The 270/271 Version 4010A1 Health Care Eligibility Benefit Inquiry and Response Companion Guide (Real-Time and Batch Transactions) was updated to reflect the following changes:

Benefits Identification Card (BIC) Returned in Eligibility Inquiry Verification Response Transaction
Effective October 25, 2008, Medi-Cal will implement the return of the BIC number in the 2100C, NM109 field when a recipient’s Social Security Number (SSN) and valid card issue date are submitted on either a “Spend Down” that certifies the recipient’s eligibility, or on an “Eligibility Inquiry” dial-up or leased-line transmission. The recipient’s SSN will be returned in the REF02 field with the REF01 field set to Qualifier Value Q4 of a 2100C REF segment. A 2100C INS segment will be returned signifying the identifying data element changes.

The Medi-Cal POS NCPDP Pharmacy Transaction Specifications, Third Party Vendors (Dial-Up and Leased-Line) technical specifications have been updated to reflect the following changes:

Pharmacy Claims Transactions and Issue Date
Effective October 25, 2008, Medi-Cal will no longer require the Issue Date as a separate field on National Council of Prescription Drugs Program (NCPDP) Version 5.1 dial-up and leased-line pharmacy claim transmissions submitted with a 14-character BIC number. If the Issue Date is sent with a 14-character BIC number, it will be ignored. The Issue Date as a separate field continues to be required for non-BIC cardholder IDs.

Pharmacy Eligibility Verification Transactions
Effective October 25, 2008, Medi-Cal will accept NCPDP Version 5.1 Eligibility Verification transactions through dial-up and leased-line transmissions only. Providers currently using the Medi-Cal Point of Service (POS) dial-up network to submit pharmacy transactions will also be approved to submit NCPDP Eligibility Verification requests. No additional mandatory testing is required.

Testing
All testing must be done through the Medi-Cal system test environment. Once testing is successfully completed, the software will be enabled to run in the Medi-Cal production environment. The Medi-Cal system test environment will be enabled for testing from September 1, 2008 through October 6, 2008.

For assistance with testing, please contact:
Henry Schneider at (916) 636-1073, e-mail: Henry.Schneider@eds.com; or
Bindu Vijayakumar at (916) 852-4940, e-mail: Bindu.Vijayakumar@eds.com.

Eligibility Verification Requirements
All providers should verify eligibility prior to rendering Medi-Cal services. Providers are encouraged to use the recipient’s identification number from their BIC or paper ID card when verifying eligibility instead of using a SSN. If a recipient is unknown to a provider, the provider must make a “good faith effort” to verify the recipient’s identification before rendering services. It is the provider’s responsibility to verify recipient’s eligibility and identity.

If a recipient does not bring a BIC to an appointment or in an emergency, providers may access the
Medi-Cal Eligibility Verification System (EVS) and use the recipient’s SSN (with the recipient's approval) to verify eligibility. Providers should remind recipients to take their BIC with them to the doctor, pharmacy, hospital or any other health care provider. Providers are encouraged to print copies of the Always Take Your BIC With You! information is located on the Web site. CWDs may only release the recipient’s BIC number and date of birth after verifying the caller and the recipient’s identity.

Providers may contact the local County Welfare Departments (CWD) for necessary information required to verify Medi-Cal eligibility in certain situations when a recipient does not have a BIC, or if the recipient’s BIC is invalid. Medi-Cal County Contacts for Providers information is located on the Web site. CWDs may only release the recipient’s BIC identification number and date of birth after verifying the caller and the recipient’s identity.

Medi-Cal recognizes the importance of protecting the identity and health information of recipients and strongly encourages all providers to avoid using a recipient’s SSN whenever possible.