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Updated Clinic Billing Policy for Managed Care Differential Rate

July 26, 2016

The claims processing system was recently modified to accommodate proper differential rate billing for Medi-Cal members enrolled in both Medi-Cal and Denti-Cal managed care plans. Effective retroactively for dates of service on or after January 1, 2014, an update to policy regarding multiple daily billings of per visit code 18 (managed care differential rate) applies as follows:

Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs):

  • FQHC and RHC providers located in Los Angeles and Sacramento counties may be reimbursed for two code 18 visits per day, per recipient: One medical visit, and one dental visit, if the Medi-Cal member is enrolled in a Denti-Cal managed care plan. These visits do not require medical justification in the Remarks field (Box 80) or on an attachment to the claim.
  • Note:

    Per visit code 03 (dental visit) may not be billed if the Medi-Cal member is enrolled in a Denti-Cal managed care plan.

  • A third visit is allowed if the recipient suffers illness or injury requiring additional health diagnosis or treatment.
  • The third visit requires medical justification in the Remarks field (Box 80) or on an attachment to the claim.

Providers need take no action. Claims previously denied will be reprocessed with an Erroneous Payment Correction (EPC).

Note:

There is no change to policy for the number of allowable visits per day. This is a billing procedure change only.