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Medi-Cal Inpatient Claims Processing Update1/1/2019Current (C)Description C.1 Revenue Codes Claims billed withNot Available in CA- invalid ancillary codesare denied becauseMMISsome revenue codes Initial Bulletin: N/Aare NOT allowed by RAD Code: N/AMedi-Cal, but still usedby other payers. C.2 Paper Claims for Due to systemlimitations, theAppeal/CIF processAppeal/CIF process Initial Bulletin: N/Ahas to drop to paper RAD Code: N/Aclaim format, causingclaim limits of 18procedure codes and 6diagnosis codes to beprocessed forpayment. C.3 Claim admission The SAR authorizedfrom through dates dodate outside SARnot include the claimAuthorized datesadmission date. The Initial Bulletin: N/A RAD Code: 9970 (No system is looking for aSAR approval on file SAR that matches thefor CCS/GHPP APR- claim admission date,since it is not found,DRG inpatientthe claim is denying.admission)StatusThis issue is being reviewed by the Department of HealthCare Services (Department) and being discussed withinrelated divisions. Void and Resubmit(V&R) / EPC: N/A System Change Date:N/A Latest PublicationDate: N/AThe Department and State Fiscal Intermediary, Conduent,are aware of the limitations of the CA-MMIS system. Wecontinue to brainstorm work around solutions, if possible. Void and Resubmit(V&R) / EPC: N/A System Change Date:TBD Latest PublicationDate: TBDThe Department is aware of this issue and it is beingresearched by the Department and State FiscalIntermediary, Conduent. Void and Resubmit(V&R) / EPC: TBD System Change Date:TBD Latest PublicationDate: TBD
Medi-Cal Inpatient Claims Processing Update1/1/2019Current (C) C.4 Surgical codesnot recognized Initial Bulletin: N/A RAD Code: 67 (Theprimary/secondarysurgical code has nomatch on theprocedure file)DescriptionStatusClaims submitted using The codes are now valid in the system and claims with this Void and Resubmitspecific ICD-10issue will be processed correctly. An EPC will be run for(V&R) / EPC: EPCsurgical codes are not claims denied only for this reason. System Change Date:recognized by the11/16/2018system and claims are Latest Publicationbeing denied.Date: N/A
Medi-Cal Inpatient Claims Processing Update1/1/2019Current (R)DescriptionStatusProvider bills theThe Department has fixed this issue and is advising R.1A Acute Dateaffected DRG providers to void and resubmit claims, andOutside of Admission surgery date oroutpatient date, which continue to adhere to timely filing requirements.Dateoccurs within 24 hours Initial Bulletin: N/Abefore the Admission RAD Code: 509date on the inpatient(adjustment due toclaim. This causesan inappropriatepayment made for a claims to deny whenservice rendered on examiners cannot lookat hours.a denied acuteinpatient day)Emergency roomThe Provider Manual ("ub spec ip" page 5) was updated to R.1B Acute Dateaccurately define such policy. The language states, "DRGOutside of Admission outpatient servicesrendered on the same and non-DRG: If emergency services are rendered on theDatecalendar day or on the same calendar date as the date of admission, the services Initial Bulletin: N/Aday prior to admission should be billed on the UB-04 with the appropriate ancillary RAD Code: 0076are not separatelycode, along with the appropriate revenue code."(The Submittedreimbursable.WhenanEmergency room outpatient services rendered on the sameDocumentation Wasoutpatient service has calendar date as the day of admission, or the day prior toNot Adequate)been rendered and the admission, are not separately reimbursable.patient is then admitted If emergency services are rendered on a different calendarto the hospital withindate and are not the day prior to the date of admission, the24 hours and the RTD services should be billed on the UB-04 claim using theis not received, theappropriate outpatient facility codes."claim is denied. Void and Resubmit(V&R) / EPC: V & R System Change Date:6/16/2017 Latest PublicationDate: 6/16/2017 Void and Resubmit(V&R) / EPC: N/A System Change Date:N/A Latest PublicationDate: 5/15/2016
Medi-Cal Inpatient Claims Processing Update1/1/2019Current (R)Description R.2 Partial Eligibility The recipient is noteligible for Medi-Cal Initial Bulletin:and has no other8/31/2015insurance on the date RAD Code: 0314of admission, but(Recipient is NotEligible for the Month becomes eligible forFFS the followingof Service Billed)month. R.3 SFY 15-16 OBPolicy Adjustor forNICU Providers Initial Bulletin:9/14/2015 RAD Code: N/ADRG claims fromdesignated NICUproviders are notreceiving the ObstetricPolicy Adjustoreffective July 1, 2015.StatusThe Provider Manual ("diagnosis ip" page 12) was updatedto accurately define such policy. The language states,"DRG providers may be reimbursed for inpatient servicesonly for dates of stay on or after the date the recipientbecomes FFS eligible if the recipient had no other coverageon the date of admission."DRG providers should bill using the:- Correct type of bill- Actual admission date- Actual discharge date- “Statement Covers Period From-Through” dates limited tothe recipient’s FFS eligibility dates- Services and supplies incurred only during the recipient’sFFS eligibility dates- Diagnosis and procedure codes associated only totreatment provided during the recipient’s FFS eligibilitydatesProviders should continue to submit their initial claims. AnEPC was processed to correct the payments to the specificproviders. Void and Resubmit(V&R) / EPC: V & R System Change Date:N/A Latest PublicationDate: 4/15/2016 Void and Resubmit(V&R) / EPC: EPCSept 2016 System Change Date:11/23/2015 Latest PublicationDate: 6/30/2016
Medi-Cal Inpatient Claims Processing Update1/1/2019Current (R)Description R.4 Medicare Part B Medicare Part B claimssubmitted with bill type Initial Bulletin:121 are erroneously7/14/2014denying. RAD Code: 9952(Type of Bill Code forAPR-DRG ClaimInvalid or Missing)StatusMedi-Cal recently implemented a fix for inpatient claims Void and Resubmitwith type of bill code 121 that were erroneously denying(V&R) / EPC: V & Rwith Remittance Advice Details (RAD) code 9952: Type ofand EPC April 2015bill code for APR-DRG Claim Invalid or Missing. System Change Date:Starting July 14, 2014, providers were instructed to7/1/2014resubmit DRG claims with type of bill 121 and dates of Latest Publicationservice on or after July 1, 2013, through June 30, 2014.Date: 7/14/2014Timeliness requirements are being waived for these type ofbill 121 claims; therefore, providers do not need to submit adelay reason code, or any other documentation. This onetime timeliness waiver will allow for resubmission of theseclaims until September 26, 2014.In April 2015, an EPC was issued to catch any claims notresubmitted by providers during the resubmission period fordates of service from July 1, 2013, through June 24, 2014.
Medi-Cal Inpatient Claims Processing Update1/1/2019Current (R) R.5 Other HealthCoverage (OHC) Initial Bulletin:11/4/2014 RAD Code: 9968 (NoApproved TAR onFile for APR-DRGInpatient Admission)DescriptionDRG claims thatinclude OHC aredenying.StatusThe Department has resolved a claims processing issue Void and Resubmitthat caused DRG claims that included OHC to erroneously(V&R) / EPC: V & Rdeny with Remittance Advice Details (RAD) code 9968: No System Change Date:Approved TAR on File for APR-DRG Inpatient Admission.9/21/2015Timeliness will be waived for claims that were previously Latest Publicationdenied with RAD code 9968 for dates of service from JulyDate: 7/1/20151, 2013, through March 1, 2015. Hospital providers wereable to resubmit claims until November 20, 2015.Claims resubmitted must contain the following on the UB-04claim form to receive reimbursement:- Include the following statement in the Remarks field (Box80):“DRG claim that previously denied with RAD code 9968”- Indicate delay reason code “11” in the appropriate fieldNote that OHC must be billed prior to Medi-Cal, and anypayments received will be indicated in the Payer Name(Box 50) and Prior Payments (Box 54) sections of the UB04 claim form. The final DRG payment will be reduced bypayments received from OHC.
Medi-Cal Inpatient Claims Processing Update1/1/2019Current (R) R.6 MCP and FFSBilling for InpatientStays Initial Bulletin:11/4/2015 RAD Code: 0037(Health Care PlanEnrollee, CapitatedService Not Billableto Medi-Cal)DescriptionRecipient has Medi-CalManaged Care for thefirst portion of the stayand Medi-Cal FFS forthe second part of thestay; due to a systemissue the claims areerroneously denying.StatusEffective retroactively for dates of service on or after July 1, Void and Resubmit2013, when billing a stay at a DRG hospital for a beneficiary (V&R) / EPC: V & Rwho is covered by a MCP and FFS during the same System Change Date:inpatient stay, the hospital must first obtain reimbursement9/21/2015from the MCP. Once payment is received from the MCP, Latest Publicationthe hospital may then bill the entire stay to FFS. TheDate: 5/5/2015payment received from the MCP will be deducted from thetotal payment amount from FFS. Claims submitted for MCPand FFS must contain the following on the UB-04 claimform to receive reimbursement:**Include prior payment dollar amount (amount paid byMCP) in the Prior Payments field (Box 54)- Include one of the following statements in the Remarks(Box 80):Medi-Cal managed care and fee-for-service stayMedi-Cal MC and FFS stay- Attach the statement of payment from the MCPTimeliness will be waived for claims with dates of servicethrough April 30, 2015, for FFS claims with admission dateson or after July 1, 2013, that previously denied forRemittance Advice Detail (RAD) code 0037: Health CarePlan enrollee, capitated service not billable to Medi-Cal.This billing advice does not apply to inpatient staysauthorized by a California Children’s Services (CCS)Service Authorization Request (SAR) for a CCS client whois a Medi-Cal beneficiary enrolled in a Medi-Cal managedcare plan with carved-out CCS Services.
Medi-Cal Inpatient Claims Processing Update1/1/2019Current (R) R.7 Restricted AidCode TARs Initial Bulletin:11/4/2015 RAD Code: 0341(Units of ServiceBilled Exceed theTAR AuthorizedDays) R.8 RTDs for DRGOrgan ProcurementClaims Initial Bulletin:11/14/2014 RAD Code: N/ADescriptionThe system views anAdmit TAR instead of aDaily TAR on claimsbilled with a restrictedaid code causingclaims to deny.Hospitals reimbursedby DRG areerroneously issued aRTD when billingorgan procurementclaims with ancillarycodes 810, 811, 812,813, 814, 815, and819.StatusThe Department identified a claims processing issue Void and Resubmitcausing diagnosis-related group (DRG) claims for recipients (V&R) / EPC: V & Rwho have a restricted aid code to erroneously deny with System Change Date:Remittance Advice Details (RAD) code 0341: Units of9/21/2015service billed exceed the TAR (Treatment Authorization Latest PublicationRequest) authorized days. Please resubmit with a new TAR Date: 7/6/2015Control Number. This issue has been resolved.Claims resubmitted must contain the following on the UB-04claim form to receive reimbursement:- Include the following statement in the Remarks field (Box80):“DRG claim that previously denied with RAD code 0341”- Indicate delay reason code “11” in the appropriate fieldTimeliness for claims that previously denied with RAD code0341 will be waived for claims with dates of service throughFebruary 1, 2015 and for FFS claims with admission dateson or after July 1, 2013. Hospital providers may resubmitclaims until November 20, 2015.Previously affected hospital providers should no longer Void and Resubmitreceive erroneously issued RTDs when billing organ(V&R) / EPC: N/Aprocurement claims for ancillary codes 810, 811, 812, 813, System Change Date:814, 815 and 819, as this issue has been resolved.N/A Latest PublicationQuestions related to this past issue should be directed toDate: 11/17/2015the Telephone Service Center at 1-800-541-5555.
Medi-Cal Inpatient Claims Processing Update1/1/2019Current (R) R.9 Admin/RehabClaims - Length ofStay Invalid forInterim Claim Initial Bulletin:9/17/2015 RAD Code: 9953(APR-DRG - Lengthof Stay Invalid forInterim Claim)DescriptionThe system is notallowing interimadmin/rehab claims(per diem claims) topay if the stay does notexceed 29 days.StatusHospital providers may resubmit Level 1 or Level 2 Void and Resubmitadministrative day claims (with revenue code 169, 190 or(V&R) / EPC: V & R199) and rehabilitation claims (with revenue code 118, 128, System Change Date:138 or 158) that were previously denied with RemittanceEstimated 5/23/2016Advice Detail (RAD) code 9953: APR-DRG – Length of Latest PublicationStay Invalid for Interim Claim, with admission dates on orDate: 5/15/2016after July 1, 2013, through November 13, 2015.Type of Bill Code for Acute Inpatient IntensiveRehabilitation (AIIR), Administrative Day, and MedicareCrossover Claims:111, 112, 113, 114 Type of Bill Code forInpatient Claims with Medicare Part B:121, 122, 123, 124,Resubmission claims must contain the following informationto receive reimbursement:Appropriate revenue code: 169, 190, 199, 118, 128, 138, or158 in Box 42 (Rev. CD field)Appropriate delay reason code Delay Reason Code “11” in Box 37 if the claim issubmitted more than six months but less than 12 monthsfrom the date of admission Delay reason code “10” in Box 37 if the claim is submittedmore than 12 months from the date of admissionThe following statement in the Remarks field: “DRG claimthat previously denied with RAD code 9953”Timeliness will be waived for claims previously denied withRemittance Advice Details (RAD) code 9953: APR-DRG –Length of Stay Invalid for Interim Claim with admissiondates on or after July 1, 2013, through November 13, 2015.Timeliness for resubmitted claims that meet the abovecriteria will be waived through June 1, 2016.
Medi-Cal Inpatient Claims Processing Update1/1/2019Current (R)Description R.10 22 Line Limit on Providers are unable tosubmit electronicElectronic Claimsclaims exceeding 22 Initial Bulletin:revenue lines and are4/2/2015attempting to split bill. RAD Code: N/AThe second page ofthe claim submitted isdenying. In somecases, the secondpage of the claim isreceived andprocessed for paymentand the first page ofthe claim is denying.StatusProviders should complete a Claims Inquiry Form (CIF) void Void and Resubmitfor all paid claims that were split-billed due to the 22 line(V&R) / EPC: V & Rrestriction before July 28, 2014, where one of the following System Change Date:criteria exists:8/1/2015- First page paid, second page denied; or Latest Publication- Second page paid, first page denied; orDate: 2/5/2016- First and second page paid separately (please make sureto void both pages)Once the void appears on a future Remittance AdviceDetails (RAD) form, these claims may be resubmitted viaComputer Media Claims (CMC) as a single claim.Timeliness for claims that exceed 22 lines and meet one ofthe above criteria will be waived through April 1, 2016.When resubmitting the claims via CMC, providers must dothe following:- Indicate delay reason code “10” in the appropriate field- Use the following comment in the remarks area: “Claimexceeds 22 lines prior to July 28, 2014”Failure to follow the above instructions could result inclaims being denied or processed incorrectly.
Medi-Cal Inpatient Claims Processing Update1/1/2019Current (R) R.11 DRG ClaimsExceed 9,999,999.99 Initial Bulletin: N/A RAD Code: N/ADescriptionUnder DRGreimbursement,providers cannot splitclaims with totalcharges exceeding 9,999,999.99; splittingclaims will causeclaims to priceincorrectly.StatusThe Department has created a work around resolution to a Void and Resubmitclaim processing issue that caused DRG claims with total(V&R) / EPC: N/Acharges exceeding 9,999,999.99 to pay inaccurately. System Change Date:-To begin the process providers should submit a final claimN/Ausing type of bill 111, actual admit and discharge dates, all Latest Publicationprocedures and diagnosis codes, and as many charges that Date: N/Acan be accepted and remain below but as close to the 9,999,999.99 maximum allowed. Once the claim hasadjudicated, the provider should contact the Departmentthrough the DRG mailbox, [email protected], and submit apaper claim where the first page is identical to the originalbilled charges that were submitted and the second page isthe remaining billable charges. Both pages should reflectthe complete total charges. The subject line of the emailshould begin with the text: 10M CLAIM.-Upon submitting the total claim to the DRG mailbox, itshould be submitted on two pages with the total charges ofthe entire stay. Also, all diagnosis and procedure codesand dates of service should match the first claim that wassubmitted and paid. The DRG Section will be responsibleto price the claim with the full charges, subtract the DRGpayment from the first claim and request for the remainingportion to be sent to providers.This process allows the DRG assignment to be correctlycaptured resulting in an accurate DRG payment, as well ascapture the Medi-Cal days which is utilized in other MediCal programs.For further information or questions regarding DRG claimsexceeding 9,999,999.99 maximum allowed amount in totalcharge, contact the Department at [email protected]
Medi-Cal Inpatient Claims Processing Update1/1/2019Current (R)DescriptionThe Department has R.12 DRG Claimsidentified a mappingErroneouslyissue causing someGrouping to APRAPR-DRG claims forDRG 951 and 952vaginal deliveries with Initial Bulletin:a day of discharge on12/2/2015or after October 1, RAD Code: N/A2015, to group to APRDRG 951 or 952. Thisis resulting in incorrectpayments based on anincorrect DRGassignment. AffectedDRG providers shouldcontinue to adhere totimely filingrequirements.Provider billed their R.13 Rehab Roomand Board Payment room and board andthe charges are lessCapthan their rate on file Initial Bulletin: N/Aand are paid at the RAD Code: N/Alesser amount basedon current Medi-Calsystem design.StatusFor claims coded with ICD-10 codes, the Departmentupgraded to 3M Mapper Version 33, HAC Version 33, andGrouper Version 32 to resolve this issue. For claims codedwith ICD-9 codes, the Department also upgraded to HACVersion 32. All upgrades occurred on April 25, 2016. Void and Resubmit(V&R) / EPC: EPCAugust 2017 System Change Date:4/25/2016 Latest PublicationDate: 9/8/2016The system is working as intended and the Department has Void and Resubmitprovided policy clarification regarding this issue.(V&R) / EPC: V & R System Change Date:N/A Latest PublicationDate: 2/7/2017
Medi-Cal Inpatient Claims Processing Update1/1/2019Current (R)Description R.14 Share of Cost Issue 1- Baby usingmom's ID, the SOC isIssuebeing taking out twice Initial Bulletin: N/Afrom mom's claims and RAD Code: N/Ababy's claims.Issue 2- Claim with aFrom and Throughdate longer than 30days (final) claim isonly deducting the 1stmonth SOC.The system is looking R.15 DRG Interimfor a TAR with fromClaims Issueand thru dates that Initial Bulletin: N/A RAD Code: 9969 (No overlap the claimservice dates. Only anApproved TAR onadmit TAR is required,File for APR-DRGtherefore the denial isInpatient Interimerroneous.Claim Admission)Provider bills for R.16 Acute andAcute days, howeverAdmin Daysthere are no billing Initial Bulletin: N/Ainstructions on how to RAD Code: N/Abill for acute transfers.StatusThe Department has fixed this issue and affected DRGproviders should void and resubmit claims that were kepttimely Void and Resubmit(V&R) / EPC: V & R System Change Date:7/24/2017 Latest PublicationDate: 11/14/2016The Department has fixed this issue and affected DRGproviders were notified to void and resubmit claims thatwere kept timely. Void and Resubmit(V&R) / EPC: V & R System Change Date:6/16/2017 Latest PublicationDate: N/AThe Department has updated the Medi-Cal providermanual, UB-04 Completion: Inpatient Services BillingExamples (ub comp ip ex) for billing inpatient serviceswhen transferring a patient between acute level of careand administrative level of care in the same (DRG)hospital. Void and Resubmit(V&R) / EPC: N/A System ChangeDate: N/A Latest PublicationDate: 3/19/2018
bill code for APR-DRG Claim Invalid or Missing. Starting July 14, 2014, providers were instructed to resubmit DRG claims with type of bill 121 and dates of service on or after July 1, 2013, through June 30, 2014. Timeliness requirements are being waived for these type of bill 121 claims; therefore, providers do not need to submit a
