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ACA-Related Appeals of NICU/PICU Claims Payment

March 16, 2016

A NewsFlash article entitled “Streamlined Procedure for ACA-Related Appeals” and published February 23, 2016, notified providers of a streamlined procedure for Patient Protection and Affordable Care Act (ACA) payment increase-related appeals. Providers can appeal using this procedure, for a limited period, if they believe the ACA required increased payment to be made on a claim and they did not receive the increased amount due.

If Neonatal Intensive Care Unit (NICU) and Pediatric Intensive Care Unit (PICU) providers submit these ACA-related appeals, they must include the appropriate ACA modifier for each claim line. Providers can find which ACA modifier to use in the ACA Rate Increase for Specified Primary Care Services Implementation Update page of the Medi-Cal website.

Providers must closely follow the instructions in the “Streamlined Procedure for ACA-Related Appeals” article. This includes attaching a copy of the original claim or a corrected claim to the appeal.

If the provider attaches a copy of the original claim to the appeal, the provider must include the appropriate ACA modifier(s) in the modifier field(s). If the modifier was not on the original claim, the provider would write the modifier(s) on the copy of the claim in the appropriate field(s).  

If the provider attaches a corrected claim to the appeal instead of a copy of the original claim, the provider also must include the appropriate ACA modifier(s) in the modifier field(s).

Providers with questions can call the Telephone Service Center (TSC) at 1-800-541-5555.