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Certifying Share of Cost Benefits and Coverage

Thursday, Oct. 13th 2011 6:37 AM

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 is not certified through the Medi-Cal eligibility verification system will be denied. Exception:    Share of Cost is certified differently for Long Term Care (LTC) subscribers with specific aid codes. To avoid duplicate billing, Hospice providers must indicate the SOC on the UB-04 claim when billing for hospice room and board (revenue code 658) if the SOC was not already met on a Payment Request for Long Term Care (25-1) claim.

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  1. 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 […]...
  2. 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 […]...
  3. How to find out if a subscriber must pay a SOC Providers access the Medi-Cal eligibility verification system to determine if a subscriber must pay an SOC.  The message returned by the eligibility verification system includes the SOC dollar amount the subscriber must pay.  The eligibility verification system is accessed through the Point of Service (POS) device, Automated Eligibility Verification System (AEVS), state-approved vendor software and […]...
  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. 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 […]...
  6. Share of Cost is calculated independently for CMSP and Medi-Cal SOC policy also applies to County Medical Services Program (CMSP) providers and subscribers. Share of Cost is calculated independently for CMSP and Medi-Cal, however, the same subscriber income is included in both calculations. Therefore, the same medical expenses may be used to clear SOC for both programs.  Providers may apply the same services used to […]...
  7. County Welfare Department Generally Determines SOC Amount Generally, a subscriber’s SOC is determined by the county welfare department and is based on the amount of income a subscriber receives in excess of “maintenance need” levels.  Medi-Cal rules require that subscribers pay income in excess of their “maintenance need” level toward their own medical bills before Medi-Cal begins to pay....
  8. Share of Cost Dental Plans, California Dental Network Share of Cost Dental Plans, California Dental Network...
  9. Types of coverage that are NOT Medigap policies Types of coverage that are NOT Medigap policies...
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  11. Providers may collect SOC payments Providers may collect SOC payments from a subscriber on the date that services are rendered or providers may allow a subscriber to “obligate” payment for rendered services.  Obligating payment means the provider allows the subscriber to pay for the services at a later date or through an installment plan.  Obligated payments must be used by […]...
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  13. Share of Cost Case Summary Your Medi-Cal case has been affected by a lawsuit called Sneede v. Kizer.  This lawsuit limits which family members may use medical expenses that are not billed to Medi-Cal to meet their family’s Share of Cost. If you are a spouse or a parent, you have the choice of listing your medical expenses in any […]...
  14. The AEVS: Carrier Codes for Other Health Coverage list The AEVS: Carrier Codes for Other Health Coverage list is updated monthly. A complete AEVS: Carrier Codes for Other Health Coverage list is available online. Additions and changes are shown in bold and underlined type. Providers may order a hard copy update of the section by calling the Telephone Service Center (TSC) at 1-800-541-5555. There […]...
Posted on Thursday, Oct. 13th 2011 6:37 AM | by Share of Cost | in Social Security | Comments Off on Certifying Share of Cost Benefits and Coverage