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Medi-Cal Update

Part 1 - Program and Eligibility | April 2022

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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. April 2022 Update to AEVS: Carrier Codes for Other Health Coverage

The AEVS: Carrier Codes for Other Health Coverage list has been updated. These codes are updated monthly. Additions and deletions are shown between the start and end change brackets on the updated provider manual pages. Updates are listed below.

Add(s)

Code Carrier Code Carrier
A022 Allwell Medicare D522 Devoted Health Advance
A056 AARP MAP Walgreens (GA) H419 HumanaChoice (NY)
A057 AARP Medicare Advantage Plan 1 H427 HealthSun SunPlus Advantage
A058 AARP MAP Walgreens H433 Humana Gold Plus
A062 Aetna Medicare Premier H434 Humana Gold Plus (AZ)
A063 Aetna Medicare Premier (PA) H435 HumanaChoice PPO
A064 Atrio Bronze RX I105 Imperial Insurance Company
A065 Aetna Medicare Select Plan K005 KelseyCare Advantage RX
A066 Aetna Medicare Value Plan K895 Kaiser Senior Advantage
A067 Amerivantage Choice M014 Medicare Plus Blue
A068 Aetna Medicare Prime Plan R001 Renown Preferred Plan
A069 AARP MAP Patriot U015 UCare Complete
A071 AARP MAP Patriot (PA) W079 Wellcare Premier (TX)
A058 AARP MAP Walgreens W080 Wellcare Texanplus Classic
A072 AARP MAP 4 W081 Wellcare Absolute
B006 BlueAdvantage Sapphire W082 Western Health MyCare
B007 BlueCHiP For Medicare Value W083 Wellcare Premier (IL)
B008 Blueshield Inspire W084 Wellcare Premier (AZ)
C024 Community Health Plan    

3. New Electronic Claim Resubmission Helps Providers Avoid Paper CIFs/Appeals

Providers can electronically resolve a claim denial or incorrect payment for 837I (Institutional) and 837P (Professional) electronic claims. By resubmitting the claim with either frequency type code “7” (replacement of prior claim) or “8” (void/cancel of prior claim), there is no longer a need to adjust claims using paper Claims Inquiry Forms (CIFs) or Appeal Forms with accompanying Remittance Advice Details (RADs) to show proof of previous claim payment or denial. Electronic claim resubmission is not available for pharmacy claims.

The ANSI X12 v.5010 837 electronic transactions claim format allows a provider to initiate changes to already-adjudicated claims. The 837 Implementation Guides refer to the National Uniform Billing Data Element Specifications Loop 2300 CLM05-3 for explanation and usage. In the 837 formats, the codes are called “claim frequency codes.”

Replacement and void claims can be sent in the same batch as new claims.

Electronic replacement claims must be submitted within six months of the previous claim payment or denial. Providers may submit an electronic follow-up claim even if the original was a paper claim. Claims for which a CIF or appeal are already in progress must not be electronically resubmitted. Claims for which a CIF or appeal is in progress will be denied.

The following chart outlines the use of codes “7” and “8.”

Claim Frequency Code/Definition Use Filing Guidelines Result
7
Replacement of Prior Claim
Use to replace a claim line or entire claim in an already adjudicated paid or denied claim (see following instructions per claim type) File the claim line or entire electronic claim including all services for which reconsideration is requested Medi-Cal will adjust the original claim. The corrections submitted will be reflected on the 835 Transaction and/or paper Remittance Advice Details (RAD) and other standard claim response vehicles
8
Void/Cancel of Prior Claim
Use to eliminate an already adjudicated claim for a specific provider, recipient and date of service (see following instructions per claim type) File the claim electronically and include all claims data and charges that were on the original claim Medi-Cal will void the original claim from history based on request, which will be reflected on the 835 Transaction and/or paper RAD and other standard claim response vehicles

Frequency Type Code ‘7’

Electronic allied health, long term care, medical services, obstetric, outpatient and vision care claims resubmitted with Frequency Type code “7” (replacement claim):

  • Are used to modify only one claim line. They cannot be used to replace multiple original claim lines.

  • A separate replacement claim transaction must be performed for each claim line being replaced. For example, to replace all five lines of an outpatient claim, the submitter must submit five separate transactions.

  • Must contain corrected information for the original claim.

  • Must include the 13-digit Claim Control Number (CCN) from the original paid claim. For the claim to be considered for full reimbursement, the RAD date for the previous claim payment or denial must be within six months of the date the replacement claim was submitted.

Electronic inpatient claims resubmitted with Frequency Type code “7” (replacement claim):

  • Replace the entire inpatient care claim.

Frequency Type Code ‘8’

Electronic long term care, medical services, outpatient and vision care claims resubmitted with Frequency Type code “8,” (void/cancel of prior claim):

  • Must include the 13-digit CCN from the original paid claim.

  • Serve as a full void for one claim line only. Multiple original claim lines cannot be voided with one void claim transaction.

  • A separate void claim transaction must be performed for each claim line being voided. For example, to void all five lines of an outpatient claim, the submitter must submit five separate transactions.

Electronic inpatient claims resubmitted with Frequency Type code “8” (void/cancel of prior claim):

  • Void the entire inpatient care claim.

Errors to Avoid

Providers should pay attention to the instructions above that certain claim types can replace or void one claim line only. Additionally, the CCN of the original claim is the proper information to insert in the REF segment.

Correct CCN for Crossover Claims

Providers resubmitting a Medicare to Medi-Cal crossover claim should take care to enter the CCN from the Medi-Cal claim they are resubmitting and not the CCN from the Medicare claim.

Claim Attachments

Attachments required with the initial claim submission are required for replacement claim submissions. Copies of claims initially submitted on paper are not needed. Information from the paper claim will already have been keyed into the claims processing system.

No attachments are required when voiding a claim.

Information about submitting attachments for electronic claims is available in the Billing Instructions: Acceptable Claims, Attachments and ASC X12N 835 v.5010 Transactions section of the Medi-Cal Computer Media Claims (CMC) Billing and Technical Manual, specifically under the following headings:

  • “Supporting Documentation – Attachments”

  • “Attachment Control Form: Required and Optional Fields”

  • “Attachment Control Form (ACF) Guidelines”

Associated RAD Code and Correlation Table Update

The following Remittance Advice Details (RAD) message has been added in the Part 1, RAD Repository, provider manual section to help providers reconcile claims submitted using claim frequency code “7.” (The claim frequency code is the third digit of the “Type of Bill” Code.)

Code Message
9174 Computer Media Claims (CMC) replacement submitted after six months of referred claim Remittance Advice Details (RAD) is not payable

Reimbursement

If the initial adjudicated claim was subject to a reimbursement reduction due to late claim submission, then reimbursement for the resubmitted claim also will be reduced.

Reference

Providers may wish to save a copy of this article for future reference.

Provider Manual(s) Page(s) Updated
Part 1 appeal (1); cif (1); elect (3–5); RAD Repository
AIDS Waiver Program
Chronic Dialysis Clinics
Clinics and Hospitals
Community-Based Adult Services
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Inpatient Services
Local Educational Agency
Multipurpose Senior Services Program
Rehabilitation Clinics
ub sub (2, 6)

4. 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.”

5. Medi-Cal Hotlines


Medi-Cal Hotlines

Border Providers 1-916-636-1200
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 1-800-527-5443. 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.

6. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



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