Q1.

How should MH 1982B’s be submitted?

A1.

DMH requests that signed claim forms be submitted to:

Do not include the MH 1982B with the MH 1982A in the claim submission zip file.  If you have any questions regarding these forms, please contact MedCCC at (916) 651-3283 or MedCCC@dhcs.ca.gov.

Updated: 11/01/2011

Q2.

 Is an outpatient mental health service Medi-Cal reimbursable on the day of discharge from an Inpatient Psychiatric Hospital?

A2.

 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. 

Updated: 10/21/2010

Q3.

How are FFP and EPSDT SGF payments distributed?

A3.

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.

Updated: 05/12/2010

Q4.

Q. If a county/provider bills another payer and does not receive a response (payment or denial) within 90 days, how does the county bill Short-Doyle / Medi-Cal (SD/MC)?

A4.

A. 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 a provider does not receive a response (payment or denial) from another insurer within 90 days, the claim may be submitted to SD/MC with an adjustment code of OA*A7. Counties should follow their standard collection practices to recover funds due from third party payers. If a payment is subsequently received from the other insurer, the county shall submit a replacement claim.

Use of the unique identifier in the claim will allow the Department to evaluate and audit the claims. Counties should maintain documentation to support the use of the adjustment code.

Updated:10/21/2010

Q5.

Q. If a Healthy Families Program (HFP) enrollee becomes eligible for Medi-Cal with no share of cost, should the Mental Health Plan (MHP) submit the claim as a Medi-Cal or HFP claim?

A5.

A.  Managed Risk Medical Insurance Board (MRMIB) policy states that an individual cannot have zero share of cost Medi-Cal simultaneously with HFP coverage; however, this scenario occasionally occurs because the HFP enrollment/eligibility period is 12 months and disenrollment from the HFP is not triggered within the 12 month enrollment period as long as the family continues to pay its HFP premiums.  There is no retroactive HFP disenrollment.  Therefore, since both payor sources are valid, and since MRMIB regulations, Title 10, California Code of Regulations, Section 2699.6700(f) (1) stipulate that coverage provided under the HFP Program is secondary to all other coverage, except Medi-Cal, HFP should be claimed.

(1) CCR citations can be located at this website: http://government.westlaw.com/linkedslice/search/default.asp?tempinfo=find&RS=GVT1.0&VR=2.0&SP=CCR-1000.  To access specific sections, enter the title number (e.g., Title 10) and the section number (e.g., 2699.6700).  Direct links to the CCR sections are not available.

Updated:12/10/2010

Q6.

Q. If medical necessity criteria are not met, may counties bill for Healthy Families Program (HFP) Seriously Emotionally Disturbed (SED) services?

A6.

It would be a rare occurrence for a child to meet SED criteria, but not meet medical necessity criteria; however HFP does not use the term “medical necessity” and HFP is not part of the Medi-Cal program.  HFP SED services are provided by county mental health departments when the HFP 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.  HFP SED claims should indicate “SED” in the note field.  This note indicates that the HFP enrollee meets SED criteria, or, in the case of an SED assessment, is being assessed to determine if SED criteria are met. 

(1) W&I Code citations can be located at this website: http://leginfo.ca.gov/calaw.html.  To access specific code sections, check the appropriate code (e.g., Welfare and Institutions) and enter the section number below (e.g., 5600).  Direct links to code sections are not available. 
(2) CCR citations can be located at this website: http://government.westlaw.com/linkedslice/search/default.asp?tempinfo=find&RS=GVT1.0&VR=2.0&SP=CCR-1000.  To access specific sections, enter the title number (e.g., Title 9) and the section number (e.g., 1820.205).  Direct links to the CCR sections are not available.

Updated:12/10/2010