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 Vision Care and Appliances (45-1) Completion section. This guide summarizes important vision care-related changes that resulted from the September 2003 phase of HIPAA implementation.

Conversion of Place of Service Codes and Billing Limit Exception to Delay Reason Codes

Place of Service Field (Box 7) and Billing Limit Exception Field (Box 9)

Local Medi-Cal Place of Service codes are being replaced with national Place of Service codes, which are entered in the same field (Box 7) as previously entered.

Local Medi-Cal billing limit exception codes are being replaced with national delay reason codes. Delay reason codes are entered in the Billing Limit Exception field (Box 9).

National Place of Service codes are two characters and delay reason codes may be one or two characters. Two-character codes may not fit in the field allotted 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 or right of the field, but the preferred method of entering numbers is illustrated in the preceding graphic.

Guidelines

HIPAA changes for the September 2003 phase of HIPAA implementation established the following guidelines:

• Claims with dates of service on or after September 22, 2003 must be submitted with national delay reason and Place of Service codes.
• Claims for services prior to September 22, 2003 must be billed with local Medi-Cal billing limit exception and Place of Service codes.
• Claims for services rendered on dates of service that include both pre- and post-September 22, 2003 dates must be billed on separate claims (split billed) with national codes on one claim and local Medi-Cal codes on another.

Manual Changes

• Medi-Cal Place of Service code values are changed to national Place of Service code values.
• A Code Correlation Guide showing the relationship between local Medi-Cal/national Place of Service and local Medi-Cal billing limit exception and national delay reason codes is added at the end of the Payment Request for Vision Care and Appliances (45-1) Completion section to help you understand how the Medi-Cal billing limit exception codes have been converted to national delay reason codes and local Place of Service codes have been converted to national Place of Service codes when required.