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Claims Processing Issue Affecting PFC/PPCW Provider Claims

December 29, 2016

A processing issue is causing some claims billed for Partners for Children/Pediatric Palliative Care Waiver (PFC/PPCW) service codes 90837, G0176, G9001, G9012, S5110, S9123, T1005, T2022, T2025 and X9508, which were also submitted with an approved California Children’s Services (CCS) Service Authorization Request (SAR), to erroneously deny with Remittance Advice Details (RAD) codes:

  • 008: The provider of service is not eligible for the type of services billed;
  • 037: Health Care Plan enrollee, capitated service not billable to Medi-Cal;
  • 311: Recipient is not eligible for Medi-Cal benefits without complete denial coverage statement from PHP/HMO (Prepaid Health Plan/Health Maintenance Organization);
  • 647: Recipient not eligible for Medi-Cal benefits without complete denial of coverage from private insurance carrier; and
  • 657: Recipient not eligible for Medi-Cal benefits until payment/denial information is given from other insurance carrier.

Additionally, some claims billed with HCPCS code T2025 (waiver services; not otherwise specified [NOS]) are underpaying and returning RAD codes:

  • 401: The payment was adjusted to the maximum allowable or in accordance with comparative pricing methodology (deductibles plus coinsurance are reduced to the Medi-Cal allowed amount less payments from Medicare, OHC [Other Health Coverage] and SOC [Share of Cost]); or
  • 414: Payment was reduced by Medical Review.

Affected claims with dates of service on or after October 23, 2009, will be reprocessed via a future Erroneous Payment Correction (EPC). No action is required of providers.

Providers should continue to submit claims in a timely manner and are encouraged to check the Medi-Cal website regularly for updates regarding this issue.