64. Medi-Cal Benefits Identification Cards/ Out of State Billing

Transcription

1 Medi-Cal Handbook page Medi-Cal Benefits Identification Cards/ Out of State Billing 64.1 Medi-Cal Identification Cards Background Prior to January 1994, California issued monthly eligibility paper cards to Medi-Cal beneficiaries. The monthly eligibility card consisted of: Two Proof of Eligibility (POE) labels which were used by health care providers for billing purposes. Additional POE labels were available upon the Medi-Cal beneficiary s request. Two MEDI labels which were used for specific medical services. The Medi-Cal eligibility card issuance procedures required complex paper work every month in dealing with payment authorization and tracking of medical services. Therefore, these procedures were eliminated. In January 1994, California began issuing permanent plastic Benefits Identification Card (BIC) to replace the monthly Medi-Cal eligibility paper card. The BIC implementation began in Santa Clara County in March A temporary Paper Card is still issued in immediate need situations at Social Services District Offices. The BIC and the Paper Card are for access to the California Eligibility Verification and Claim Management System (CA-EV/CMS) and identification purposes only; The BIC/Paper Card does not guarantee Medi-Cal eligibility. The BIC and/or temporary Paper Card: Allows online access for providers to verify client eligibility. Providers are given an Eligibility Verification Claim Number (EVC), by Electronic Data Systems (EDS) online. This guarantees provider payment for services. Allows the provider to record online share of cost obligation in share of cost Medi-Cal cases. Update# Revised: 04/11/08

2 page 64-2 Provide online tracking of MEDI Services. Medi-Cal Handbook Provide online claim billing capabilities for pharmacies. The Benefits Identification Card (BIC) The BIC is a permanent plastic card that is tied to the client s Medi-Cal Eligibility Data System (MEDS) record. The BIC is issued by Electronic Data Systems (EDS) to: All Medi-Cal beneficiaries, including Public Assistance (PA) and Other PA recipients (i.e. CalWORKS, AFDC-Foster Care, AAP, Kin-GAP, SSI/SSP). Ineligible Members (Aid Code IE) whose medical expenses can be applied to family members in the same MFBU with a share of cost. Responsible Relatives (Aid Code RR) whose medical expenses can be applied to family members in the same MFBU with a share of cost. In this chapter, the above people are referred to as BIC recipients. The Paper Identification Card The temporary Paper Identification Card is issued online by the MEDS Terminal Operator (MTO) in County Social Services District Offices to: Minor Consent beneficiaries, and Beneficiaries with an Immediate Need. In this chapter, the above people are referred to as Paper Card recipients California Eligibility Verification System and Claim Management System (CA-EV/CMS) The CA-EV/CMS is a statewide Medi-Cal eligibility verification system. The BIC/Paper Card allows the provider to access the CA-EV/CMS system. The health care provider must verify recipients eligibility for the month(s) of service. In order to access the CA-EV/CMS, the provider must have the following information from the BIC/Paper Card: 14-digit identification number Client s Date of Birth, and Card Issue Date. Revised: 04/11/08 Update# 08-06

3 Medi-Cal Handbook page 64-3 The CA-EV/CMS provides online eligibility messages which include the following information: Client s ID BIC Issue Date Date of Service County Code Medi-Cal Aid Code(s) Other Health Coverage Share-of-Cost, if applicable MEDI Services Restriction messages Eligibility messages to tell providers whether a client is entitled to pregnancy services or other special programs with no SOC (e.g. Federal Poverty Level, TB, Post-Partum) and/or SOC with other services. Medi-Cal Eligibility Verification There are 4 ways for a provider to verify eligibility. 1. Point of Service (POS) Device The POS device is similar to the bank/credit card readers in retail stores. It communicates with the POS Network to confirm eligibility. The device is triggered either by swiping the BIC through the card reader or keying in the recipient information. The POS comes with a printer that provides users with proof of eligibility by printing out the eligibility confirmation from the POS device. 2. Claims and Eligibility Real-Time System (CERTS) Software CERTS is designed to run on a personal computer (PC) to verify recipient eligibility, clear Share of Cost liability and reserve Medi-Services. Providers can print out eligibility confirmation using the printer attached to their PC. 3. Automated Eligibility Verification System (AEVS) The AEVS is an automated system that providers access via a touch-tone telephone or computer to verify eligibility, clear share of cost liability and reserve MEDI Services. The provider must use a valid Provider Identification Number (PIN) to access AEVS. Update# Revised: 04/11/08

4 page Third-Party or Provider Developed Software Medi-Cal Handbook The providers can develop their own software capable to interact with the POS network to verify recipients eligibility BIC Use/Authorization [50731, 50733, 50735] Use Only the person whose name appears on the front of the BIC/Paper Card can use that BIC/Paper Card. The BIC is always sent by EDS to the Medi-Cal beneficiary s address as shown on MEDS record. A permanent BIC must not be mailed to a temporary address unless there are extenuating circumstances. In these situations, the EW must change the address on MEDS to the temporary address (and request a new card if necessary), then change the address back the following day. This procedure should only be used with extreme caution. The BIC must NOT be mailed to any address other than that of the eligible beneficiary, nor given to any person other than the beneficiary. Exception: The BIC may be given/mailed to the spouse of an eligible person residing in Long Term Care (LTC), if that spouse is acting as Authorized Representative; or to the AR when the beneficiary is comatose, amnesiac, or incompetent. Similar situations must be approved by an EW supervisor. The BIC must be retained by the recipient even if there is a change in Medi-Cal eligibility status (i.e. Medi-Cal eligibility is discontinued, an IE or RR becomes eligible for Medi-Cal). The BIC recipient will use the same BIC when Medi-Cal eligibility is activated or reestablished even if in another county or different cases. Authorization for use The BIC, in conjunction with the CA-EV/CMS, shall: Serve as authorization for payment of claims for the cost of covered services which meet all the following conditions: (1) Incurred during a month the beneficiary is eligible for Medi-Cal, and Revised: 04/11/08 Update# 08-06

5 Medi-Cal Handbook page 64-5 (2) Not paid or obligated by the beneficiary to meet the share of cost requirement, and (3) Not covered by Other Health Coverage (OHC)/ Prepaid Health Plan (PHP)/ Managed Care when the beneficiary is a member, and (4) Not payable by a Third Party, and (5) Not prohibited due to limited service status. Be issued under the SSI/SSP program for children who receive both SSI/SSP and an AFDC/FC supplemental payment. Serve as authorization for payment of covered services received in or outside California [Refer to Out-of-State Billing, page 64-26]. Identify beneficiaries enrolled with a Medi-Cal Managed Care plan for benefit purposes. This will be of benefit to a beneficiary who needs emergency treatment when away from the Managed Care areas. The Medi-Cal beneficiary may also receive a plan identification card from their own Managed Care plan. Services provided to a newborn child in the month of birth and the following month can be billed to the mother s Medi-Cal card if the mother remains eligible for Medi-Cal. A separate BIC must be issued for the infant by the third month as services must then be billed separately for each beneficiary. Benefits under the 60-Day Postpartum Program (Aid Type 76-0) do not cover services to the newborn Medi-Cal Identification Card Format BIC format The permanent plastic BIC looks like a credit card. The card is white with blue printing on the front and black printing on the back. Update# Revised: 04/11/08

6 page 64-6 Front of the BIC Medi-Cal Handbook The front of the BIC contains the following basic information about the client: Recipient s name Sex: M (male) or F (female) Date of Birth (MMDDCCYY) Issue Date (MMDDYY): date the card was issued by EDS. Recipient ID Number: Client Index Number (CIN) followed by a check digit followed by a 4-digit Julian (calendar) date that matches the date of issuance on the BIC. Prior to March 26, 2003, the Social Security Number (if available) is printed on the front of the BIC. In order to comply with the Health Insurance Portability and Accountability Act (HIPAA) standards and to protect the identity of clients, the Department of Health Services (DHS) made some changes on the front of the BIC. New or replacement BICs issued on or after March 26, 2003 will have the CIN printed on the front of the BIC instead of the client s SSN. Back of the BIC The back of the BIC contains a magnetic strip which allows the provider to access the CA-EV/CMS via the Point-of Service (POS) device. Below the magnetic strip is a box for the BIC recipient s signature, followed by a message indicating that the card is for identification purposes only, possession of the card does not guarantee eligibility, and that misuse of the card is unlawful. Signature Requirements The BIC recipient must sign the back of the card upon receipt, except for beneficiaries who are: Under 18 years of age, or In Long Term Care, or Unable to sign the BIC because of a disability determined by the provider. Revised: 04/11/08 Update# 08-06

7 Medi-Cal Handbook page 64-7 The EW must inform all applicants and beneficiaries or Authorized Representatives that they must sign the BIC upon receipt. The EW is NOT required to witness the signature The Paper Card The front of the Paper Card has the same information that is found on the front of the BIC (recipient s name, ID number, sex, birthdate). The Paper Card has the Good Thru Date showing that the card is valid for identification purposes for a limited time only. The beneficiary s signature is required on the front of the card. The back of the Paper Card contains general instructions to the recipients when using the card. It also contains the Social Security Administration (SSA) phone number for SSI recipients to contact when needed Client Index Number The CIN is a unique identifier assigned to an individual. The CIN is different from the pseudo ID number. The CIN begins with a 9, followed by 7 numeric digits, then an alpha character other than B,I,J,K,L,O,P,Q,R,S, and ends with a check digit (i.e A 2). The CIN is recorded on MEDS to allow other state programs to use it for identification and indexing purposes. The CIN may not be altered by the County MEDI Reserve System The following providers must bill certain treatments/services as MEDI services: Chiropractors Psychologists Acupuncturists Podiatrists Occupational therapists Speech pathologists Audiologists Update# Revised: 04/11/08

8 page 64-8 Medi-Cal Handbook Medi-Cal beneficiaries are limited to two MEDI services each month. The provider may reserve a MEDI service online when making an appointment for the current month (or the future month if after MEDS renewal) by using the CA-EV/CMS. A provider may release a MEDI reservation online so that other MEDI service providers can provide necessary care to the Medi-Cal beneficiary. With this reservation system, providers have some guarantee that they will be able to bill for the MEDI scope of service and receive payment. Medi-Cal beneficiaries must direct MEDI reservation system questions and/or problems to their providers. The EW has no control over the MEDI reservation procedure Non SSI/SSP Medi-Cal Identification Card Issuance BIC issuance for Non-SSI/SSP Recipients Once Medi-Cal eligibility is approved in CalWIN and the Add (EW 20) transaction is processed by MEDS, MEDS will trigger the Electronic Data Systems (EDS) to issue a BIC to any Medi-Cal beneficiary who: Is being added as a new client to MEDS, or Has never received a BIC before (i.e. Ineligible Persons in a no SOC case). Normally, the BIC is generated and mailed by EDS to the BIC recipient two work days after the EW 20 transaction is filed. Example: An Add (EW 20) transaction filed on Wednesday 6/14/06 by the EW will be processed by MEDS on Thursday evening, 6/15/06. A transaction is then generated by MEDS to EDS to generate a new card. EDS will process this transaction on either on Friday 6/16/06 or Monday 6/19/06 and the card will be mailed the same work day. Revised: 04/11/08 Update# 08-06

9 Medi-Cal Handbook page Paper Card Issuance for Non-SSI/SSP Recipients A temporary Paper Card is issued by the Medi-Cal Terminal Operator (MTO). It is issued only when eligibility for Minor Consent or Immediate Need has been established. A Paper Card for an Immediate Need beneficiary is valid for 30 days (i.e. if the Issue Date is 07/03/06, then the Good Thru date is 8/02/06). A Paper Card for the Minor Consent Program is valid for one year (i.e. if the Issue Date is 7/3/06, then the Good Thru date is 7/2/07). Minor Consent Program beneficiaries are eligible for only the month of request and must reapply for each month of eligibility as needed. The EW must inform Minor Consent beneficiaries to keep their Paper Card for one year from the date of issue as a new paper card is not issued monthly. The paper card for Presumptive Eligibles (PE) is issued by the provider to pregnant women Health Access Program Card (HAP) The HAP Card is a plastic identification card used in some health care programs which are directly administered by the state. The HAP Card is similar to the BIC but is teal-colored with black print, and has less information printed on the face. Currently, the state administered Family Planning, Access, Care and Treatment Program (Family PACT) is issued on the HAP card Family Planning, Access, Care and Treatment Program (Family PACT) California residents can receive family planning services through the Family PACT Program, previously known as the State Only Family Planning Program (SOFP), when they meet the following criteria: No other health coverage which covers family planning, and Gross family income at or below 200% of the federal poverty level, and Unmet share of cost (this criterion applies only for Medi-Cal beneficiaries). Update# Revised: 04/11/08

10 page Medi-Cal Handbook There is no property limit or alien status requirement for Family PACT. Health Care providers, not the EW, determine Family PACT eligibility. The participating providers will enroll the eligible person in the Family PACT program, and issue a Health Access Programs (HAP) card for people who don t have a valid BIC; or add Family PACT eligibility to the Medi-Cal BIC. The provider is responsible for the HAP card replacement. [Refer to Update 97-9] 64.6 Non SSI/SSP Medi-Cal Identification Card Replacement BIC Replacement There is no need to issue a replacement card when Medi-Cal aid categories change. The BIC is an ID card that can be activated and deactivated based on any type of Medi-Cal eligibility. When a BIC is lost, damaged, stolen or information on one or both sides of the BIC must be modified, the EW can request a replacement BIC through the Benefit Issuance Subsystem in CalWIN. The system will send a card request transaction to the MEDS system through the daily batch interface process. [Refer to "Request Replacement BIC Card" in the CalWIN OLUM for instructions on how to replace a BIC card]. It normally takes two work days for EDS to reissue and mail a replacement BIC after the EW has completed the [Maintain Card Requests] window in CalWIN. No affidavit is needed when the client requests a replacement BIC. MEDS deactivates the previous BIC when generating a replacement BIC with a new Date of Issue. The EW must advise the card recipient to discard the previous BIC if it is found later and use the BIC with the latest issue date, as it is no longer valid Replacement of Paper Cards Medi-Cal beneficiaries can request a paper card replacement at County Welfare Offices by completing a Request For Immediate Need Paper BIC (SC 1233). The replacement of a temporary Paper Card is done online by the MTO at any district office. Revised: 04/11/08 Update# 08-06

11 Medi-Cal Handbook page When replacing a Minor Consent paper card, the MTO must use the same pseudo ID number in order to avoid duplicate records on MEDS. (Duplicate records may cause duplicate cards to be issued for the same client for overlapping time periods). The replacement card will have a new Issue Date and new Good Thru date. The beneficiaries must be reminded to keep their cards until the Good Thru date SSI/SSP Medi-Cal Identification Cards SSI/SSP Initial BIC Issuance SSI/SSP eligibility is determined by Social Security Administration (SSA). SSA completes computer entries to transmit cash-based Medi-Cal eligibility to MEDS via State Data Exchange (SDX). SDX transactions are sent to MEDS on a weekly basis; MEDS then sends transactions to EDS to generate BICs for SSI/SSP beneficiaries who are initially added to MEDS. A new BIC is not issued to SSI/SSP recipients if they have already received a BIC under another Medi-Cal program (i.e. a CalWORKs recipient continues to use the same BIC if he/she becomes SSI/SSP eligible). Due to the weekly SDX transaction, it takes at least 5 work days for a newly approved SSI/SSP individual to receive a BIC and/or to have Medi-Cal eligibility recorded into the CA-EV/CMS. Therefore, newly approved SSI/SSP recipients who need emergency care must contact the County Welfare Department to have their Medi-Cal eligibility recorded on MEDS and/or a Paper Card /BIC issued online. When an SSI/SSP individual requests an immediate need Medi-Cal Paper Card/ BIC, follow the procedure below: Stage Who Action 1. EW Verifies proof of SSI/SSP eligibility by any of the following: The SSI/SSP check for the month for which Medi-Cal is requested. Documentation from the Social Security Administration (i.e. SC 169). An SSI/SSP award letter received that month. Other proof of eligibility as specified by DHS. (Chart page 1 of 2) Update# Revised: 04/11/08

12 page Medi-Cal Handbook Stage Who Action 2. EW Fills out a Request for Online Transaction (SC 1296) to have SSI/SSP based Medi-Cal eligibility recorded for eligible months, and/or a BIC/ Paper Card issued (indicate EW 15 on SC 1296). 3. MTO Records SSI/SSP eligibility. Issues a Paper ID card and/or requests a BIC be sent, if appropriate. NOTE: In order to receive an immediate need Paper Card/BIC, the SSI/SSP individual must not be enrolled in a comprehensive Prepaid Health Plan (PHP) for the month for which Medi-Cal eligibility is requested. (Chart page 2 of 2) If SSI/SSP based Medi-Cal eligibility is requested for a period one year or more prior to the current month, the EW must follow the procedure to request a Letter of Authorization. [Refer to Letter of Authorization, page ] SSI/SSP BIC Replacement A BIC can be replaced for a beneficiary who is currently SSI/SSP active on MEDS when: The card was mutilated, lost, or stolen. An [INQM] screen from MEDS showing SSI/SSP eligibility is the only verification needed in these situations. No affidavit is required from the SSI/SSP beneficiary. A temporary Paper Card can be issued if an immediate need exists. The BIC contained erroneous data (i.e. address, health coverage, birthdate). SSI recipients reporting erroneous data on their cards can contact any County Welfare District Office to request BIC replacement. The following procedure must be followed: Stage Who Action 1. EW Advises the SSI/SSP recipient to report changes or incorrect information to their local SSA office if the recipient has not done so. The toll free number is not appropriate to report address changes. Revised: 04/11/08 Update# 08-06

13 Medi-Cal Handbook page Stage Who Action Verifies proof of changes requested: Documentation from the Social Security Administration (SC 169), or The Social Security Administration Referral Notice (MC 194) returned from SSA, or Other proof of changes as specified by DHS. Completes a Request for Online Transaction (SC 1296) requesting an EW 55 transaction to: Make the appropriate MEDS record changes, and Issue a replacement BIC/ Paper Card, if necessary. 2. MTO Updates the changes on MEDS and issues a replacement BIC/Paper Card, as requested. IMPORTANT: EWs must not change the address of an SSI/SSP recipient on MEDS without verification from Social Security Administration (i.e., SC 169, SC 1955 or phone confirmation). If the client s Social Security address is not updated first, the system will default to the address where the SSI/SSP check is sent Letter of Authorization An eligibility Letter of Authorization (MC 180) authorizes payment for medical services received 12 months or more prior to the current month. The County department must not issue a Letter of Authorization (LOA) or submit a request that a LOA be issued to any beneficiary, including SSI/SSP recipients unless one of the following conditions exists: SSI/SSP was approved but cards were never issued by EDS. A court action requires that benefits be issued. A State or other administrative hearing decisions. The County determines that an administrative error has occurred. Update# Revised: 04/11/08

14 page Administrative Error Medi-Cal Handbook Some examples of acceptable administrative errors include, but are not limited to the following: (1) Failure to approve a Medi-Cal application due to legitimate errors made in the course of determining eligibility (i.e., the application is misplaced and eligibility was never determined, an applicant was denied but should have been approved and an appeal was not filed). (2) Failure to issue a BIC within a year from the date of the service because the county system or MEDS shows an incorrect beneficiary address for the month of request. (3) BIC issued within one year, but it is coded incorrectly and can not be used to bill for the services rendered (i.e., the BIC shows a Medically Indigent/Long Term Care 53-0 Aid Code and the applicant received and was eligible for acute care services in that month). If the EW finds that an administrative error does not exist, but extenuating circumstances exist beyond the beneficiary s or the county s control, or if the EW is unsure whether a particular situation meets the definition of an administrative error, the Medi-Cal Program Coordinator should be contacted for assistance. An example of extenuating circumstances beyond a beneficiary s control would be a medical condition that severely impaired his/her functioning. The beneficiary needs to describe how the impairment prevented him/her from giving the provider the necessary documentation of his/her Medi-Cal eligibility. Reminder: Please note that billing problems, such as the provider failed to bill Medi-Cal timely, are not by themselves considered an extenuating circumstance. Beneficiaries who are sent to collections after providing a Medi-Cal card should be told that Welfare and Institutions Code Section precludes a provider from billing the beneficiaries in these situations. Medi-Cal providers are obligated to accept Medi-Cal payment for covered services even if eligibility is established retroactively from the month of application. Revised: 04/11/08 Update# 08-06

15 Medi-Cal Handbook page Non SSI/SSP Letter of Authorization (LOA) Process Follow the procedure below when a valid reason exists to issue a non-ssi/ssp LOA for payment of medical services received one year or more prior to the current MEDS month: STAGE WHO ACTION 1 EW Completes the Letter of Authorization Request (SC 1594), documenting all of the following information: The client s name, SSN/Pseudo number, 14 digit County ID, address, and SOC amount, The EW s name, worker number and phone number, The Medi-Cal date of application and the date of approval (this is the date the EW authorizes the case in CalWIN), and other health coverage code, The EW Supervisor name/number, his/her phone number and signature, The provider s name and if available, the provider number, The month(s) for which the client received services and is being billed for, The reason for the request must be one of the following: (1) Court action - Attach a copy of the Court Order. (2) Fair Hearing decision - Attach a copy of the decision. (3) Administrative Error - Include a clear description of the error and attach supporting documents. 2 EW Attaches the following documents to the SC 1594: MEDS screen for the month(s) requested (INQM, INQ6, and/or INQ7), AND If the client has no SOC: a copy of MC 176M or MC 176M-LTC budget worksheet OR a relevant CalWIN wrap-up window(s) showing zero SOC, OR If the client has SOC: a copy of MC "Record of Health Care Cost" completed by the provider OR a MEDS screen (INQM, INQ6, INQ7, SOCR) showing that the SOC has been certified. 3 EW Submits the SC 1594 and the appropriate documents to the Supervisor for review. Update# Revised: 04/11/08

16 page Medi-Cal Handbook STAGE WHO ACTION 4 EW Supervisor 5 MC Program Coordinator Reviews the SC 1594 and attachments for completeness, enter signature, and forwards the packet to the Medi-Cal Program Coordinator. Reviews the request packet and issues a "Letter of Authorization" (MC 180) if all criteria are met. Sends the MC 180 to the EW Supervisor. 4 EW Completes a Request for Online Transaction (SC 1296) to have Medi-Cal eligibility for the month(s) of request recorded (EW 50). Attach a copy of the LOA to the SC Mails both copies of the MC 180 to the beneficiary. The LOA is only valid for 60-days, it is important that the client submits the original to the provider immediately. Submits the SC 1594 packet and a copy of the MC 180 for IDM scanning. NOTE: If the client s Share of Cost is not yet certified on MEDS, a SOCO transaction must be requested at the same time by completing the MEDS SOCO form to have the amount the client has agreed to pay or has already paid toward the required SOC. [Refer to Chapter 62 in the Medi-Cal Handbook.] 5 MTO Records Medi-Cal eligibility for the month(s) of request (EW 50). Records Share of Cost Obligation (SOCO transaction), if requested. Only one LOA is issued for each provider for up to 12 months of services. A provider needs only one letter for all months for which the client received medical services SSI/SSP Letter of Authorization (LOA) Process SSI recipients sometimes contact Social Services Agency to request a Letter of Authorization (LOA) for payment authorization of medical services received a year or more prior to the current MEDS month. Requests made by SSI only recipients are processed at Valley Medical Center; requests from SSI/QMB clients are processed at the district office where the case is located. An SSI/SSP recipient must request a Medi-Cal LOA (MC 180) within six months of the approval decision or four months from the date of SDX update known as the "LAST-SDX-CHG" date on the [INQX] screen. Revised: 04/11/08 Update# 08-06

17 Medi-Cal Handbook page The "LAST-SDX-CHG" date is not a reliable date as it changes in MEDS every time an update to the record is processed. For exceptions due to extenuating circumstances, contact the Medi-Cal Program Coordinator. An example of an extenuating circumstance would be a medical condition that severely impaired the SSI/SSP recipient s functioning. Additionally, the beneficiary would need to describe how this reduced function prevented him/her from giving the provider the necessary documentation of his/her Medi-Cal eligibility. Billing problems are not by themselves considered an extenuating circumstance. Follow the procedure below when a valid reason exists to issue an SSI/SSP LOA for payment of medical services received one year or more prior to the current MEDS month: Stage Who Action 1 EW Verifies SSI/SSP eligibility (SC 169 or other document from SSA). Completes a Request for Online Transaction (SC 1296) to have a Paper Card / BIC issued (EW 15), if necessary. 2 MTO Generates an EW 15 (Immediate Need transaction) to issue a Paper Card and/or a BIC if appropriate. 3 EW Completes the Letter of Authorization Request (SC 1594). Writes SSI/SSP Recipient on the top of the SC1594 and documents all of the following information: The client s name, SSN/Pseudo number, 14 digit County ID, and address, The EW s name, worker number and phone number, The SSI date of application, if known (if not known, enter "Unknown, SSI"), the date of SSI approval, and other health coverage code, The EW Supervisor name/number, his/her phone number and signature, The provider s name and if available, the provider number, The month(s) for which the client received services and is being billed for, The reason for the request (check the SSI/SSP box, explain why an LOA is requested, and attach supporting documents such as SC 169). Update# Revised: 04/11/08

18 page Medi-Cal Handbook Stage Who Action 3 EW Submits the SC 1594, supporting documents, and the appropriate MEDS screen (INQM, INQ6, INQ7) to the supervisor for review. 4 EW Supervisor 5 Program Coordinator or Designated VMC Staff Reviews the SC1594 packet for completeness, enters signature, and sends the request to the Medi-Cal Program Coordinator. LOA requests processed at VMC may be submitted to the VMC staff person authorized to issue MC 180s. Completes the MC 180 (if the client is entitled), and sends it to the EW Supervisor to forward to the EW. The MC 180 does not require the EW name/number, and telephone number when eligibility is established by Social Security Administration. 6 EW Completes a Request for Online Transaction (SC 1296) to have Medi-Cal eligibility for the month(s) of request recorded (EW 50). Mails both copies of the MC 180 to the beneficiary. (The LOA is good for 60-days only, it is important that the client submits the original to the provider immediately. 7 MTO Records Medi-Cal eligibility for the month(s) of request (EW 50) Share-of-Cost Record System Share of Cost Online Record The BIC allows health care providers online access to eligibility and share of cost information. The provider can input the SOC obligation directly to the CA-EV/CMS. The SOC remaining balance is updated in real time to allow the next provider to know that the SOC has been reduced or met. SOCO Transactions When a provider is unwilling or unable to input the share of cost obligation to the CA-EV/CMS, the Medi-Cal beneficiary can contact their EW to have their share of cost obligation recorded online on MEDS. The EW must complete the MEDS SOCO form to request the MTO to generate a SOCO transaction. The SOC remaining balance for the month in question will be updated online. Revised: 04/11/08 Update# 08-06

19 Medi-Cal Handbook page Share-of-Cost Reversal The provider can reverse a SOC transaction online if an error exists (i.e. an amount of share of cost was entered incorrectly into the CA-EV/CMS, and the error is found later by the provider). The reversal can only be done if the SOC has not been met. SOC files will be updated immediately and the provider will receive confirmation that the reversal has been completed. This procedure can also be done at the County Social Services Office with the SOCO transaction generated by the MTO per request of the EW via the form MEDS SOCO Service Restrictions for Medi-Cal Abuse/Codes and Messages The Department of Health Services enters restriction messages in the CA-EV/CMS when a beneficiary is found abusing Medi-Cal services. Therefore, when the provider verifies eligibility through the POS network, the following are examples of messages/codes that may be seen: Message Description Restriction Codes * TAR Required For Drugs TAR Required For Scheduled Drugs TAR Required For Physician Visits An approved Treatment Authorization Request (TAR) is required from a Medi-Cal field office drug unit for all nonemergency prescription drugs for a beneficiary found misusing drugs supplied through Medi-Cal. An approved TAR is required from a Medi-Cal field office drug unit for all nonemergency prescription for a beneficiary found misusing scheduled drugs supplied through Medi-Cal. An approved TAR is required for nonemergency outpatient physician visits for a beneficiary found utilizing an excessive number of outpatient physician visits. Code on MEDS: 010 Code on MEDS: 050 Code on MEDS: 110 Update# Revised: 04/11/08

20 page Medi-Cal Handbook Message Description Restriction Codes * TAR Required for Physician Visits and Drugs An approved TAR is required for non-emergency outpatient visits and non-emergency prescription drugs for a beneficiary found abusing both outpatient physician visits and scheduled drugs. Code on MEDS: 120 NOTE: Restriction codes on MEDS may be seen on the [INQM] Screen, [RESTRICT] Field. Refer the beneficiary to his/her provider to request a Treatment Authorization Request (TAR) BIC/CIN Information on MEDS Screens The 14-digit BIC number can be found on the INXB screen. Information about the BIC can be found in MEDS on the following screens: INQM and INQ1 Screens BIC Issue Date The date that EDS issued the most recent, permanent BIC. If it is blank, a BIC has never been issued for the client (e.g. a MEDS record which has not been active since BIC implementation). This date is critical for clients and for providers to access the CA-EV/CMS. Paper ID Card Issue Date Usually this field is blank unless the Medi-Cal beneficiary asks for a paper card. If there is a date, it shows that a paper card was issued on that specific day by the MTO for an immediate need. Revised: 04/11/08 Update# 08-06

21 Medi-Cal Handbook page MOPI Screen This screen allows the EW access to the same eligibility messages that the health care providers receive when they do an eligibility inquiry on the POS device. The EW can research client/provider problems. The Recipient ID required in this screen can be a Social Security Number (SSN), a pseudo ID or the Client Index Number (CIN) SOCR Screen This screen provides access to the online query Share of Cost database. The Share of Cost database contains up to the minute information (real time) on all cases reported to MEDS with a SOC. The SOC database contains query data such as the list of all cases in which the recipient is a member, the SOC case amount and the SOC balance (the remaining amount of SOC obligation for the month in question) Copayment Some Medi-Cal recipients are required to make copayment for their benefits. See the chart below for services subject to copayment, the fees and the exceptions to the requirement. The copayment fee is to be collected by or obligated to the provider at the time the service is rendered. The fee is in addition to the amount the provider receives from Medi-Cal. This means the amount received by the provider is not reduced by the copayment collected. The collection of the copayment is: Optional May be waived entirely at the discretion of the provider. Update# Revised: 04/11/08

22 page Medi-Cal Handbook This section is for information only. No action is required. Services Subject to Copayment Copayment Fee Exceptions To Fee NONEMERGENCY SERVICES PROVIDED IN AN EMERGENCY ROOM A nonemergency service is defined as any service not required for alleviation of severe pain or the immediate diagnosis and treatment of severe medical conditions which, if not immediately diagnosed and treated, would lead to disability or death. Such services provided in an emergency room are subject to copayment. OUTPATIENT SERVICES Physician, optometric, chiropractic, psychology, speech therapy, audiology, acupuncture, occupational therapy, podiatric, surgical center, hospital or outpatient clinic, physical therapy. DRUG PRESCRIPTIONS Each drug prescription or refill. $5.00 Persons age 18 or under. $1.00 $1.00 Any woman during pregnancy and the postpartum period (through the end of the month in which the 60-day period following termination of pregnancy ends.) Persons who are inpatients in a health facility (hospital, skilled nursing facility or intermediate care facility). Any child in AFDC-Foster care. Any service for which the program's payment is $10.00 or less. Any hospice patient. Family planning services or supplies Disposition of Returned Medi-Cal Cards Returned (Undeliverable) Cards A returned (undeliverable) BIC is sent back to EDS. EDS swipes the returned BIC through a reading device that produces two separate files: one for bad addresses and one for deceased recipients. EDS keeps the returned BICs for three days and then destroys them. The Bad Address File and the Deceased Recipient File are sent to DHS to update the MEDS database on a daily basis. DHS alerts the EW through the daily County Eligibility Worker Alerts (CEWA) numbered 9003, 9008 or Revised: 04/11/08 Update# 08-06

23 Medi-Cal Handbook page EW Responsibilities When a CEWA is generated which advises the County Welfare Department of a returned BIC, the EW must follow the agency procedures to fix the problems. [Refer to the Users Guide, Chapter 9.] Release of Medi-Cal Eligibility Information to Providers The Department of Health Care services (DHCS) policy and the Welfare & Institution Codes allow providers to contact county welfare departments for information necessary to verify client s Medi-Cal eligibility. Providers must make a good faith effort to obtain the BIC information from the Medi-Cal beneficiary prior to contacting the worker. An exception to Provider s good faith effort exist if ALL of the following conditions are met: The beneficiary has an immediate need for medical services (such as he/she is currently in the doctor s office, has an appointment scheduled prior to anticipated receipt of BIC, and/or needs to have a prescription filled). The beneficiary does not have his/her card or a new card has been issued that invalidates the card she/he has. The Eligibility Worker (EW) can confirm the identity of the beneficiary. Under certain conditions, the EW or designated staff member is allowed to provide verification of Medi-Cal eligibility to medical providers, in order for the provider to bill Medi-Cal. For billing purposes, limited beneficiary information may be given to any Medi-Cal provider as long as sufficient information is obtained to identify the beneficiary and establish that the individual is a Medi-Cal provider. The information obtained from the provider must be sufficient to assure there is no question as to the identity of the provider or the beneficiary. To ensure that individuals phoning to request this information are, in fact, who they represent themselves to be, the EWs must: Take the caller s name and phone numbers, and Call them back with the requested information. Update# Revised: 04/11/08

24 page Medi-Cal Handbook If the case is closed, the "Information Supervisor of the day" will receive this referral and provide the information. Medical providers include but are not limited to: Doctors Dentists Chiropractors Acupuncturists Optometrists Hospitals Nursing homes Primary care clinics. If in doubt that an individual/association qualifies as a medical provider, the EW Supervisor may contact the Medi-Cal Program Coordinator for a determination. Information may not be released to a billing agent or collection agency, such as the Department of Revenue. Do not give out extraneous information. The EW is responsible for ensuring that the confidentiality of the beneficiary s eligibility information is maintained. Under no circumtance must a Medi-Cal client s information to be given to anyone unless the purpose is directly related to the administration of Medi-Cal Medi-Cal Eligibility Data System (MEDS) Medi-Cal Eligibility Data System (MEDS) terminal access is available only to agencies involved in the administration of the Medi-Cal program. The Social Services Department, the Department of Mental Health, the Local Child Support Agence, California s Children s Services, and their outstationed staff may have access to MEDS terminals. Medi-Cal providers and third party creditors, such as collection agencies working under contract for such providers, may NEVER HAVE ACCESS TO MEDS. Department of Health Care Services policy regarding confidentiality also prohibits county staff to release MEDS print outs (including MOPI screens) Information Which May be Released to a Provider The EW or designated staff member is allowed to provide the following information to medical providers: Revised: 04/11/08 Update# 08-06

25 Medi-Cal Handbook page The 14-digit BIC ID number (which contains the 9-digit Client Index Number [CIN], a check digit and a 4-digit Julian date that is equal to the card issue date). Date of Birth. Eligibility staff should only need to provide the client s 14-digit BIC and date of birth. Refer the provider to the Medi-Cal Eligibility Verification System or the telephone Automated Eligibility Verification System at for verification of the client s eligibility. This is the only situation in the Medi-Cal program when a signed Release of Information is not required in order to provide beneficiary information to a third party Ineligible Individual EWs must not release any information for an ineligible individual other than the fact that he/she is not eligible for Medi-Cal (for a time period or for a specific month). If the hospital is requesting a denial reason to determine the individual s need for charity assistance, the EW may provide the denial reason Request for Medi-Cal Eligibility Information for a Deceased Individual The EW may release the CIN, BIC Issue Date and Birthdate to any Medi-Cal provider who rendered a service for a beneficiary who is now deceased. The request must be made within twelve months following the month of service Release of Information on an Ineligible Person No information on an ineligible individual shall be released other than the fact that he/she was not eligible for a specific month. Update# Revised: 04/11/08

26 page Medi-Cal Handbook Out-of-State Billing Medi-Cal Card Use The BIC may serve as authorization for payment covering a service provided outside California only under the following conditions: There is an emergency due to an accident, injury or illness. The health of the individual would be endangered if care and services were postponed until it is feasible to return to California. The health of the individual would be endangered if s/he traveled to return to California. It is the customary practice in border communities for residents to use medical resources in adjacent areas outside the State. The beneficiary's physician has proposed an out-of-state treatment plan which has been reviewed and authorized by the Department of Health Services (DHS) before the services are provided. DHS may authorize such treatment only when it is not available within the State. Health care is needed for eligible California children placed in other states through the Interstate Compact on Placement of Children Prior Authorization Prior authorization is required for all out-of-state claims except: Emergency services, i.e., required for alleviation of severe pain or immediate diagnosis and treatment of unforeseen medical conditions which would lead to disability or death if not diagnosed and treated immediately. Services provided in border areas adjacent to California where it is customary practice for California residents to avail themselves of such services. No services are covered outside the United States, except for emergency services requiring hospitalization in Canada or Mexico. Revised: 04/11/08 Update# 08-06

27 Medi-Cal Handbook page Claims Procedure Electronic Data Systems (EDS) processes Medi-Cal claims for the State of California. All providers, including out-of-state providers, should send claims directly to EDS as follows: San Francisco Field Office Inpatient Claims P.O. Box San Francisco, CA Telephone: (415) Providers may also call the EDS number in Sacramento (916) for assistance. If a claim is sent to the County by mistake, the following action is required by the EW: Completes the form Medi-Cal Out-of-State Provider Letter (SC 1175), Mails original form to the provider, Mails one copy and the claim to EDS, Mails one copy to the client, Scans a copy of the form into the IDM system. Update# Revised: 04/11/08

28 page Medi-Cal Handbook Revised: 04/11/08 Update# 08-06