A frequent cause of claim denials by Medi-Cal is due to incorrect recipient admission and discharge dates and/or incorrect patient status codes submitted by providers. Erroneous “from-through” dates or patient status billed by one provider and paid by Medi-Cal can result in the denial of correct claims billed by another provider. This often occurs between hospitals and nursing homes during the transfer of the recipient. Providers see this on their Remittance Advice Details (RADs) as a claim denied by RAD code 010.
Should the denied provider choose to dispute the claim and there is no resolution between the two providers regarding the dates in question, Medi-Cal could recoup the full reimbursement of the original erroneously paid claim, and will not make an adjustment without a correction request from that provider.
Incorrectly paid and denied claims can also create incorrect provider reimbursement data and inaccuracies in the health service records that may impact beneficiary share of cost, access to services and estate recovery.
For assistance in resolving these issues, providers are advised to write to the Correspondence Specialist Unit at:
Correspondence Specialist Unit
P.O. Box 13029
Sacramento, CA 95813-4029
For information about proper claim form completion, refer to the claim completion section in the appropriate Part 2 manual.
A new Frequently Asked Questions (FAQs) section is now available on the COVID-19 Medi-Cal Response page of the Medi-Cal Providers Website. Access it here: https://files.medi-cal.ca.gov/pubsdoco/COVID19_response.aspx.
The following Remittance Advice Details (RAD) messages have been added to help reconcile provider accounts:
|9304||This procedure/accommodation/revenue code is limited to only one occurrence in 22 days.|
Additionally, the Claim Adjustment Reason Code (CARC), Claim Adjustment Group Code (CAGC), Remittance Advice Remark Code (RARC) and description updates are added to the RAD and Remit Code Repository.
The Office of Administrative Hearings and Appeals (OAHA) will conduct informal reviews, pre-hearing matters, settlement conferences, formal hearings and other matters via telephone or video conference, while Executive Orders N-55-20 and N-63-20 are in effect. The Department of Health Care Services (DHCS) recently issued guidance on timeframe extensions and data submittal deadlines for audits, and updates to administrative hearing timelines and processes, available on the DHCS website. For questions regarding this guidance, please email the OAHA inbox at OAHAmailbox@dhcs.ca.gov.
The AEVS: Carrier Codes for Other Health Coverage list has been updated. These codes are updated monthly. Additions and changes are shown in bold and underlined type on the updated provider manual pages. Updates are listed below.
|U402||UPMC HEALTH PLAN|
The monthly-updated Medi-Cal Suspended and Ineligible Provider List (S&I List) is available on the Suspended and Ineligible Provider List page of the Medi-Cal website.
Always refer to the S&I List when verifying ineligibility. Eligibility or ineligibility must also be verified through the Health and Human Services (HHS) Federal Office of Inspector General (OIG) List of Excluded Individuals/Entities.
Suspension of Entities Submitting Claims for Suspended Providers
Entities submitting claims for services rendered by a health care provider suspended from Medi-Cal or excluded from Medicare or Medicaid by the OIG are subject to Medi-Cal suspension.
Welfare and Institutions Code (W&I Code), section 14043.61, subdivision (a), states, in relevant part, that “a provider shall be subject to suspension if claims for payment are submitted under any provider number used by the provider to obtain reimbursement from Medi-Cal for the services, goods, supplies or merchandise provided, directly or indirectly, to a Medi-Cal recipient by an individual or entity that is suspended, excluded, or otherwise ineligible because of a sanction to receive, directly or indirectly, reimbursement from Medi-Cal and the individual or entity is listed on either the Medi-Cal Suspended and Ineligible Provider List or any list published by the Federal Office of Inspector General regarding the suspension or exclusion of individuals or entities from the Federal Medicare and Medicaid programs, to identify suspended, excluded, or otherwise ineligible providers.”
|Border Providers||(916) 636-1200|
|DHCS Medi-Cal Fraud Hotline||1-800-822-6222|
|Telephone Service Center (TSC)||1-800-541-5555|
|Provider Telecommunications Network (PTN)||1-800-786-4346|
For a complete listing of specialty programs and hours of operation, refer to the Medi-Cal Directory in the provider manual.
California MMIS Fiscal Intermediary
PO Box 13029
Sacramento, CA 95813-4029
Medi-Cal Fraud is Against the Law
Medi-Cal fraud costs taxpayers millions each year and can endanger the health of Californians. Help protect Medi-Cal and yourself by reporting violations today.
DHCS Medi-Cal Fraud Hotline: 1-800-822-6222
The call is free and you can remain anonymous. Knowingly participating in fraudulent activities can result in prosecution and jail time. Help prevent Medi-Cal fraud.
Stop Illegal Tobacco Sales
The simplest way to stop illegal tobacco sales to persons under the age of 21 is for merchants to check ID and verify the age of the tobacco purchasers. Report illegal tobacco sales to 1-800-5-ASK-4-ID. For more information, see the California Department of Public Health – California Tobacco Control Program website.
Free Smoking Cessation Resources
The California Smokers’ Helpline provides free help for quitting smoking in multiple languages. Services can be accessed via toll-free hotline 1-800-NO-BUTTS, text, online chat or mobile app. For more information, see the California Smokers’ Helpline website.