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1. California Dental Plan, New Dental Choice Provider Choices California Dental Plan, New Dental Choice Provider Choices...
2. Accountable Care Organizations: The Case For Flexible Partnerships Between Health Plans And Providers Under the Affordable Care Act, the new Center for Medicare and Medicaid Innovation will guide a number of experimental programs in health care payment and delivery. Among the most ambitious of the reform models is the accountable care organization (ACO), which will offer providers economic rewards if they can reduce Medicare’s cost growth in their […]...
3. Suspension of Entities Submitting Claims for Suspended Providers The July Update is a list of providers who have been added to or removed from the Medi-Cal Suspended and Ineligible Provider List (S&I List) for the month of July. New providers have been added in bold and reinstated providers were removed from the following lists: susp A, susp C, susp E, susp G, susp […]...
4. Share of Cost Clearance Transaction To clear a subscriber’s SOC, the provider accesses the Medi-Cal eligibility verification system, enters a provider number, Provider Identification Number (PIN), subscriber identification number, BIC issue date, billing code and service charge.  The SOC information is updated and a response is displayed on the screen or relayed over the telephone. Several clearance transactions may be […]...
5. Certifying Share of Cost Benefits and Coverage Subscribers are not eligible to receive Medi-Cal benefits until their monthly Share of Cost dollar amount has been certified online. Certifying SOC means that the Medi-Cal eligibility verification system shows the subscriber has paid or become obligated for the entire monthly dollar SOC amount owed. Claims submitted for services rendered to a subscriber whose SOC […]...
6. Health Plan of San Mateo is expanding its covered services Providers cannot bill Medi-Cal or CHDP for Medi-Cal-covered mental health services (for pharmacies and labs only) and CHDP services rendered to children and adolescents enrolled in the Health Plan of San Mateo on or after July 1, 2010. As of July 1, the health plan will be responsible for reimbursing providers for such services.  Effective […]...
7. SOC: What is a Eligibility Verification Confirmation (EVC) number for Share of Cost Once SOC has been certified, an Eligibility Verification Confirmation (EVC) number is displayed in the message returned by the Medi-Cal eligibility verification system.  Return of an EVC number does not guarantee that a subscriber qualifies for full-scope Medi-Cal or CMSP benefits.  It does, however, indicate that the subscriber qualifies for at least partial services.  Providers […]...
8. Welfare and Institutions Code 14018.2 requires providers to make a good faith effort Welfare and Institutions Code 14018.2 requires providers to make a good faith effort to verify the identity of a Medi-Cal recipient by matching the recipient’s name and signature on their Medi-Cal card with a valid California driver’s license, ID card issued by the Department of Motor Vehicles, another type of picture identification card or other […]...
9. Long Term Care Share of Cost Providers receiving an eligibility verification message (see following example) that indicates a subscriber has an LTC SOC should not  clear the SOC online.  Subscribers with aid codes 13, 23, 53 and 63 must have their LTC SOC cleared on the claim.  The LTC facility  includes the LTC SOC amount for Medi-Cal-covered services on the  Payment […]...
10. Analyzing Shifts In Economic Risks To Providers In Proposed Payment And Delivery System Reforms [Payment & Delivery] A key consideration in implementing the Patient Protection and Affordable Care Act of 2010 will be changing Medicare payments to providers to slow the growth in costs and spur improvements in health care delivery. In addition to the technical feasibility of new payment models, a crucial issue will be the capacity of the health care […]...
11. Medi-Cal Claims: A frequent cause of claim denials by Medi-Cal is due to incorrect recipient admission A frequent cause of claim denials by Medi-Cal is due to incorrect recipient admission and discharge dates and/or incorrect patient status codes submitted by providers. Erroneous “from-through” dates or patient status billed by one provider and paid by Medi-Cal can result in the denial of correct claims billed by another provider. This often occurs between […]...
12. PacifiCare Dental Plan, United HealthCare Providers Plan Review Regarding the PacifiCare Dental Insurance Plan (Region 1). This dental plan offers individual and family dental benefits. A family membership covers the head of household including spouse, your children 19 years of age or younger and your children up to age 23 if attending school full time. Your online request must be processed on or […]...
13. Reversing Share of Cost Transaction To reverse SOC transactions, providers enter the same information as for a clearance but specify that the entry is a reversal transaction.  After the SOC file is updated, providers receive confirmation that the reversal is completed.  Once a subscriber has been certified as having met the Share of Cost, reversal transactions can no longer be […]...
14. New Dental Choice Plan Description New Dental Choice Plan Description...