HIPAA: Vision Care Cutoff Date Reminder for Providers of Vision Care Services Including Outpatient Clinics and Hospitals
July 31, 2006On July 1, 2006, the California Department of Health Services (DHCS) discontinued the Vision CMC proprietary claims transaction format regardless of the date services were performed. Additionally, there is a new 50-3 Treatment Authorization Request (TAR) form that must be used to request prior authorization for medically necessary contact services and materials, low vision aids and non-Prison Industry Authority items for dates of service on or after July 1, 2006 regardless of media used to bill the claim.
To bill vision services with dates of service on or after July 1, 2006, providers have three options: paper claims, compliant electronic claims submission and electronic claims submission via the Internet (IPCS).
Paper ClaimsThe Payment Request for Vision Care and Appliances (45-1) claim form was end-dated July 1, 2006. The 45-1 can only be used to bill paper claims with dates of service prior to July 1, 2006. The CMS 1500 claim form must be used to bill paper claims with dates of service on or after July 1, 2006.
Electronic Claim Submission
Providers who successfully completed the Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153) and test claims may bill electronically on the HIPAA-compliant 837 v.4010A1 transaction.
The ASC X12N 837 v.4010A1 Professional Medical Data Specifications must be used to submit vision claims with dates of service on or after July 1, 2006. For dates of service on or after July 1, 2006, the Medical Data Specifications (part of the 837 v.4010A1 Health Care Claim Companion Guide) has been updated to include the required segments for vision claims. The ASC X12N 837 v.4010A1 Professional Vision Data Specifications must be used for claims with dates of service prior to July 1, 2006.
The companion guides are available on the ASC X12N Version 4010A1 Companion Guides and NCPDP Technical Specifications page of the Medi-Cal Web site. Electronic Claim Submission Using the Internet
Available for claims with dates of service on or after July 1,
2006, the HIPAA-compliant 837 Internet Professional Claim
Submission (IPCS) Online Claim Form has been updated to give
vision care providers an alternate method of submitting
electronic claims through the Medi-Cal Web site. The online
claim form has been updated to include new fields for billing
vision services. The
Internet Professional Claim Submission (IPCS) User Guide
has been updated to reflect these changes.
The IPCS system allows users to submit single vision service claims in real-time. The IPCS system does not perform online adjudication nor does it accept crossover claims. Claims submitted successfully receive a Claim Control Number (CCN) on the host response screen. If the IPCS system detects errors, the user will receive a “CLAIM REJECTED” message on the host response screen, and the claim can be edited to correct these errors before resubmitting. Submitted claims enter the daily batch cycle of the Medi-Cal claims processing system.
The IPCS system allows faster, more efficient data exchange between providers and the California Department of Health Services (DHCS).
To use the IPCS system, providers must have both of the following:
- A Medi-Cal Point of Service (POS) Network/Internet Agreement form on file with DHCS for each provider number. If providers currently have valid forms on file, no additional updates are needed. Providers should print the form, complete, sign and return it to Medi-Cal at the address shown on the form.
- A valid Computer Media Claims (CMC) submitter ID and password. To obtain or update your ID and password, complete the Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153). Check the “Internet” box in the Real Time Submission Type section, check Medical/Allied Health (05) and enter 4010X098 where indicated in the ANSI X12N 837 Version section.
Submitters with a current, valid CMC submitter ID must still submit the Medi-Cal Telecommunications Provider and Biller Application/Agreement to add the IPCS Internet options.
As of July 1, 2006, only professional medical and vision claims can be submitted using IPCS; Institutional claims cannot be submitted.
Additional ResourcesFor more information, in-state providers may call the Telephone Service Center (TSC) at 1-800-541-5555, 8 a.m. to 5 p.m., Monday through Friday. Border providers, software vendors and out-of-state billers who bill for in-state providers should call (916) 636-1200.
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