September 27, 2023
In August, the California Department of Health Care Services (DHCS) announced it had established payment rates for four preventive services codes that were added as Medi-Cal benefits.
The new payment rates are effective retroactively to June 1, 2022. The California Medical Association had strongly advocated for this change. Along with the preventive services codes, DHCS also established payment rates for sleep apnea and prolonged evaluation and management services.
Claims that were previously denied or underpaid* will automatically be reprocessed at the new rates. DHCS has said it plans to issue an Erroneous Payment Correction (EPC) and will reprocess claims. The exact timeline has not yet been solidified, but DHCS estimates the EPC will go out later this year.
If physicians do not want to wait for the EPC, they can resubmit affected claims. DHCS has confirmed the claims will not be denied as duplicates.
Because the codes were previously paid “by report”— meaning practices had to submit medical records and then DHCS decided the amount it would pay—there may be cases where physicians were paid less than the new established payment rates. DHCS will include claims reimbursed at a lower rate in the automatic reprocessing through the EPC. However, physicians may also use the updated billing policy to correct and resubmit claims. Physicians should review the Claim Inquiry Form (CIF) and Timeliness Instructions before doing so.
*Physicians are reminded that Medi-Cal pays the lesser of the billed charge and the fee schedule amount. Therefore, if your billed charge was less than the new established payment amount, Medi-Cal will not pay any additional money on those claims.