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Medi-Cal Guidance on Reporting Provider-Preventable Conditions

Welfare and Institutions Code 14131.11, as well Title 42 of the Code of Federal Regulations, sections 447, 434 and 438,  require all Medi-Cal providers to report provider-preventable conditions (PPCs) that are associated with claims for Medi-Cal payment or with courses of treatment prescribed to a Medi-Cal patient for which payment would otherwise be available. Providers do not need to report PPCs that existed prior to the initiation of treatment of the beneficiary by the provider.

Providers caring for patients with either Fee-For-Service (FFS) or managed care Medi-Cal must report a PPC to the Department of Health Care Services (DHCS) after discovery of a PPC and confirmation that the patient is a Medi-Cal beneficiary.   

Secure online reporting portal

Providers should use the DHCS’ new secure online reporting portal to report PPCs to DHCS. Please see the instructions about using the portal, which includes the link to the online portal. Managed Care Plan network providers should also report the PPC to the beneficiary's plan. Please see All Plan Letter 17-009 for more information for managed care plans. Providers may fax PPC reports to DHCS at (916) 440-5060 until June 30, 2017. DHCS stopped accepting paper copies of form DHCS 7107 on July 1, 2017.
 
Please note that reporting PPCs for Medi-Cal beneficiaries to DHCS does not remove the reporting requirement of adverse events and healthcare-associated infections (HAI) to the California Department of Public Health, pursuant to Health and Safety Code sections 1279.1 and 1288.55.

Payment adjustments

Medi-Cal will withhold payment from providers for treatment associated with acquired PPCs. DHCS will investigate all reports of PPCs, including those discovered through any means, to determine if payment adjustment is necessary. Please see Frequently Asked Questions about payment adjustments.
 

Definitions

PPCs consist of health care-acquired conditions (HCAC) when they occur in acute inpatient hospital settings only and other provider-preventable conditions (OPPC) when they occur in any health care settings. HCACs are the same as hospital-acquired conditions (HAC) for Medicare, except that Medi-Cal does not require providers to report deep vein thrombosis/pulmonary embolism for pregnant women and children under 21 years of age. Please see PPC definitions section of the Frequently Asked Questions or the reporting instructions for a list of HCACs and OPPCs. 

Resources:

Frequently Asked Questions about PPCs (updated April 3, 2017)

 

Providers may email questions about PPCs to PPCHCAC@dhcs.ca.gov

CAUTION: THIS IS A PUBLIC MAILBOX. Please DO NOT include any personal or private information about yourself or anyone else in your email. DHCS is unable to protect such information submitted through this public mailbox. Personal and/or private information includes the name, address, Social Security number, and any other information that helps identify the patient. Examples include the geographic area where the patient lives, phone number, email address, date of birth, account numbers, medical condition or diagnosis, and information about the kind of care the patient received in the past and where and when they have received this care.

Updated April 3, 2017

Last modified on: 6/30/2017 2:13 PM