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Update to IHS-MOA Provider Managed Care Differential Rate Billing

September 7, 2017

The claims processing system was recently modified to accommodate proper differential rate billing for Medi-Cal members enrolled in Medi-Cal managed care plans. Effective retroactively for dates of service on or after July 1, 2016, an update to policy for Indian Health Centers – Memorandum of Agreement (IHS-MOA) 638, regarding multiple daily billing of per-visit code 18 (managed care differential rate) applies: Providers may be reimbursed for three code 18 visits per day, per recipient, one medical visit, one mental health visit and one ambulatory visit or dental visit. These visits do not require medical justification in the Remarks field (Box 80) or on an attachment to the claim.

Providers need take no action. Claims with dates of service on or after July 1, 2016, that were previously denied will be reprocessed with an Erroneous Payment Correction (EPC).