The September 2003 Health Insurance Portability and Accountability Act (HIPAA) implementation resulted in the following changes in the Medi-Cal provider manuals. All changes are effective for dates of service on or after September 22, 2003.

New HIPAA In Review

A handy HIPAA In Review guide has been included in this bulletin for you to insert in your provider manual at the end of the Payment Request for Long Term Care (25-1) Completion section. This guide summarizes important long term care-related changes that resulted from the September 2003 phase of HIPAA implementation.

Billing Limit Exception to Delay Reason Codes and “From-Thru” Billing

Billing Limit Exception Field (Box 11) and Date of Service Field (Boxes 12 & 13)

Local Medi-Cal billing limit exception codes are being replaced with national delay reason codes. Delay reason codes are entered in the Billing Limit Exceptions field (Box 11). The delay reason code, which may be one or two characters, may not fit in the field because the original box on the claim was created for a single character. The Medi-Cal system is modified to scan data that overflows to the left of the field, as illustrated in the preceding graphic.

“From-thru” services with a “from” date of service on or after September 22, 2003 are billed with national codes. “From-thru” services with a “from” date of service prior to September 22, 2003 are billed with local Medi-Cal codes.

Manual Changes

• The Payment Request for Long Term Care (25-1) Completion section is updated to include the preceding “from-thru” information.
• A Code Correlation Guide showing the relationship between billing limit exception and delay reason codes is added at the end of the Payment Request for Long Term Care (25-1) Completion section to help you understand how Medi-Cal billing limit exception codes have been converted to national delay reason codes.