Medi-Cal Billing Manual - DHCS Homepage
State of California—Health and Human Services AgencyDepartment of Health Care ServicesMental Health Services DivisionMedi-Cal Billing ManualSeptember 2019
2019 MHSD Medi-Cal Billing Manual ReviewersACKNOWLEDGEMENTSWe would like to give a very special thanks to the following Department of Health CareServices staff for their expertise and guidance to the content of this manual:Amanda RidgewayBarbara JohnsonBeth LucasCarla MinorCarmen RomoCarol SakaiChris DicelyCheryl WardChuck AndersDaniel NahounDeepa PochirajuDina Kokkos-GonzalesDon LarsonErika CristoGary RensloHop NguyenJerry BalabanJohn GriffithJohn LessleyKaren EckelKathie TylerKen RhodesKirk EhniszKris DubbleLucille PadillaMarcelo AcobMike RiceMinh HoangMunny ChitneniRahki MalpaniRobert GeorgeSarah AguirreSesha KuvariShelly OsunaTatyana NelsonTeresa CastilloThomas TiptonNon-DHCS Contributing EditorsMaria Barteaux, San Francisco CountyMemo Keswick, Behavioral HealthConsultant Dan Walters, Kern CountyNatalie Courson, Alameda CountyThank you!Please submit any comments or questions to: MedCCC@dhcs.ca.gov
MHSD MEDI-CAL BILLING MAUNALTABLE OF CONTENTSCHANGES / UPDATES FROM PREVIOUS VERSION (JULY 2019) . 3INTRODUCTION . 51.0 Introduction . 61.1 About This Billing Manual . 61.2 Program Background . 71.3 Authority . 91.4 Medi-Cal Claims Customer Service Office (MedCCC) . 10GETTING STARTED . 122.0 Introduction . 132.1 Enrolling in ITWS . 132.2 Legal Entity, Provider Numbers and NPIs . 132.3 Provider Enrollment and Medi-Cal Certification. 142.4 Online Provider System . 152.5 X-12 Companion Guide and Appendix . 16CLIENT ELIGIBILITY . 173.0 Introduction . 183.1 Client Eligibility . 183.2 Aid Codes . 21COVERED SERVICES. 224.0 Introduction . 234.1 Covered Services . 234.2 Mode of Service and Service Function Codes . 29OTHER MENTAL HEALTH CLAIMING . 365.0 Introduction . 375.1 Inpatient Psychiatric Facilities (Non-MHP Contracted) . 375.2 IMD Exclusion . 385.3 Outpatient Claiming. 395.4 Other Health Care . 395.5 Coordination of Benefits and Gross Billing . 405.6 Claiming for Dual Eligibles (Medi-Medi) . 425.7 Non-Medicare Reimbursable: Specialty Mental Health Services. 485.8 AB3632 Children’s Services . 515.9 Administrative, Utilization Review, and Medi-Cal Admin Activities. 525.10 Annual Year-end Cost Report and Fiscal Audit: Minutes & Units . 53CLAIM PROCESSING OVERVIEW . 556.0 Introduction . 566.1 Claim Processing Overview . 576.2 High-level Mental Health Medi-Cal Claim Overview . 57Figure 6-1: Example of Mental Health Medi-Cal Claim Payments . 606.3 Funding Sources . 62Figure 6-2: High-Level SDMC Claim Processing System Flow. 646.4 Mental Health Medi-Cal Claim Stages . 65September 2019MHSD M/C Billing ManualPage 1
MHSD MEDI-CAL BILLING MAUNALTABLE OF CONTENTS6.5 Submission Timeliness . 676.6 Voids and Replacements . 686.7 UMDAP: Uniform Method of Determining Ability to Pay . 706.8 Medi-Cal Share of Cost Eligibility. 706.9 Title XXI: Enhanced Services for Children . 726.10 Healthy Families. 726.11 EPSDT: Early and Periodic Screening, Diagnostic, and Treatment . 746.12 Mental Health Medi-Cal Service Claim Rates . 776.13 Federal Funding Ratios . 786.14 Mental Health Medi-Cal Claim Processing . 796.15 Disallowance and Void Transactions. 816.16 Paper Claims, Error Correction and Replacement Transactions . 826.17 Denials vs. Rejections . 826.18 Mental Health Medi-Cal Reports . 83CLAIM LIMITS AND SPECIAL CONDITIONS . 847.0 Introduction . 857.1 Overview . 857.2 Duplicate Claims and Scenarios. 857.3 Multiple Services and Lockouts . 87Table 7-1: Multiple Services and Lockouts . 887.4 Duplicate Service Error Messages . 897.5 Special Claiming and Denial Situations . 92Table 7: Duplicate and Multiple Service Billing Scenarios . 98FREQUENTLY ASKED QUESTIONS . 119GLOSSARY . 131REFERENCE GUIDE TO HYPERLINKS IN THIS MANUAL . 136September 2019MHSD M/C Billing ManualPage 2
MHSD MEDI-CAL BILLING MANUALCHANGES / UPDATES TO PREVIOUS VERSIONCHANGES / UPDATES FROMPREVIOUS VERSION (JULY 2019)September 2019MHSD M/C Billing ManualPage 3
MHSD MEDI-CAL BILLING MANUALCHANGES / UPDATES TO PREVIOUS VERSIONSECTIONDESCRIPTION OF CHANGE AND/OR UPDATETable ofContentsChange “diagnosis” to “diagnostic” in reference to EPSDT6.0Change “diagnosis” to “diagnostic” in reference to EPSDT6.11Change “diagnosis” to “diagnostic” in reference to EPSDT6.11.1Change “diagnosis” to “diagnostic” in reference to EPSDT6.11.1Delete “supplemental” in reference to EPSDT7.5.4Change “diagnosis” to “diagnostic” in reference to EPSDTFrequentlyAskedQuestionGlossaryDelete “supplemental” in reference to EPSDTChange “diagnosis” to “diagnostic” in reference to EPSDTAppendices Updated Day Treatment Units of Measure to match regulationAppendices Changed Linkage (TCM) / Brokerage: Professional IP Visit cost unit from15 Mins to MinsSeptember 2019MHSD M/C Billing ManualPage 4
MHSD MEDI-CAL BILLING MAUNALChapter 1: IntroductionINTRODUCTIONSeptember 2019MHSD M/C Billing ManualPage 5
MHSD MEDI-CAL BILLING MAUNALChapter 1: Introduction1.0 IntroductionThe Short-Doyle/Medi-Cal (SDMC) claim process system allows California’s CountyMental Health Plans (MHPs) to obtain reimbursement of funds for medicallynecessary specialty mental health services provided to Medi-Cal-eligiblebeneficiaries and also to Healthy Families subscribers diagnosed as SeriouslyEmotionally Disturbed (SED).1 The Department of Health Care Services MentalHealth Services Division (DHCS MHSD) oversees the SDMC claim processingsystem. This Billing Manual provides information about the system. This chapterincludes:About This Billing ManualProgram BackgroundAuthorityMedi-Cal Claims Customer Service Office (MedCCC)1.1 About This Billing ManualThis Mental Health Medi-Cal Billing Manual is a publication of the DHCS. DHCSadministers the Mental Health Medi-Cal program (administered by the Departmentof Mental Health until 6/30/12).The scope of this Billing Manual is to provide stakeholders with a referencedocument that describes the processes and rules relative to SDMC claims forspecialty mental health services. Stakeholders include MHPs, Billing Vendors ofMHPs, etc.1W & I Code, Division 5, Part 2, Chapter 1, § 5600.3September 2019MHSD M/C Billing ManualPage 6
MHSD MEDI-CAL BILLING MAUNALChapter 1: Introduction1.1.1ObjectivesThe primary objectives of this Billing Manual are to: Provide explanations, procedures and requirements for claiming Provide claiming system overviews and process descriptions Provide links and/or information related to: State and Federal laws and regulations Letters and Information Notices Reference documents such as: SDMC system user guides X-12 Companion Guides X-12 Companion Guide AppendixThis Manual is not intended to duplicate the content of the Companion Guides orthe Companion Guide Appendix. However, key concepts from those documentshave been included to help explain the SDMC claiming process.1.1.2Internet Addresses and LinksAll internet addresses (URLs) and links in this document were current as of thepublication date of this manual but are subject to change without notice.1.2 Program BackgroundTitle XIX of the Social Security Act, enacted in 1965, authorizes Federal grants toStates for medical assistance to low-income persons who are age 65 or over, blind,disabled, or members of families with dependent children or qualified pregnantwomen or children. The program is jointly financed by the Federal and Stategovernments and administered by States. Within broad Federal rules, each StateSeptember 2019MHSD M/C Billing ManualPage 7
MHSD MEDI-CAL BILLING MAUNALChapter 1: Introductiondecides eligible groups, types and range of services, and administrative andoperating procedures.Each Federally-approved State plan must designate a single State agencyresponsible for administration of its State Medicaid Program. In the case ofCalifornia’s Medicaid program (known as Medi-Cal), DHCS is the responsible Stateagency in California.DHCS holds administrative responsibility for Medi-Cal specialty mental healthservices including but not limited to:1. Determination of Aid Code22. Maintenance of eligibility information technology systems (e.g. Medi-CalEligibility Determination System [MEDS])3. Adjudication of SDMC Mental Health claims4. Processing of claims for Federal Financial Participation (FFP) payments5. Submission of expenditure claims to CMS to obtain FFPFor Medi-Cal specialty mental health services provided to a beneficiary by acertified provider, the cost of these services is paid by a combination of, State, andFederal funds.The Federal Financial Participation (FFP) sharing ratio (the percentage of costsreimbursed by the Federal government) is determined on an annual basis and isknown as the Federal Medical Assistance Program (FMAP) percentage.County expenditures represent a combination of State realignment funds; Statemanaged care allocations, State General Fund (SGF) [For services provided through2010], Mental Health Services Act (MHSA) funds, local county funds and othersources such as grants. Counties submit claims to the State to obtain2SDMC Aid Codes Master ChartSeptember 2019MHSD M/C Billing ManualPage 8
MHSD MEDI-CAL BILLING MAUNALChapter 1: Introductionreimbursement of some or all of their costs based on FMAP and EPSDT eligibilityand sharing ratios.1.3 AuthorityAuthority for the Mental Health Medi-Cal program is governed by the followingFederal and State of California statutes and regulations:1.3.1Social Security ActFederal Social Security Act Title XIX, Grants to States for Medical AssistancePrograms, 42 USD § 1396-1396v, Subchapter XIX, Chapter 7 (1965),provides the basis for development of each State’s Medicaid plan.1.3.2Health Insurance Portability and Accountability Act of 1996The Code of Federal Regulations (CFR) provides statutory authority for theHealth Insurance Portability and Accountability Act of 1996 (HIPAA, TitleII) 42 USC 1320d – 1320d-8, Public Law 104-191, § 262 and § 264; also 45CFR, Subchapter C, Parts 160, 162 and 164.1.3.3Federal RegulationsTitle 42 of the Code of Federal Regulations (42 CFR) Chapter IV SubchapterC Parts 430-456 – Medical Assistance Programs provides regulatoryguidance for the Medicaid Program.1.3.4Welfare and Institutions Code (W&I Code)The California Welfare and Institutions (W&I) Code provides statutoryauthority for the Mental Health Medi-Cal program and implementslegislation.September 2019MHSD M/C Billing ManualPage 9
MHSD MEDI-CAL BILLING MAUNALChapter 1: Introduction1.3.5California Code of Regulations (CCR)State regulations applicable to SMHS are found in the California Code ofRegulations, CCR Title 9, Division 1, Chapters 1-14. Those applicable toDHCS that also affect SMHS are found in Title 22, Division 3, Subdivision1, Chapter 3.1.3.6Companion Guides for the 837 Professional and InstitutionalHealth Care Claims1.3.7Health Care Claim Payment/Advice (“837 Companion Guide” and“835 Companion Guide”)1.3.8Short-Doyle/Medi-Cal (SDMC) Companion GuideAppendix (Rev.10/7/11) (“Companion GuideAppendix)1.3.9ASC X12/004010X096A1 Health Care Claim: Institutional(837I) Implementation Guide1.3.10ASC X12/004010X098A1 Health Care Claim: Professional(837P) Implementation Guide1.3.11ASC X12/004010X091A1 Health Care Claim Payment/Advice(835) Implementation Guide1.4 Medi-Cal Claims Customer Service Office (MedCCC)MedCCC was created to provide MHPs a single point of contact to assist them withSDMC claim process questions and issues. MedCCC provides MHPs direct accessto the state when they have questions regarding claim payment, need technicalassistance with claim processing, have a question about policy, need assistancewith accurate and timely submission and processing of claims or have other billingand/or claim-related issues. MedCCC also uses a proactive approach of deliveringSeptember 2019MHSD M/C Billing ManualPage 10
MHSD MEDI-CAL BILLING MAUNALChapter 1: Introductioninformation to MHPs when a potential issue with a claim process or business rulehas been identified. MedCCC assists MHPs with streamlining the claim process,resulting in improved processes and understanding of requirements at both theMHP and state levels.What MHPs can expect when contacting MedCCC: An email response back within 24 hours, acknowledging receipt of theMHP’s issue or concern The most current information on an MHP’s Medi-Cal claims Assistance with troubleshooting claim and/or payment issues Helpful answers to policy and procedure questionsTo ensure the accuracy of the inquiry and responses, MedCCC requests thatMHPs email inquiries to: MedCCC@dhcs.ca.govMHPs may also call 916.650.6525 or Fax 916.440.7621September 2019MHSD M/C Billing ManualPage 11
MHSD MEDI-CAL BILLING MANUALChapter 2: Getting StartedGETTING STARTEDSeptember 2019MHSD M/C Billing ManualPage 12
MHSD MEDI-CAL BILLING MANUALChapter 2: Getting Started2.0 IntroductionThis chapter provides the requirements that must be met before submitting aclaim, including:Enrolling in ITWSLegal Entity, Provider Numbers and NPIsProvider Enrollment and Medi-Cal CertificationOnline Provider SystemX-12 Companion Guide and Appendix2.1 Enrolling in ITWSDHCS Information Technology Web Services (ITWS) are a collection of webapplications that allow Mental Health Services Division business partners (e.g.MHPs, Contracted Providers, and authorized Vendors) to access informationsecurely over the Internet. Requests for access to specific areas of ITWS areapproved by ‘approvers’ appointed by each MHP director.3For basic information related to ITWS enrollment and uploading claim files, aVirtual Tour is available. For further information, please call ITWS Support at (800)579-0874 or go to ITWS contact information.2.2 Legal Entity, Provider Numbers and NPIsAll MHPs and providers wishing to bill Med-Cal for providing specialty mentalhealth services must have:1. a Legal Entity (“LE”) number3ITWS: Approver Certification FormsSeptember 2019MHSD M/C Billing ManualPage 13
MHSD MEDI-CAL BILLING MANUALChapter 2: Getting Started2. a State-assigned Provider number3. an NPI (Natio
About This Billing Manual : This Mental Health Medi-Cal Billing Manual is a publication of the DHCS. DHCS administers the Mental Health Medi-Cal program (administered by the Department of Mental Health until 6/30/12). The scope of this Billing Manual is to provide stakeholders with a. reference
Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153) Medi-Cal Point of Service (POS) Network/Internet Agreement Note: These forms can be downloaded from the Forms page on the Medi-Cal Provider website (www.medi-cal.ca.gov). When the provider or submitter has approval for electronic submission, then a .
55 11-13 Crisis Referral Not Medi-Cal Eligible 55 14-16 MHS Contract Admin. Not Medi-Cal Eligible 55 17-19 Discounted MH Outreach Not Medi-Cal Eligible 55 21-23 SPMP Case Management Not Medi-Cal Eligible 55 24-26 SPMP Program Planning Not Medi-Cal Eligible 55
Directorio de Proveedores y Servicios Medi-Cal Network 661.716.7270 Toll Free: 800.918.7302 Contracted with Health Net Medi-Cal Plan Contratado con el Plan de Health Net Medi-Cal . Aceptando pacientes mayores de 5 Ned Devasia, MD (m) 661.327.3747 5801 Truxtun Ave Bakersfield, CA 93309 BC: Internal Medicine LS: Spanish. 4 Medi-Cal Jae Kim, MD .
Medi-Cal Dental Action Reason for Action Code(s) (see enclosed for explanation) You can discuss different treatment plans with your dentist to obtain the best care allowable under the Medi-Cal Dental program. If. have a question regarding this action, please contact your dentist or Medi-Cal Dental at 1-800-322-6384 for a more detailed .
Receive continuing medical education in addiction medicine annually . 7. Physician Responsibilities Review each beneficiary's personal, medical and substance . beneficiary's Medi-Cal/Drug Medi-Cal eligibility and benefits. 30 Same Day, Second Service (51341.1(j) and 51490.1) Retain in the beneficiary's record, Form DHCS MC 7700
abide by the information found in this manual. Information referenced in this manual incorporates requirements from the following key sources: Code of Federal Regulations (CFR); California Code of Regulations (CCR); State Plan Amendments (SPA); State Contract; State DHCS Mental Health Services Division Medi-Cal Billing Manual (Medi-Cal
billing. For detailed information on the format and content of the electronic claims, remittance advices, status request/response transactions, and unsolicited claims status used in the DMC billing process, consult the Short Doyle Medi-Cal Phase II ADP Standard Companion Guide. 7 . Questions related to the Companion Guide should be
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