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Erroneously Denied Claims for FQHC/RHC Services

February 1, 2019

The Department of Health Care Services (DHCS) identified a claims processing issue affecting Federally Qualified Health Centers/Rural Health Clinics (FQHC/RHC) claims for crossover payments, Medi-Cal managed care payments and capitated Medicare Advantage payments. This issue caused claims to erroneously deny with Remittance Advice Details (RAD) code 0640: Recipient is not eligible for Medi-Cal benefits without complete denial of coverage from the Medicare Health Maintenance Organization (HMO), Competitive Medical Plan (CMP) or Health Care Prepayment Plan (HCPP). Medi-Cal is not obligated for plan services when the recipient chooses not to go to a plan provider. The issue affects claims adjudicated on or after October 17, 2018.

DHCS and the California Medicaid Management Information System (MMIS) Fiscal Intermediary (FI) are working to resolve this issue. 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.