Claim/Billing Updates

1. Claim/Billing Updates

2. Claim/Billing Updates Baby Using Mom’s ID – Scenario 1 • CCS issues a SAR to cover the newborn’s inpatient stay • SAR is issued with CCS assigned CIN number • Mom had Medi-Cal eligibility at time of delivery • Provider submits claim using Mom’s ID • Claim denies 9669 – CCS claim recipient does not match the SAR

3. Claim/Billing Updates Resolution • Provider must rebill claim with the Mom’s ID • Include in remarks field: Baby using Mom’s ID • Claim will suspend at EDS for manual review • Examiner will override edit • Claim will adjudicate using Medi-Cal funds

4. Claim/Billing Updates Baby Using Mom’s ID – Scenario 2 • CCS issues a SAR to cover the newborn’s inpatient stay • SAR is issued with CCS assigned CIN number • Newborn acquires Medi-Cal after SAR has been issued or; • Mom had Medi-Cal eligibility at time of delivery • Provider submits claim using newborn’s CIN number on SAR • Claim adjudicates from CCS funds as opposed to Medi-Cal funds

5. Claim/Billing Updates Resolution • Link newborn’s CCS CIN to Medi-Cal’s CIN through CMSNet • Provider or County may complete and submit to EDS a Claims Inquiry Form (CIF) or an Appeal form requesting EDS to void original claim due to incorrect funding source • Void claim and adjustments will appear on future MR910/940 reports • Provider must submit a new claim with Mom’s ID or the newborn’s CIN that reflects Medi-Cal eligibility

6. Claim/Billing Updates • CALPOS • Update to Client Index Number (CIN) • County/Regional office staff link the CCS CIN number to Medi-Cal’s CIN through CMSNet • CMS Branch combines the CIN numbers in MEDS • This transaction causes an update of CINs to existing SARs which is transparent to the Counties and Providers

7. Claim/Billing Updates • CALPOS, continued • CALPOS did not recognize the updated SARs • Therefore, claims were erroneously denied to providers • Problem was corrected January 12, 2005 • Provider must rebill erroneously denied claims

8. Claim/Billing Updates • CALPOS, continued • SARs issued to Pharmacies were denying when multiple lines were billed on the same transaction through CALPOS • Contact the Help Desk • Problem statement submitted • Resolution pending

9. Claim/Billing Updates • CALPOS, continued • Healthy Families claims erroneously denying again for Other Health Coverage (OHC) • Pharmacy must rebill the claim and override the OHC edit • Problem statement submitted • Resolution pending

10. Claim/Billing Updates • Prosthetics and Orthotics (P&O) • P&O providers are receiving denials when a referring provider is not indicated on the claim form • P&O providers are required to indicate a referring physician on the claim form even though the SAR is issued directly to the P&O provider • Providers must rebill the claim indicating the referring providers nine digit Medi-cal provider number in box 17a or; • Indicate the provider’s name in box 17 and their five digit state license number in box 17a

11. SAR Survey • Considering combining New Referral SAR and Established SAR • Contact your Regional office with your comments and concerns • No later than February 7, 2005

12. Provider Training • Provider trainings will begin in March 2005 • Both instructor led and satellite trainings • Information on trainings in future Medi-Cal bulletins and on Medi-Cal website. • To access the website go to www.medi-cal.ca.gov. Click on the Provider Relations link for training information.

13. Any Questions?