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New Managed Care Payment Process for IHS-MOA

February 2, 2018

Effective for dates of service on or after January 1, 2018, Indian Health Services (IHS) – Memorandum of Agreement (MOA) 638, Clinics should no longer submit Medi-Cal managed care claims for services covered by Medi-Cal Managed Care Plans (MCPs). This includes claims for Medicare enrollees also enrolled in a Medi-Cal MCP.

IHS-MOA facilities must use the billing processes outlined below:

  • Effective for dates of service prior to October 1, 2017, IHS-MOA facilities must use per-visit code 18 (managed care differential rate).
  • Effective for dates of service from October 1, 2017, through December 31, 2017, IHS-MOA facilities must use the following code set:
Revenue Code HCPCS Code Modifier
520
Managed care differential rate, covered by managed care and rendered to recipients enrolled in Medi-Cal managed care plans
T1015
Clinic visit/encounter, all-inclusive
SE
State and/or federally funded programs/services
  • Effective for dates of service on or after January 1, 2018, IHS-MOA providers must bill the MCP only for reimbursement directly from the plan. No differential billing is required.

IHS-MOA facilities are no longer required to submit claims for the MCP differential rate. Effective January 1, 2018, claims submitted with code set 520 T1015 SE will be adjudicated at a $0 payment:

All other claims – dental, Medi-Cal fee-for-service, carve-out managed care (services not covered by the MCP), Medicare crossover and Capitated Medicare Advantage Plan (for members not enrolled in a Medi-Cal MCP) – will continue to be adjudicated per current processes.