FAQs: General Information
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Where do I find the IPC-134 report?
Transaction Enrollment requirements
Why did the EPSDT and Adult FFP percentage for FY 2012-13 go down from FY 2011-12?
It didn't. The percentage actually went up from Fiscal Year (FY) 2011-12 to FY 2012-13. The confusion may be because in FY 2011-12, the funding categories were split into two categories: EPSDT FFP and Adult FFP, each having its own individual ratio. In FY 2012-13, these two funding categories were merged into one. There is no combined FFP ratio for FY 2011-12 to compare to the percentage for FY 2012-13. A combined FFP ratio for FY 2011-12 would be lower (though not represented on the budget detail spreadsheet).
If you were to compare like funding categories for each year, your combined FFP ratio might actually increase from FY 2011-12 to FY 2012-13.
I didn’t see an amount for MAA (Medi-Cal Administrative Activities). Is this amount supposed to be handled separately outside of this contract?
All types of Administration FFP are factored into the Administration figures on the spreadsheet, including MAA, however MAA is not specifically listed on the spreadsheet. It is built into the other categories of Administration amounts.
How were the Supplemental Payments and AB 1297 Payments above SMA computed?
Estimates for supplemental payments is based upon the amount the Department expects to expend for the uncompensated cost of services rendered in FY 2008-09 (i.e., January 1, 2009* – June 30, 2009) and FY 2009-10 as well as interim payments for costs in excess of the SMA in FY 2012-13. The estimate for supplemental payments in FY 2008-09 and 2009-10 was calculated based upon the county’s gross costs less gross SMA multiplied by the appropriate FMAP adjusted for contract providers. The estimate for payments in excess of the SMA for FY 2012-13 was based upon the estimate for FY 2009-10 inflated using a cost of living index and adjusted for the percent of claims submitted in FY 2012-13.
*Note that the state plan amendment that will authorize these payments will have an effective date of January 1, 2009.
Is an outpatient mental health service Medi-Cal reimbursable on the day of discharge from an Inpatient Psychiatric Hospital?
Yes. Immediately upon discharge from an inpatient psychiatric hospital, outpatient mental health services are Medi-Cal reimbursable. Title 9, Section 1820.100(c) states "Per Diem Rate" means a daily rate paid for reimbursable psychiatric inpatient hospital services for a beneficiary for the day of admission and each day that services are provided excluding the day of discharge." In addition, the citations in Title 9, Chapter 11 (1840.360, 1840.362, 1840.364, 1840.366. 1840.368, and 1840.370) provide service specific indications that lockouts apply only on the days when inpatient psychiatric hospital services are reimbursed. Since the day of discharge is not reimbursed, the lockouts do not apply.
How are FFP and EPSDT SGF payments distributed?
July 2009 and after, FFP and SGF was paid to the counties with two warrants based on the SD1 claim cutoff cycles. With SD2, FFP and SGF is paid with one warrant based on an FFP invoice cycle for the prior week's claims. All SD1 and SD2 payments (FFP and SGF) since July 2009 are to the submitting county.
Prior to July 2009, EPSDT SGF payments were to the beneficiary county except for approved claims with adoption assistance aid codes (03, 04, 06, 4A), in which EPSDT SGF went to the submitting county. At all times, FFP is paid to the submitting county.
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If an MHP/provider bills another payer and does not receive a response (payment or denial) within 90 days, how does the MHP bill Short-Doyle/Medi-Cal (SDMC)?
Welfare and Institutions (W&I) Code section 14023.7 requires that any provider of services seeking payment for services provided to an eligible person shall first seek to obtain payment from any private or public health insurance coverage to which the person is entitled. In the event that the claim submitted to a private or public health insurer has not been paid within 90 days of billing by the provider, a claim may be submitted to SD/MC.
If an MHP/provider does not receive a response (payment or denial) from a third party payer within 90 days, the claim may be submitted to SD/MC with an adjustment code of OA*210. MHPs should follow their standard collection practices to recover funds due from third party payers. If a payment is subsequently received from the third party payer, the MHP shall submit a replacement claim.
Use of the unique identifier in the claim will allow the Department to evaluate and audit the claims. MHPs should maintain documentation to support the use of the adjustment code.
If a Healthy Families (HF) beneficiary becomes eligible for Medi-Cal with no Share of Cost (SOC), should the MHP submit the claim as a Medi-Cal or HF claim?
Managed Risk Medical Insurance Board (MRMIB) policy states that an individual cannot have zero SOC Medi-Cal simultaneously with HF coverage; however, this scenario occasionally occurs because the HF enrollment/eligibility period is 12 months and disenrollment from the HF is not triggered within the 12 month enrollment period as long as the family continues to pay its HF premiums. There is no retroactive HF disenrollment. Therefore, since both payer sources are valid, and since MRMIB regulations, Title 10, California Code of Regulations, Section 2699.6700(f) (1) stipulate that coverage provided under the HF Program is secondary to all other coverage, except Medi-Cal, HF should be claimed.
If medical necessity criteria are not met, may MHPs bill for Healthy Families (HF) Seriously Emotionally Disturbed (SED) services?
Yes. However, it would be a rare occurrence for a child to meet SED criteria, but not meet medical necessity criteria; however HF does not use the term “medical necessity” and HF is not part of the Medi-Cal program. HF SED services are provided by county mental health departments when the HF enrollee meets SED criteria at Welfare and Institutions (W&I) Code Section 5600.3 (1). SED criteria per W&I Code Section 5600.3 differ from medical necessity criteria in Title 9, California Code of Regulations, Sections 1820.205, 1830.205, and 1830.210. (2) W&I Code Section 5600.3 does not list specific included diagnoses, has different impairment criteria, and does not include intervention requirements. HF SED claims should indicate “SED” in the note field. This note indicates that the HF enrollee meets SED criteria, or, in the case of an SED assessment, is being assessed to determine if SED criteria are met.
Where should 1982Bs and 1982Cs be submitted?
MHP Director-signed 1982B and 1982C Claim Forms should be submitted by email to:
1982BClaim@dhcs.ca.gov or 1982CClaim@dhcs.ca.gov
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