CHA News Article

Medi-Cal Changes DRG Billing Requirements for Dual Coverage Beneficiaries

The Department of Health Care Services has notified providers that, when diagnosis-related group (DRG) hospitals bill Medi-Cal for a beneficiary stay that is covered by a managed care plan and fee-for-service (FFS), they must first obtain reimbursement from the managed care plan. The requirement is effective retroactively for dates of service on or after July 1, 2013. Additionally, when payment is received from the managed care plan, the hospital should then bill the entire stay to FFS, and the managed care plan payment will be deducted from the FFS payment amount.

Submitted claims must contain the following on the UB-04 claim form:

  • Prior payment from the managed care plan in the “prior payments” field;
  • One of the following statements in the “remarks” field:
    • Medi-Cal Managed Care and fee-for-service stay
    • Medi-Cal MC and FFS stay
  • An attached statement of payment from the managed care plan

For FFS claims with admission dates between July 1, 2013, and April 30, 2015, that were previously denied for RAD code “0037: Health Care Plan enrollee, capitated service not billable to Medi-Cal,” timeliness will be waived. Additionally, the requirement does not apply to inpatient stays authorized by a California Children’s Services (CCS) service authorization request for a CCS client enrolled in a Medi-Cal managed care plan with carved-out CCS services.

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