Medi-Cal Billing Manual - California

1 State of California Health and Human Services Agency Department of Health Care Services Mental Health Services Division Medi-Cal Billing Manual September 2019 2019 MHSD Medi-Cal Billing Manual Reviewers ACKNOWLEDGEMENTS We would like to give a very special thanks to the following Department of Health Care Services staff for their expertise and guidance to the content of this Manual : Amanda Ridgeway Barbara Johnson Beth Lucas Carla Minor Carmen Romo Carol Sakai Chris Dicely Cheryl Ward Chuck Anders Daniel Nahoun Deepa Pochiraju Dina Kokkos-Gonzales Don Larson Erika Cristo Gary Renslo Hop Nguyen Jerry Balaban John Griffith John Lessley Karen Eckel Kathie Tyler Ken Rhodes Kirk Ehnisz Kris Dubble Lucille Padilla Marcelo Acob Mike Rice Minh Hoang Munny Chitneni Rahki Malpani Robert George Sarah Aguirre Sesha Kuvari Shelly Osuna Tatyana Nelson Teresa Castillo Thomas Tipton Non-DHCS Contributing Editors Maria Barteaux, San Francisco County Memo Keswick.

2 Behavioral Health Consultant Dan Walters, Kern County Natalie Courson, Alameda County Thank you! Please submit any comments or questions to: MHSD Medi-Cal Billing MAUNAL TABLE OF CONTENTS September 2019 MHSD M/C Billing Manual Page 1 CHANGES / UPDATES FROM PREVIOUS VERSION (JULY 2019) .. 3 INTRODUCTION .. 5 Introduction .. 6 About This Billing Manual .. 6 Program Background .. 7 Authority .. 9 Medi-Cal Claims Customer Service Office (MedCCC) .. 10 GETTING STARTED .. 12 Introduction .. 13 Enrolling in ITWS .. 13 Legal Entity, Provider Numbers and NPIs .. 13 Provider Enrollment and Medi-Cal 14 Online Provider System.

3 15 X-12 Companion Guide and Appendix .. 16 CLIENT ELIGIBILITY .. 17 Introduction .. 18 Client Eligibility .. 18 Aid Codes .. 21 COVERED 22 Introduction .. 23 Covered Services .. 23 Mode of Service and Service Function Codes .. 29 OTHER MENTAL HEALTH CLAIMING .. 36 Introduction .. 37 Inpatient Psychiatric Facilities (Non-MHP Contracted) .. 37 IMD Exclusion .. 38 Outpatient 39 Other Health Care .. 39 Coordination of Benefits and Gross Billing .. 40 Claiming for Dual Eligibles (Medi-Medi) .. 42 Non-Medicare Reimbursable: Specialty Mental Health 48 AB3632 Children s Services.

4 51 Administrative, Utilization Review, and Medi-Cal Admin 52 Annual Year-end Cost Report and Fiscal Audit: Minutes & Units .. 53 CLAIM PROCESSING OVERVIEW .. 55 Introduction .. 56 Claim Processing Overview .. 57 High-level Mental Health Medi-Cal Claim Overview .. 57 Figure 6-1: Example of Mental Health Medi-Cal Claim Payments .. 60 Funding Sources .. 62 Figure 6-2: High-Level SDMC Claim Processing System Flow .. 64 Mental Health Medi-Cal Claim Stages .. 65 MHSD Medi-Cal Billing MAUNAL TABLE OF CONTENTS September 2019 MHSD M/C Billing Manual Page 2 Submission Timeliness .. 67 Voids and Replacements.

5 68 UMDAP: Uniform Method of Determining Ability to Pay .. 70 Medi-Cal Share of Cost 70 Title XXI: Enhanced Services for Children .. 72 Healthy Families .. 72 epsdt : Early and Periodic Screening, Diagnostic, and Treatment .. 74 Mental Health Medi-Cal Service Claim Rates .. 77 Federal Funding Ratios .. 78 Mental Health Medi-Cal Claim Processing .. 79 Disallowance and Void 81 Paper Claims, Error Correction and Replacement Transactions .. 82 Denials vs. Rejections .. 82 Mental Health Medi-Cal Reports .. 83 CLAIM LIMITS AND SPECIAL CONDITIONS .. 84 Introduction .. 85 Overview.

6 85 Duplicate Claims and Scenarios .. 85 Multiple Services and Lockouts .. 87 Table 7-1: Multiple Services and Lockouts .. 88 Duplicate Service Error Messages .. 89 Special Claiming and Denial Situations .. 92 Table 7: Duplicate and Multiple Service Billing Scenarios .. 98 FREQUENTLY ASKED QUESTIONS .. 119 GLOSSARY .. 131 REFERENCE GUIDE TO HYPERLINKS IN THIS Manual .. 136 MHSD Medi-Cal Billing Manual CHANGES / UPDATES TO PREVIOUS VERSION September 2019 MHSD M/C Billing Manual Page 3 CHANGES / UPDATES FROM PREVIOUS VERSION (JULY 2019) MHSD Medi-Cal Billing Manual CHANGES / UPDATES TO PREVIOUS VERSION September 2019 MHSD M/C Billing Manual Page 4 SECTION DESCRIPTION OF CHANGE AND/OR UPDATE Table of Contents Change diagnosis to diagnostic in reference to epsdt Change diagnosis to diagnostic in reference to epsdt Change diagnosis to diagnostic in reference to epsdt Change diagnosis to diagnostic in reference to epsdt Delete supplemental in reference to epsdt Change diagnosis to diagnostic in reference to epsdt Frequently Asked Question Delete supplemental in reference to epsdt Glossary

7 Change diagnosis to diagnostic in reference to epsdt Appendices Updated Day Treatment Units of Measure to match regulation Appendices Changed Linkage (TCM) / Brokerage: Professional IP Visit cost unit from 15 Mins to Mins MHSD Medi-Cal Billing MAUNAL Chapter 1: Introduction September 2019 MHSD M/C Billing Manual Page 5 INTRODUCTION MHSD Medi-Cal Billing MAUNAL Chapter 1: Introduction September 2019 MHSD M/C Billing Manual Page 6 Introduction The Short-Doyle/ Medi-Cal (SDMC) claim process system allows California s County Mental Health Plans (MHPs) to obtain reimbursement of funds for medically necessary specialty mental health services provided to Medi-Cal -eligible beneficiaries and also to Healthy Families subscribers diagnosed as Seriously Emotionally Disturbed (SED).

8 1 The Department of Health Care Services Mental Health Services Division (DHCS MHSD) oversees the SDMC claim processing system. This Billing Manual provides information about the system. This chapter includes: About This Billing Manual Program Background Authority Medi-Cal Claims Customer Service Office (MedCCC) 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 document that describes the processes and rules relative to SDMC claims for specialty mental health services.

9 Stakeholders include MHPs, Billing Vendors of MHPs, etc. 1 W & I Code, Division 5, Part 2, Chapter 1, MHSD Medi-Cal Billing MAUNAL Chapter 1: Introduction September 2019 MHSD M/C Billing Manual Page 7 Objectives The 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.

10 SDMC system user guides X-12 Companion Guides X-12 Companion Guide Appendix This Manual is not intended to duplicate the content of the Companion Guides or the Companion Guide Appendix. However, key concepts from those documents have been included to help explain the SDMC claiming process. Internet Addresses and Links All internet addresses (URLs) and links in this document were current as of the publication date of this Manual but are subject to change without notice. Program Background Title XIX of the Social Security Act, enacted in 1965, authorizes Federal grants to States for medical assistance to low-income persons who are age 65 or over, blind, disabled, or members of families with dependent children or qualified pregnant women or children.