Managed Care

As an HHPCA member you have the option of becoming a part of the Managed Care Program Services Network—enjoying all the benefits of membership.

Information related to your practice as a Managed Care Provider will be posted.

Ensure You Meet Guidelines of Professional Conduct: HHPCA contracts with insurance companies to ensure that members receive the maximum amount of benefits. Due to the requirements of the insurance companies currently under contract it is important that HHPCA members know that effectively immediately the amounts of required professional liability has changed. Please read all about these new requirements.

HIPPA Transactions:

Electronic attachments for 837 v.4010A1 Claims are now available. The link below includes the article and links to the documents that were updated as a result of the implementation of electronic attachments, including the list of approved third party vendors and the billing instructions area of the 837 Health Care Claim Companion Guide. Visit www.medi-cal.ca.gov.

To submit electronic attachments, providers must be authorized to bill 837 v.4010A1 electronic claims. For instructions visit www.medi-cal.ca.gov. For further details on enrollment procedures and necessary forms visit www.medi-cal.ca.gov.

For more information call the Telephone Service Center (TSC) 800-541-5555 from 8am-5pm Monday through Friday. Border providers, software vendors and out-of state billers who bill for in-state providers should call 916-636-1200.

Important Notice For Member Who Accept Medi-Cal:

The dual usage period (having to use the newly assigned NPI as well as your Medi-Cal provided number is being extended. There is a web link www.medi-cal.ca.gov to more information. Here is more specific information for you to review.

The Department of Health Care Services (DHCS) is extending the current dual-use period, which began on May 23, 2007, to continue beyond the NPI implementation date. Effective November 26, 2007, the NPI implementation date, a Medi-Cal provider number will continue to be required, even though the NPI is also being requested. Failure to include the Medi-Cal provider number beyond the NPI implementation date could result in delay or denial of payment.

Providing both sets of provider numbers will assist DHCS in its continuing effort to provide prompt and accurate claims payment to Medi-Cal providers. As a result, until post-implementation NPI evaluations occur, use of the Medi-Cal provider number on all transactions will continue to be mandatory to achieve optimal success. Medi-Cal providers must continue using their Medi-Cal provider numbers until instructed otherwise.

The only exception to the dual-use rule is for those transactions where both sets of provider identifiers are not supported, such as the electronic pharmacy claims (NCPDP 5.1/1.1 standard). Where both sets of provider identifiers are not supported, providers must continue to use the Medi-Cal provider number beyond the November 26, 2007 NPI implementation date. Providers defined by the HIPAA final rule and Medi-Cal policy as “atypical” will also continue to use only their Medi-Cal provider numbers.

Please note that the following exceptions apply after the November 26, 2007 implementation date. For these exceptions, only the Medi-Cal provider number can be used during the dual-use period. Below is a partial list:

  • Electronic pharmacy claims (NCPDP 5.1/1.1 standard)
  • All proprietary Medi-Cal forms, including the Payment Request for Long Term Care form (25-1), Pharmacy Claim Form (30-1), Compound Drug Pharmacy Claim Form (30-4), Treatment Authorization Request (TAR), Claims Inquiry Form (CIF, 60-1) and Appeal Form (90-1)
  • Direct Data Entry (DDE) applications, including Internet Professional Claim Submission (IPCS), Real-Time Internet Pharmacy (RTIP) and the Point of Service (POS) network

Please share this information with your membership, including a notice in your newsletters. Should you have any questions or need additional information, please call the Telephone Service Center (TSC) at 1-800-541-5555 or visit the NPI page on the Medi-Cal Web site.

Use of Social Security Numbers for Billing Prohibited Beginning February 1, 2008.

Executive Director, Tricia Hunter, has provided the following analysis.

Over the course of 2006 and 2007, the Department of Health Care Services (DHCS) published various bulletin articles regarding the new billing requirements prohibiting use of Social Security Numbers. These requirements go into effect in a couple of week’s time. To ensure you and your membership are fully aware and prepared for this change, please review and disseminate the article synopsis and Web links that follow:

All providers are expected to use the 14-character Medi-Cal identification number from the recipient’s Benefits Identification Card (BIC) or paper ID card when submitting claims. The ID number is located on the front of the card and consists of a 9-digit Client Index Number, a Check Digit and a 4-digit issue date. The issue date is used to deactivate cards that have been reported as lost or stolen.

Effective for dates of service on or after February 1, 2008, most providers may no longer bill Medi-Cal or the Child Health and Disability Prevention (CHDP) program using a recipient’s Social Security Number (SSN). Claims submitted with a recipient’s SSN for a date of service on or after February 1, 2008 will be denied. Please refer to the December 2007 Medi-Cal Update for information on billing exceptions: www.medi-cal.ca.gov.

New Denial Message
A new denial message has been developed for the paper Remittance Advice Details (RAD): RAD code 0046: Social Security Number (SSN) not permitted for billing Medi-Cal.

Pharmacy claims submitted with a recipient’s SSN will be denied with reject code 07 (missing or invalid cardholder [recipient] identification number) and denial code 0046.

Use of the 9-digit Client Index Number for Billing
Claims submitted with a valid 9-digit Client Index Number will continue to be accepted. The Medi-Cal claims processing system currently only validates the first nine digits of the BIC ID. Changes to process the full 14-digit BIC ID for claims and reporting (for example, RADs) will be implemented in 2008.

In addition, all providers are expected to use the Medi-Cal identification number from the recipient’s BIC or paper ID card when verifying eligibility, billing Medi-Cal or submitting a Treatment Authorization Request (TAR).

Please refer to the January 2008 Medi-Cal Update link to read the full article:
www.medi-cal.ca.gov.

BIC Information Returned in Eligibility Response

Changes have also been made to the EVS response message to include the 14-digit BIC ID number and BIC issue date for eligible recipients only when a valid SSN is used to verify eligibility.

Currently, BIC information is returned in the eligibility response message, or the text message field of the ASC X12N 271 Version 4010A1 Real-Time Health Care Eligibility Benefit Inquiry transaction, for eligibility inquiries submitted using the following methods:

  • Telephone Automated Eligibility Verification System (AEVS
  • Point of Service (POS) device
  • Real-Time Internet Eligibility (RTIE) single-subscriber transactions
  • ASC X12N 270 Version 4010A1 Real-Time Health Care Eligibility Benefit Inquiry transactions

Effective for a limited submission period, from January 1, 2008 through January 31, 2008, BIC information will be returned at the end of the eligibility messages within the text message field of batch eligibility submissions. This will allow larger providers, such as hospitals and LTC facilities, an opportunity to update their patient records and databases with the BIC information.

All providers are expected to use the Medi-Cal identification number from the recipient’s BIC or paper ID card when verifying eligibility, billing Medi-Cal or submitting TARs.

Medi-Cal recognizes the importance of protecting the identity and health information of recipients and strongly encourages all providers to avoid using a recipient’s SSN whenever possible.

Thank you for your continued support of the Medi-Cal and CHDP programs. Please feel free to share this information with your membership. Should any questions arise regarding this matter, please contact the EDS Medi-Cal Telephone Service Center (TSC) at 1-800-541-5555.

Some Forms Important to Managed Care Members Are Listed

Atena 2009 Hearing Aid Statement of Satisfaction Form

Blue Cross of California Member Responsibility Agreement (word doc)
Blue Cross of California Member Responsibility Agreement (pdf)

A Sample of HHPCA Financial Policy (word doc)
Hearing Healthcare Providers Fitting Protocol (word doc)
Hearing Healthcare Providers Hearing Aid Dispensing Protocol (word doc)
Hearing Healthcare Providers Code of Ethics (word doc)

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