Since the Department of Health Care Services (DHCS) announced the carve-in of behavioral health services as a Medi-Cal managed care plan (MCP) responsibility in 2013, CPCA has been closely monitoring implementation, as well as engaging with the State, managed care plans, and representatives from the county, with a specific focus towards appropriate billing procedures. Prior to the carve-in, FQHCs billed for mental health services using Codes 11, 12, or 13 based on the provider that served the patient. Up to this point, CPCA was provided with verbal guidance from DHCS’ Audits & Investigations Unit (A&I) that health centers should continue billing “status quo” or billing practices prior to 2014 – Codes 11, 12, and 13 directly to the State – until formal written guidance was released by the State. This understanding was verbally confirmed multiple times during monthly in-person meetings with the DHCS A&I team, as well as in CPCA meetings with executive DHCS staff. Despite multiple requests, DHCS staff would not clarify nor confirm the proper billing procedures in writing.
During a recent CPCA phone call with representatives from California Medicaid Management Information System (CA-MMIS), A&I, DHCS’ Primary, Rural and Indian Health Division (PRIHD), and Xerox (Medi-Cal fiscal intermediary), CPCA received new information about how FQHCs should bill for mental health services. DHCS stated that FQHCs should follow the information included in the Medi-Cal provider manual, as of December 2013, which stipulates the following:
- For any services not covered by the managed care plan, FQHCs should bill the Code 11, 12 and 13;
- For any services covered by the managed care plan, FQHCs should submit a claim to the health plan and bill the Code 18.
DHCS followed this statement acknowledging that there remains confusion within DHCS and among managed care plans as to which behavioral health services are and are not covered. However, until clarification is provided by the Department, FQHCs should continue to bill Code 11, 12, and 13 for services that are not covered by the managed care plan and bill the health plan and the wrap around Code 18 claim for services that are coveredby the managed care plan.
The language in the provider manual means that health centers providing mental health services to managed care Medi-Cal beneficiaries should be billing the managed care plan and a code 18 for all mental health services that are covered by the plan. If a health center has not been billing the managed care plan up to this point and has instead been billing DHCS directly for all mental health claims, that health center should resubmit all the mental health claims for mental health services to the contracted managed care plan and submit a code 18 to the state.
To correct the claims submitted to Medi-Cal (Code 11, 12, 13 claim submitted when it should have been a Code 18), health centers should follow the instructions in the Medi-Cal manual for voiding and processing a corrected claim (detailed instructions are also attached).
- Submit a Claims Inquiry Form (CIF) to void the code 11, 12, or 13 claim.
- Health Centers must wait for the code 11, 12, 13 claim to appear as a VOID on the Remittance Advice Details (RAD).
- Once the void appears on the RAD, submit an Appeal to request processing of a corrected code 18 claim and attach a copy of the RAD showing the voided claim.
- Please do not submit an Appeal right after submitting the CIF. You must wait until the RAD shows the void.
- Following these steps should avoid any reduced payment to the Code 18 claim for timeliness as long as the original code 11, 12, or 13 claim was submitted timely.
In the case where the health center made the decision not to submit a claim to the health plan and instead submitted a code 11, 12, 13 claim to the State due to lack of clarity from the managed care plan on covered mental health services, CPCA nonetheless recommends submitting the claim to the health plan as a precaution, as the State may later determine that the managed care plan was responsible.
Health centers that have been billing their code 18 for services covered by the managed care plan and codes 11, 12, 13 (when it was a service not covered by the plan) do not need to change their billing practice.
CPCA is working with DHCS to ensure there will be no adverse impact to health centers that resubmit claims to their managed care plans, as they may not meet the health plan timeliness claim submission requirements. DHCS is committed to resolving this issue and working with CPCA and the plans to clarify which behavioral health services are and are not included in the Medi-Cal mental health benefit as soon as possible. Additional information is forthcoming.
For any questions specifically about Medi-Cal claims please contact Denise Highfill, Associate Director of Health Center Operations, at email@example.com and questions regarding behavioral health can be sent to Erynne Jones, Associate Director of Policy, at firstname.lastname@example.org.
Director of Health Center Operations
California Primary Care Association
1231 I Street, Suite 400
Sacramento, CA 95814
Phone: (916) 440-8170 ext. 1096
Fax: (916) 440-8172