Medicare / Medi-Cal News

Don't forget to check Medicare patients' eligibility! Traditional Medicare doesn't require much pre-authorization, but Medicare HMO's often do. Medicare could deny your claim if your patient switches to an HMO, then the HMO could deny your claim because you didn't have prior authorization.

When documentation is required to process a Reopening, providers must submit the request as a Written Reopening with a completed "Reopening Form" or through Endeavor. If a request is more complex, beyond clerical errors or omissions, it is appropriate to submit a Redetermination via the "Redetermination Form."

For more Telephone Reopening information, go to






First of the Increased Medi-Cal fee-for-service Primary Care Payments to go Out This Week

The Centers for Medicare and Medicaid Services (CMS) recently approved California's proposed implementation plan for the primary care rate increases called for under the Affordable Care Act. The increases are retroactive to January 1, 2013.

After the approval was announced, the California Department of Health Care Services (DHCS) announced it would make an interim payment on November 4 to physicians who have already attested to their eligibility. This payment will be an estimate of what DHCS believes is owed to the physician for fee-for-service Medi-Cal claims retroactive to January 1 dates of service, however the payment will not include claim level detail.

After that, DHCS said that it will begin sending weekly lump sum payments, in addition to regular Medi-Cal payments, to primary care physicians enrolled in fee-for-service Medi-Cal. The weekly interim payments will be issued for estimated amounts due going forward, until DHCS's computer systems can be updated to reflect the new pricing for affected CPT codes. DHCS doesn't anticipate it will have the ability to begin processing individual claims at the new rates until July. At that time, DHCS will issue a final settlement, which will reflect a "true up" of payment owed but not reimbursed, or possibly a refund request if overpaid. This final settlement will include claim level detail for the entire amount paid as part of this increase.

While the increase also applies to services provided by physicians to Medi-Cal managed care patients, it is unclear when each Medi-Cal managed care plan will make the retroactive payments or implement the increase. One plan, Inland Empire Health Plan, has already released first quarter monies due to its physicians - even before it received the state's funding. These primary care payment increases have been put in place by the federal government in an effort to recruit more primary care physicians to treat low-income patients who will be newly eligible for health coverage under the Patient Protection and Affordable Care Act (ACA) in 2014.

The increased payment are not automatic. In order to receive the payment increases, provider must first attest to their eligibility. Physicians should complete attestation immediately, to begin receiving the increased payments as soon as possible.