Medi-Cal

Medi-Cal is California's state Medicaid program.

Helpful Billing Tips

When submitting an insurance claim for surgical procedures performed, the Medi-Cal global fee includes the preoperative visit 7 days before surgery, the surgical procedure, and the postoperative care (0, 10, 30, or 90 days). This differs from standard surgical and Medicare global package policies.

To find out whether a particular service requires a TAR, refer to the Medi-Cal Provider Manual for Medical Services that is updated monthly on the Medi-Cal website at www.medi-cal.ca.gov. Find the TAR benefit and nonbenefit list that indicates what services require a TAR or are not a benefit. Some of the TAR-required services are as follows:

 

•                    Long-term care facility services

•                    Some vision services

•                    Inpatient hospital services

•                    Home health agency services

•                    Kidney transplants and chronic hemodialysis services

•                    Magnetic resonance imaging (MRI)

•                    Some transportation services

•                    Some durable medical equipment (DME), medical supplies, or prosthetic/orthotic appliances

•                    Hearing aids

•                    Some pharmacy services

•                    Some surgical procedures

 Time Limit

Medi-Cal claims must be submitted within 6 months from the end of the month of service to be reimbursed at 100% of the Medi-Cal maximum allowable. To be eligible for full reimbursement on late claims, one of the approved billing limit exception codes (1-8 or A) shown in the provider manual must be used in Field 22 of the CMS-1500 claim form. Claims submitted more than 6 months after the month of service are reimbursed at the following reduced rates:

100%     1 to 6 months after the month of service

75%     7 to 9 months after the month of service

50%     10 to 12 months after the month of service

0%    Over 1 year from the month of service

An Over-One-Year (OOY) claim may be submitted with appropriate documentation or justification attached using exception code 8 for one of the following reasons:

·         Retroactive eligibility

·         Court order

·         State of administrative hearing

·         County error

·         Department of Health Services approval

·         Reversal of decision on appealed TAR

·         Medicare or other health coverage

*find links to Medi-Cal resources on The Internet Resource tab.