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Reminder: Upcoming Changes to CHDP Billing

May 16, 2017

The transition of Child Health and Disability Prevention (CHDP) claim adjudication to the California Medicaid Management Information System (CA-MMIS) is effective for dates of service on or after July 1, 2017. CHDP well-child health assessments and immunizations will be billed as Medi-Cal services under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit for persons under 21 years of age. The chart below highlights some of the changes from current CHDP claims processing to new billing in Medi-Cal claims processing.

Current Billing New Billing
Confidential Screening/Billing Report (PM 160) proprietary form Use of HIPAA-compliant (CMS 1500 or UB-04) claim forms
CHDP computer media claims (CMC) electronic transactions Use of HIPAA-compliant  ASC X 12N 837 V.5010A1 electronic health care transactions
CHDP local codes Use of the HIPAA-compliant CPT-4 procedure codes
Current CHDP local codes were billed as full component with no modifiers Use of modifiers
Whole claim processing Single claim line processing
Claims subject to 12-month billing limit Claims subject to six-month billing limit
Reimbursement at CHDP rates for proprietary local codes Reimbursement at Medi-Cal rates for CPT-4 procedure codes and a HCPCS code
CHDP subsystem does not support functionality to check status during claims processing CA-MMIS supports functionality that allows providers to check claim status during processing
CHDP multi-page Provider Correction Notice (PCR) to follow up on missing or invalid information Use of Medi-Cal Resubmission Turnaround Documents (RTDs) will be initiated when applicable for missing or invalid information
Use of CHDP Remittance Advice (RA) fee adjustment codes Reporting of the adjudicated paper claims on Remittance Advice Details (RAD) forms
or
Adjudicated electronic claims using the 835 Health Care Claim Payment/Remittance Advice (RA)
Submit a new PM 160 to request a balance due or adjustment to paid amount Use of Claims Inquiry Form (CIF) for claim adjustments
Submit a new PM 160 to trace a claim Use of a CIF for tracking status of submitted claims
Submit a new PM 160 to initiate the CHDP appeal process Submit an Appeal Form (90-1) to challenge denials, and use an appeal reference number (ARN) to track appeal status