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Authorizations & Claims

Authorization Process

How to Avoid Denials

Claims Processing 

Claims Mailing Address

Helpful Tools When Requesting GHPP Benefits

 

Authorization Process

All requests for GHPP diagnostic and treatment services must be submitted using a Service Authorization Request (SAR) form. Only active Medi-Cal Providers may receive authorization to provide GHPP program services. Services may be authorized for varying lengths of time during the GHPP client’s eligibility period.

Some helpful tips when submitting a SAR:

  1. Providers must request GHPP services using a SAR form.
    Note: Providers should verify GHPP eligibility before submitting a SAR.

  1. Providers are required to submit documentation to substantiate medical necessity at the time the SAR is submitted. Send the completed SAR form with supporting documentation to the GHPP via fax or mail. Examples of required supporting documentations include prescriptions, clinic visit reports, physical therapy evaluation reports, etc. A SAR without supporting documentation will be deferred back to the provider for additional information.

  1. Each SAR submitted to the GHPP is reviewed for medical necessity.
    1. If the SAR is approved, a copy of the authorization letter will be sent to the provider via fax or mail.
    2. If the SAR is denied, a copy of the denial letter with the reason for denial of service will be sent to the provider via fax or mail. If the SAR is denied, you may appeal the denial. Please see Frequently Asked Questions on how to appeal a denial.
    3. If the SAR is incomplete and lacks supporting documentation to substantiate medical necessity, the GHPP will request the provider to submit additional information. There will be no further action on the SAR until the GHPP receives requested information. 

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How to avoid denials for GHPP Services

The GHPP is a prior authorization program. This means that a Service Authorization Request (SAR) must be submitted to the GHPP State office for approval for all diagnostic and treatments services, except for emergencies. Authorization request for emergency services must be submitted to the GHPP by the close of the next business day following the date of service.

The most common reasons why your request may be denied:

  1. You submit a request (retroactive) for a service that you provided without prior authorization or approval from the GHPP.

  1. You submit a request (retroactive) for a service that you provided to a client who is no longer eligible to receive GHPP benefits or is not enrolled with the GHPP. Check for client’s GHPP eligibility by:
    1. Swiping the client’s Benefit Identification Card at the point of service. GHPP eligibility is linked to the Medi-Cal database
    2. Accessing Medi-Cal Eligibility Data System (MEDS) online
    3. Calling the GHPP at 1-800-639-0597

  1. You submit a request (retroactive) for a service you provided without GHPP approval or authorization to a client who has other health insurance coverage. If a client has other health care insurance, the GHPP is a secondary payer or payer of last resort. The GHPP will cover medically necessary services not included in the health plan. See other insurance for more information.
    Please note: The GHPP does not pay client co-pays or deductibles

  1. You submit a request for services covered by Medicare Part D. The GHPP will only cover medically necessary drugs that are specifically excluded from coverage by Medicare Part D.

The following drugs are excluded from Medicare Part D:

  • agents when used for anorexia, weight loss, or weight gain
  • agents when used to promote fertility
  • agents when used for cosmetic purposes or hair growth
  • agents when used for the symptomatic relief of cough and colds
  • prescription vitamins and mineral products
  • nonprescription drugs
  • outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee as a condition of sale
  • barbiturates
  • benzodiazepines
  1. You submit a request for a service that is not a GHPP benefit. Examples of services that  are not covered by the GHPP:
    • Fertility treatments
    • Herbal supplements
    • Experimental treatments
    • Home modifications (such as widening the door to accommodate wheelchair) or car modifications (such as an automatic lift for a  wheelchair)
  2. You submit a request for a service that is deemed not medically necessary or does not meet criteria established for specific program benefits. Please review additional information for some of the GHPP services.

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Claims Processing

The GHPP is currently not automated for claims processing. Providers must submit paper claims to the GHPP State office. The following are some helpful reminders when submitting claims.

  1. Submit claims for services that were approved or authorized by the GHPP. Claims for services without GHPP approval or prior authorization may be denied.
  2. Submit claims for services rendered to a client confirmed eligible to receive GHPP benefits. Claims for services rendered to clients who are not enrolled with the GHPP or are no longer eligible to receive GHPP benefits will be denied.
  3. Submit claims to the GHPP in a timely manner.
  4. Submit claims for services rendered to clients with other health insurance coverage with the Explanation of Benefits (EOB) attached to the claims. The EOB must have the glossary and definition of codes. Claims received without EOB’s will be returned to providers.
  5. Submit all claims for services rendered to clients enrolled in the following Medi-Cal Managed Care Plans (MMCPs) to the GHPP State office:

    1. Santa Barbara Health Initiative
    2. Health Plan of San Mateo
    3. Partnership Health Plan of California, Solano
    4. Partnership Health Plan of California, Napa
    5. Partnership Health Plan of California, Yolo        

Note: The GHPP case manages for the above MMCPs only. All claims for clients enrolled in MMCPs not listed above must submit claims to their respective county health plans.     

If you have billing questions, please contact EDS at (800) 541-5555. You can also visit the Medi-Cal website for billing procedures and updates.

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Claims Mailing Address

GHPP
MS 8100
P.O. BOX 997413
SACRAMENTO, CA  95899-7413

Phone: (800) 639-0597
Fax: (916) 440-5318

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Last modified on: 6/19/2013 9:04 AM