrier Codes for Other Health Coverage: October 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
C017 BLUE SHIELD – PPO EXTERNAL RX
S385 SIERRA HEALTH AND LIFE INS
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7. ESRD Pilot Project Extended for VillageHealth

The End Stage Renal Disease (ESRD) Pilot Project for VillageHealth has been extended through December 31, 2020. All existing billing instructions remain the same and are applicable to the participating provider.

The ESRD Pilot Project was established to accept and process claims for participating providers who meet the criteria for Medi-Cal secondary payments. This allows for payment of coinsurance and deductibles for dual-eligible recipients in a Medicare Advantage plan. VillageHealth is the only Medicare Advantage plan for which its providers meet the 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
Acupuncture
Adult Day Health Care Centers
AIDS Waiver Program
Audiology and Hearing Aids
Chiropractic
Durable Medical Equipment
Expanded Access to Primary Care Program
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Inpatient Services
Local Educational Agency
Medical Transportation
Multipurpose Senior Services Program
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
oth hlth (1)
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
dial end (5); oth hlth (1)
Part 1 mcp spec (7); medicare (3)
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8. Medi-Cal Celebrates Medi-Cal Subscription Service Milestone Achievement

The Department of Health Care Services (DHCS) is excited to announce that its Medi-Cal Subscription Service (MCSS) reached and surpassed 20,000 total subscribers as of September 2019.

DHCS first launched its new MCSS in December of 2012, and since that launch, it has witnessed steady growth each year in the volumes of providers and stakeholders who have joined up and officially subscribed to this free and tailored information-based notification service.

Since launching in 2012, DHCS has marketed its MCSS via informational flyers, online articles and at annual Provider Training Seminars throughout California. It’s at these seminars where MCSS representatives directly informed and assisted providers in signing up for the MCSS at the MCSS information booth.

DHCS has received an impressive array of positive and encouraging feedback from countless providers about the MCSS including their individual and satisfied experiences with this service each year.

The MCSS offers an array of provider communication notifications that subscribers can choose to receive including NewsFlash articles, Medi-Cal Update Bulletins and System Status Alerts (SSAs). In addition, each subscriber is able to tailor their individual MCSS experience by selecting only the provider communications and subject matters that interest them and pertain to their Medi-Cal business.

MCSS is a terrific way for providers and stakeholders to save time and ensure that they never miss important program updates and policy changes. The MCSS notifies subscribers the same day whenever the Medi-Cal program releases articles, bulletins and SSAs on the Medi-Cal website.

Providers who have not yet subscribed to the MCSS are encouraged to join this growing community of more than 20,000 subscribers and take full advantage of this free informational service. DHCS invites providers and other interested parties to subscribe today by completing the MCSS Subscriber Form located online.

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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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