DHCS announces additional delays for some ACA Medi-Cal primary care rate increases

September 18, 2014
Area(s) of Interest: Advocacy Health Care Reform 

The California Department of Health Care Services (DHCS) has released additional information about the timing of the outstanding Affordable Care Act (ACA) Medi-Cal primary care rate increase for certain claim types. Specifically, DHCS had previously announced delays in payment of three types of claims, including certain NICU/PICU services, Child Health and Disability Prevention Program (CHDP) services and crossover claims (also referred to as Medi/Medi claims).

  • Retroactive NICU/PICU claims – At the request of CMA and other stakeholders DHCS will allow claims data to be submitted via a one-time spreadsheet upload without the need for individual claim inquiry forms. Spreadsheets must be submitted by October 1, 2014, to receive retroactive payments based upon the uploaded claims information. Providers who do not upload claims information before October 1, 2014, will receive claims payments based solely on original claims information or by submitting individual claim inquiry forms. For more information, see the DHCS bulletin.


DHCS also recently announced it will issue interim estimated payments for these retroactive claims in October with a final true up EPC to occur in December.

  • CHDP claims – Some practices were previously instructed by DHCS to bill at their Medi-Cal rates. This caused concern—based on DHCS's pricing logic of paying the lessor of Medicare’s rate or the billed charges—that some practices would not qualify for the increase. At CMA and other stakeholders' urging, DHCS agreed to a workaround to allow these practices to be paid at the higher rates. DHCS is working on a web application that will allow a onetime submission of the physician's usual and customary amount, which will allow the practice to receive the higher reimbursement intended by the rate increase.
  • Crossover Claims (Medi/Medi claims) – As previously reported, the Centers for Medicare and Medicaid Services (CMS) agreed with CMA and has required DHCS to modify its proposed bundled code methodology for crossover claims, as it would have consistently underpaid physicians anytime they billed a code eligible for the increase with any other codes that are not eligible. DHCS anticipates the necessary system enhancements will be made in time for checks to be issued in December.


There's still time to attest!


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