Manual Adjudication of Presumptive Eligibility Aid Codes within the Same Month of Eligibility

September 8, 2021

Background

Qualified Providers (QPs) who have attempted to enroll individuals in another Presumptive Eligibility (PE) program when the individual is currently active on the COVID-19 Uninsured Group Program (aid code V2) are receiving a response that the individual currently has Medi-Cal eligibility. QPs are unable to enroll individuals in a more beneficial Presumptive Eligibility (PE) program aid code where benefits are not limited to COVID-19 related services. This limitation has created issues in accessing care for individuals who should be receiving services beyond COVID-19 related services.

In addition, federal guidance allows retroactive eligibility for V2 back to April 8, 2020. Currently, the COVID-19 Uninsured Group Program portal does not allow for retroactive eligibility requests. As a result, the Department of Health Care Services (DHCS) has received retroactive eligibility requests for V2 which may coincide with other PE aid codes in the same month of eligibility.

Interim Process

Effective immediately and continuing until further guidance, QPs are to send the appropriate application information to DHCS to each of the respective PE programs: Child Health and Disability Prevention (CHDP), Hospital Presumptive Eligibility (HPE), Presumptive Eligibility for Pregnant Women (PE4PW), Breast and Cervical Cancer Treatment Program (BCCTP), and COVID-19 Uninsured Group Program, when the QP is unable to enroll an individual in another PE aid code within the same month of eligibility. Additional information will be released in a future Medi-Cal Update.

During the interim process, DHCS will manually process the application referrals from QPs and provide a response to the provider via secure email. QPs should note DHCS will not process incomplete application referrals. If further information is needed, DHCS will reach out to the QP.

Once the QP receives confirmation from DHCS that the PE program application has been processed and approved, QPs should contact the individual regarding their approval into the new PE program and obtain an eligibility response for the individual.

Additionally, providers are to submit their claims for processing using the appropriate billing exception code. Refer to CMS-1500 Submission Timeliness Instructions in Part 2 of the Medi-Cal Provider Manual for further instructions. If your claim is denied for timeliness or eligibility, an Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims. Claims re-processed by EPC are still subject to all edits and audits as governed by the Medi-Cal program and could be denied for a reason other than timeliness or eligibility. Providers may submit a Claims Inquiry Form (CIF) within six months of the new Remittance Advice Details (RAD) date or you may submit an Appeal Form (90-1) within 90 days of the new RAD date. For CIF completion instructions, please refer to the CIF Completion and CIF Special Billing Instructions sections in the appropriate Part 2 manual or on the Medi-Cal Providers website. For Appeal Form (90-1) completion instructions, please refer to the Appeal Form Completion section in Part 2 of the Medi-Cal Provider Manual.

Questions

  • Questions concerning the CHDP Gateway, HPE, or PE4PW Programs should be sent to PE@dhcs.ca.agov.

  • Questions concerning BCCTP PE should be sent to Nancy Ojeda at BCCTP@dhcs.ca.gov.

  • Questions concerning the COVID-19 Uninsured Group Program should be sent to COVID19Apps@dhcs.ca.gov.

  • For billing or payment questions, providers may call the Telephone Service Center (TSC) at 1-800-541-5555, from 8 a.m. to 5 p.m., Monday through Friday.