December 10, 2021
This article is intended to clarify how street medicine providers may utilize Hospital Presumptive Eligibility and Medi-Cal fee-for-service billing to provide care to the communities they serve.
Medi-Cal allows qualified providers determining presumptive eligibility under the Hospital Presumptive Eligibility (HPE) program, to complete HPE determinations off the premises of hospitals and clinics, such as in mobile clinics, street teams, or other locations. Third-party vendors may also be enlisted by hospitals to help individuals complete the paper version of the HPE application in these off-premise locations, although completion of the application must be performed by the qualified HPE provider through the HPE Application Portal. Details regarding this policy may be found in the July 12, 2021 article titled “HPE Off-Premise Flexibilities” published on the Medi-Cal Providers website. More information about the HPE program may be found on the HPE Program and HPE Program FAQs web pages on the Medi-Cal Providers website.
Qualified individuals presumptively enrolled into Medi-Cal under the HPE program are allowed immediate access to temporary, no-cost Medi-Cal services, while they apply for permanent Medi-Cal coverage or other health coverage. Providers rendering services to qualified individuals may provide and bill fee-for-service Medi-Cal for appropriate and applicable services within their scope of service.
Providers must follow Medi-Cal submission guidelines when billing for services rendered. Guidelines on how to submit claims to Medi-Cal, as well as additional documentation or billing requirements that providers should consider, may be found in the appropriate Medi-Cal Provider Manual. Some sections that providers may find immediately helpful include:
DHCS is clarifying acceptable Place of Service (POS) codes that may be billed to fee-for-service Medi-Cal when rendering medical services for street medicine. These POS include:
- 04 – Homeless Shelter (A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters)).
- 15 – Mobile Unit (A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services).
- 16 – Temporary Lodging (A short term accommodation such as a hotel, camp ground, hostel, cruise ship or resort where the patient receives care, and which is not identified by any other POS code).
Medi-Cal providers rendering services to an individual in these locations are responsible for determining and rendering appropriate and applicable eligible Medi-Cal services.
Services billed must also be submitted on a CMS-1500 paper claim form, or the equivalent electronic ASC X12N 837P v.5010 transaction. Instructions on how to submit either type of claim may be found in the following locations:
- Paper Claims
- Electronic Claims
Lastly, reimbursement for rendered services is limited to the provider’s applicable scope of services.
The California Advancing and Innovating Medi-Cal (CalAIM) initiative is a forthcoming DHCS initiative that will provide a whole-person approach to care and include expanded benefits to address clinical and non-clinical needs of Medi-Cal beneficiaries. The changes under CalAIM are intended to provide a new enhanced care management benefit and housing support services, delivered by community-based providers, and will provide needed services to individuals experiencing homelessness.
While DHCS is pioneering CalAIM, DHCS will also be evaluating any further changes that are needed to fee-for-service Medi-Cal to assist street medicine providers in the work they do with individuals that experience homelessness. DHCS will continue to keep street medicine providers up to date on changes made to fee-for-service Medi-Cal by publishing relevant articles or provider help documents to the Medi-Cal Providers website.