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Medi-Cal Update

Part 1 - Program and Eligibility | September 2021

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1. Remittance Advice Detail Code 010: Denials for Duplicate Claims

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.

2. County Medical Services Program Billing Reminder

As of October 1, 2005, the Department of Health Care Services (DHCS) no longer administers the County Medical Services Program (CMSP). All claims for CMSP services submitted to Medi-Cal after September 30, 2005, are denied.

Contact Advanced Medical Management (AMM) at 1-877-589-6807 for information on CMSP medical claims. Contact MedImpact at 1-800-788-2949 for information on CMSP pharmacy claims.

Some CMSP information is retained and updated in Medi-Cal provider manuals because verification of CMSP eligibility, including share of cost, is still provided by Medi-Cal. Updated CMSP information is also reflected in user guides, Remittance Advice Details (RAD) code messages and the FAQs page of the Medi-Cal provider website.

Information on CMSP is available on the CMSP Governing Board’s website.

3. Descriptor Updates for RAD Codes 274, 336, 9593 and 9720

The following Remittance Advice Details (RAD) descriptions have been updated in the RAD Repository:

Code Description
274 CMSP (County Medical Services Program) pharmacy claims processed by MedImpact. Contact 1-800-788-2949 for CMSP billing info.
336 CMSP (County Medical Services Program) medical claims processed by Advanced Medical Management, Inc. (AMM). Contact 1-877-589-6807 for CMSP billing info.
9593 CMSP (County Medical Services Program) pharmacy claims are processed by MedImpact. Contact 1-800-788-2949 for CMSP billing information.
9720 CMSP (County Medical Services Program) medical claims processed by Advanced Medical Management, Inc. (AMM). Contact 1-877-589-6807 for CMSP billing info.

4. AEVS: Carrier Codes for Other Health Coverage: September 2021 Update

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.

Addition

Code Carrier
C507 Alignment Health Plan 034

Changes

Code Carrier
F051 Stanislaus FMC
F055 FMC of Kern and Santa Barbara
F078 FMC of Tulare and Kings
F117 FMC of Merced and Mariposa
N053 National Elevator Industrial Benefit
N138 Vallenz Access
P291 Multiplan
R180 Cigna Pharmacy

5. Medi-Cal Suspended and Ineligible Provider List is Updated

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.”

6. Medi-Cal Hotlines


Medi-Cal Hotlines

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.

Mailing Address:
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.

7. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



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