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DHCS reopens window for NICU/PICU claims submission under ACA PCP rate increase



May 22, 2015
Area(s) of Interest: Health Care Reform Payor Issues and Reimbursement Public Payors 

On May 18, the California Department of Health Care Services (DHCS) released additional information about Medi-Cal payment increases for primary care physicians under the Affordable Care Act (ACA) who file claims for patients treated in neonatal intensive care units (NICU) or pediatric intensive care units (PICU).


In the past, NICU/PICU claims were billed to Medi-Cal using a local code. In order to be eligible for the ACA enhanced payments, physicians were required to submit claims with ACA modifiers beginning April 11, 2014, that linked the local code to an eligible CPT code level. However, DHCS provided no pathway for physicians to ensure that claims submitted prior to April 11, 2014, were paid at the enhanced rate.


At the request of the California Medical Association and other stakeholders, DHCS agreed to allow claims data to be submitted for this category via a one-time upload of the “claim to ACA modifier” spreadsheet without the need for individual claim inquiry forms to be submitted. The original deadline to submit the “claim to ACA modifier spreadsheet was October 1, 2014. However, DHCS is reopening the window to allow physicians a second opportunity to submit their spreadsheet. Spreadsheets must be received no later than June 15, 2015, to be considered for payment.


For instructions on completing and submitting the spreadsheet, click here.


DHCS also announced that the ACA Primary Care Physician Self Attestation webpage will be removed from its website and will no longer be accessible after June 15.


DHCS has advised that eligible claims from providers who attested for the ACA increase primary care rate increase between September 1 and December 31, 2014, along with any NICU/PICU claims associated with the spreadsheet submittals, will be automatically reprocessed for payment consideration at the enhanced rate in summer 2015.

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