Billing Managers Network
Chair: Martha Ontiveros-Logan Heights Family Health Center
CPCA's 2013 Billing Managers Quarterly Call/Meeting Schedule
(Webinar/Call in information and materials will be sent out prior to each call.)
Tuesday, August 13 (2-3:30pm)
Tuesday, November 12 (2-3:30pm)
Medi-Cal Managed Care Code 18 Rate Setting, Reconciliation and Medi-Cal Claims Billing Webinar
On April 23, 2013, the Department of Health Care Services (DHCS) and Xerox in collaboration with CPCA hosted a webinar on Medi-Cal Billing and Reconciliation for Code 18 (Medi-Cal Managed Care) and Code 20 (Capitated Medicare Advantage Plan). The webinar provided an introduction to establishing a Code 18 /20 rates, annual reconciliation and Medi-Cal claims billing in the Medi-Cal Managed Care environment.
Please find the slides and recording from the webinar on DHCS Primary & Rural Health Division’s website at the below link.
http://www.dhcs.ca.gov/services/rural/Pages/PRHMeetingsandWebinars.aspx
Code 19 Claims Reduced Payment
Some health centers have reported their Code 19 claims are being paid at a reduced amount. It has been discovered that the reduction in reimbursement is due to a dollar amount being entered in box 54 of the UB-04 claim form. This amount being entered in box 54 is what was received by the Healthy Families plan. CPCA has confirmed with DHCS and ACS that this reduction is how their system was designed to process the claims. Health Centers should keep box 54 blank, otherwise any amount entered will be automatically deducted from their Code 19 rate payment.
CPCA has also confirmed that there are two ways to resolve this issue:
- Submit a CIF for each claim that was paid at a reduced rate due to this issue.
- Wait for the Code 19 reconciliation process to be completed.
Code 19 Billing Instructions
Purpose: The purpose of this module is to provide participants with an overview of per-visit code 19 billing requirements. Code 19 is used by Rural Health Clinics (RHC), Federally Qualified Health Centers (FQHC) and Indian Health Services (IHS)/Memorandum of Agreement (MOA) clinic Providers.
Module Objectives:
- Provide an overview of Code 19
- Review the history and effective date
- Explain how to bill successfully
- Understand how to establish the Code 19 Rate
- Discuss aid codes and common RAD code denials
Click here to access the Code 19 Billing Instructions
FQHC/RHC Billing Examples for Code 18/19
The example in this section is to help providers bill Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) services on the UB-04 Claim Form. Refer to the Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) section in this manual for general billing information. Refer to the UB-04 Completion: Outpatient Services section of this manual for instructions to complete claim fields not explained in the following example. For additional claim preparation information, refer to the Forms: Legibility and Completion Standards section of this manual.
Click here to access the FQHC/RHC Billing Examples for Code 18/19
Code 18/19 Same Day Visits
Health Centers may experience claims being denied as a duplicate when a patient is seen on the same day for both a medical and dental visit if the proper steps are not followed. When a patient is a Managed Care Medi-Cal or Healthy Families member, a health center is entitled to bill their wrap rate with either Code 18 or Code 19, whichever applies, for both visits. Xerox has no way to identify or differentiate one claim from the other, therefore, one will get paid and the second one will deny as a duplicate. Providers must follow the current guidelines that are in place by Medi-Cal , which states to indicate justification for each visit. This can be as simple as putting in the remarks field of the UB-04 “This patient was seen for a separate medical and dental visit on the same day at this FQHC”. Another option is to include the progress notes from the visits with the claims submission. Following the guidelines will help avoid going through the appeal process.
CPCA Staff Contact
For questions regarding billing and/or coding, please contact our Director of Health Center Operations, Ginger Smith at gsmith@cpca.org or (916) 440-8170.
