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The Department of Health Care Services (DHCS) received approval from the Centers for Medicare & Medicaid Services (CMS) for the State Plan Amendment (SPA) to require reporting and to adjust payment for Provider-Preventable Conditions (PPC). Effective July 1, 2012, federal law and regulations require all providers to report PPCs that occur in inpatient and outpatient settings.
The federal Affordable Care Act (ACA) requires providers to report all PPCs that are associated with claims for Medicaid (Medi-Cal in California) payment or with courses of treatment furnished to a Medicaid patient for which Medicaid payment would otherwise be available. The ACA also prohibits Medicaid from paying for the treatment of PPCs.
Reporting is mandatory under federal law. A provider must report the occurrence of any PPC in any Medi-Cal patient that did not exist prior to the provider initiating treatment. A provider must report the occurrence regardless of whether or not the provider seeks Medi-Cal reimbursement for services to treat the PPC. A provider reports a PPC by completing and submitting the Medi-Cal Provider-Preventable Conditions (PPC) Reporting Form (DHCS 7107) (see link below). Providers must submit the form within five days of discovering the condition and confirming that the patient is a Medi-Cal beneficiary. Reporting a PPC for a Medi-Cal beneficiary does not preclude the reporting of adverse events and healthcare associated infections to the California Department of Public Health (CDPH), pursuant to Health and Safety Code (H&S Code) Sections 1279.1 and 1288.55.
The documents available on this page are updated on an ongoing basis to ensure that they contain the most up-to-date information. Providers and submitters are therefore encouraged to bookmark this page (CTRL+D on Windows or Command+D on Mac OSX) and refer to it often for the most current documents.
Frequently Asked Questions (FAQs)
- CMS Issues Final Rule on Provider-Preventable Conditions
- Reporting and Payment Adjustment for Provider-Preventable Conditions
- Modifier Required with Provider-Preventable Conditions Claims
- The Medi-Cal PPC Reporting Form can also be found under the PPC heading on the Forms Page of the Medi-Cal website.
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