Last chance to appeal payments under ACA primary care physician rate increase

April 05, 2016
Area(s) of Interest: Payor Issues and Reimbursement Practice Management 

The California Department of Health Care Services (DHCS) announced that it would provide a 90-day appeal window for physicians who believe they were not paid, or paid incorrectly, under the Affordable Care Act’s (ACA) primary care rate increase. In late February 2016, DHCS announced a streamlined appeal process, which opened on March 1.

The appeal window is only available under the following conditions:


  • The provider successfully attested for the ACA incentive by December 31, 2014
  • For previously paid Medi-Cal claims
  • For Medi-Cal crossover claims paid $0 with Remittance Advance Detail (RAD) code 442: Medicare payment meets or exceeds Medi-Cal maximum reimbursement.

Please note: This appeal process is not open to Child Health and Disability Prevention (CHDP) Program claims, as the deadline to appeal payment for those claims has passed.


The appeal window will remain open through June 30, 2016.


To determine whether your practice qualifies, it is recommended that you review eligible claims closely to determine if additional money is due. Practices should compare the interim payment made to the true up payment received. If the billed charges submitted were less than the Medicare fee schedule amount, the practice is only eligible to receive the lesser amount per federal law (42 CFR 447.405). Another reason for a lower-than-expected payment amount may be because the Medi-Cal reconciliation amount factored in the Medicare geographic pricing. The interim payment did not take that into consideration, which may have caused an overpayment.


Qualification for streamlined ACA appeals
DHCS is expediting the appeals process by not requiring proof of patients’ eligibility or proof of timely claims submission, as is sometimes required when appealing a Medi-Cal payment. For a streamlined appeals process, the following qualifications must be met:


  • Appeals must be received by Xerox by June 30, 2016.
  • Standard appeal timeframes are waived for ACA payment appeals.
  • Write or type “ACA” at the top of the “Reason for Appeal field” (Box 13) on the standard appeal form (90-1), with the following attachments:​​

    • Original claim and/or corrected claim if corrections are needed. All documentation supporting the original claim, including a copy of the most recent RAD that shows the claim was either paid or was a crossover claim paid at $0 with RAD code 442Providers can submit up to 14 claims with each appeal form as long as all the claims are for the same patient 


Additionally, DHCS published another bulletin on March 16 reminding practices that when submitting appeals on NICU/PICU claims, they must include the appropriate ACA modifier for each claim line. Providers can determine which ACA modifier to use in the ACA Rate Increase for Specified Primary Care Services Implementation Update page of the Medi-Cal website.


Questions about the appeal process can be directed to the Medi-Cal telephone service center at (800) 541-5555.



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