Medi-Cal Update

Part 1 - Program and Eligibility | December 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 Medicare Card: Medicare Beneficiary Identifier (MBI) – Courtesy Notice

Starting January 1, 2020, Medicare patients must use the Medicare Beneficiary Identifier (MBI). The Centers for Medicare & Medicaid Services (CMS) will reject claims submitted with the Health Insurance Claim (HIC) number, with a few exceptions, and reject all eligibility transactions. The MBI uses numbers 0 – 9 and all uppercase letters except for S, L, O, I, B and Z. CMS excludes these letters to avoid confusion when differentiating some letters and numbers (for example, between “0” and “O”). Providers may refer to MLN Matters article New MBI: Get It, Use It for other helpful information, such as how to get the MBI, and what to do if an MBI changes.

If Medicare patients do not have an MBI, providers should do the following:

The MACs secure portal MBI look-up tool now returns the MBI even if the new Medicare card has not been mailed. If Medicare providers do not already have access, they are encouraged to sign up for the MACs’ portal to use the tool. For more information on the transition to the MBI, providers may refer to the following resources:

Providers may also ask Medicare patients to call 1-800-MEDICARE to get a new card if they need one.

To ensure Medicare patients continue to get care, providers can use either the HIC number or the MBI for all Medicare transactions through December 31, 2019.

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3. Fabricating Optical Laboratory Services Are Noncapitated

Effective for dates of service on or after January 1, 2020, fabricating optical laboratory services are noncapitated benefits in the following counties:

Eyewear fabrication services continue to be noncapitated in other counties.

For more information, providers may contact their respective County Organized Health System

County COHS Telephone Number
San Luis Obispo,
Santa Barbara
CenCal Health 1-800-421-2560
San Mateo Health Plan of San Mateo (650) 616-2106

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

Provider Manual(s) Page(s) Updated
Part 1 mcp cohs (3, 4)
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4. New PACE Managed Care Plan in Kern and Tulare Counties

Effective for dates of service on or after January 1, 2020, Bakersfield Program of All-Inclusive Care for the Elderly (PACE) will open new Managed Care Plans (MCPs) in Kern and Tulare Counties.

PACE is an all-inclusive capitated program designed to coordinate and provide comprehensive medical, social and rehabilitative services needed to restore or preserve the independence of elderly individuals. PACE aims to help recipients live in their communities for as long as medically possible.

Enrollment is voluntary and recipients qualify for plan services if they meet the following criteria:

For more information regarding eligibility, requirements, PACE services or contracting with Bakersfield PACE, call (661) 872-3860.

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

Provider Manual(s) Page(s) Updated
Part 1 mcp code dir (5, 22); mcp spec (1)
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5. Alcohol and Drug Dependency Treatment Drugs Added in Healthcare Plan 915

Effective for dates of service on or after July 1,2019, the following Alcohol and Heroin Detoxification and Dependency Treatment Drugs are a fee-for-service benefit in AIDS Healthcare Foundation's Managed Care Plan (MCP) in Los Angeles County (HCP 915):

For more information, providers may call Positive Healthcare Pharmacy Technical Help at 1-888-554-1334, 24 hours a day, 7 days a week.

Note:

Not all forms of this drug are FDA approved for treatment of alcohol and heroin detoxification and dependency. The drug remains noncapitated regardless of the diagnosis for which it was used.

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

Provider Manual(s) Page(s) Updated
Part 1 mcp prim (5)
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6. Young Adult Expansion: Full-Scope Medi-Cal Coverage for Young Adults

Effective for dates of service on or after January 1, 2020, a new law in California will give full-scope Medi-Cal to young adults under the age of 26 regardless of immigration status. All other Medi-Cal eligibility rules, including income limits, still apply. This initiative, called the Young Adult Expansion, is modeled after Senate Bill 75, which provided full-scope Medi-Cal to all eligible children under the age of 19 regardless of immigration status.

Frequently Asked Questions (FAQs), notices, resources and other information about the Young Adult Expansion are available on the Young Adult Expansion page of the Department of Health Care Services (DHCS) website. For other questions related to the Young Adult Expansion, providers may contact DHCS at YoungAdultExpansion@dhcs.ca.gov.

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7. Counties Participating in MCIP for State Fiscal Year 2019 – 2020

Effective for dates of services on or after July 1, 2019, the following counties are participating in the Medi-Cal County Inmate Program (MCIP) for the state fiscal year 2019 – 2020:

Alameda Imperial Mono San Benito Siskiyou
Alpine Inyo Monterey San Bernardino Solano
Amador Kern Napa San Diego Sonoma
Butte Kings Nevada San Francisco Stanislaus
Colusa Los Angeles Orange San Joaquin Sutter
Contra Costa Madera Placer San Luis Obispo Tehama
El Dorado Mariposa Plumas San Mateo Tulare
Fresno Merced Riverside Santa Barbara Tuolumne
Glenn Modoc Sacramento Santa Clara Ventura

Complete information is available on the Medi-Cal State Inmate Program and Medi-Cal County Inmate Program page of the Department of Health Care Services (DHCS) website.

For additional information, providers may submit questions to DHCSIMCU@dhcs.ca.gov.

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8. RAD Code and Correlation Table Addition

The following Remittance Advice Details (RAD) message is added to help reconcile provider accounts.

Code Message
9300 This NDC (National Drug Code) is not payable with code Z5999. See the CCS (California Children’s Services) info notice on code Z5999.

Additionally, the Claim Adjustment Reason Code (CARC), Claim Adjustment Group Code (CAGC), Remittance Advice Remark Code (RARC) and description updates are added to the Remittance Advice Details (RAD) Electronic Correlation Table to National Codes section 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 (26); remit elect corr9300 (1); remit elect corr rarc (2)
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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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11. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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