Provider Manual | Section 4

Claims

Claims

Before filing any claim, be sure to confirm the member’s eligibility. It is essential to include the member’s correct identification number. Do not bill with a Social Security number. (Please see “Section 2: Customer Support”).

Data Quality and Accuracy

Effective healthcare claims processing and payment are highly contingent upon accurate, complete, and timely submission of claims and encounter data by HPSM’s provider network. These data not only reflect services rendered and payment details, but also provide insight into the potential complexity of your patient populations. HPSM is obligated to ensure the complete, accurate, reasonable, and timely submission of all encounter data, whether obtained directly as claims data or through subcontracts and other capitated arrangements, to the Centers for Medicare and Medicaid (CMS) and California Department of Health Care Services (DHCS) in accordance with existing standards and requirements.

Dental

To be eligible for payment, all paper claims must be typed and filed on fully and accurately completed ADA or Medi-Cal dental claim forms with the current CDT procedure codes. If using the ADA dental claim form, please use version 2012 or later. Claims may be suspended or denied when data items included on claim forms are incomplete or incorrect.

HPSM Dental
PO Box 1798
San Leandro, California 94577

Non-Hospital

To be eligible for payment, all paper claims must be filed on fully and accurately completed CMS 1500 forms with the current ICD-10 diagnosis codes (at the highest level of specificity) and CPT-4 or HCPCS procedure codes (including applicable modifiers). Claims may be suspended or denied when data items on claim forms are incomplete or incorrect.

Hospital

To be eligible for payment, inpatient and outpatient hospital paper claims must be submitted to HPSM using a fully and accurately completed UB-04 claim form. Claims may be suspended or denied when data items on claim forms are incomplete or incorrect.

Paper Claims

Paper claims should be submitted to the following address:

Health Plan of San Mateo
Attention: Claims Department
801 Gateway Boulevard, Suite 100
South San Francisco, California 94080

Paper dental claims should be submitted to the following address:

HPSM Dental
PO Box 1798
San Leandro, California 94577

You can check status for a claim on the provider portal after 15 days from receipt.

You may also obtain claim status by contacting HPSM’s Claims Department at 650-616-2106, or by email at ClaimsInquiries@hpsm.org.

Long Term Care Paper Claims

To be eligible for payment, long term care paper claims must be submitted to HPSM using a fully and accurately completed 25-1 claim form. Claims may be suspended or denied when data items included on claim forms are incomplete or incorrect.

It is very important to include your appropriate NPI Number when submitting claims.

LTC 25-1 Field Description and Requirements

Enter the Primary ICD-10-CM diagnosis Code (International Classification of Diseases 9th Revision, Clinical Modification) for the following:

  • Admit claim
  • Initial Medi-Cal claim for a Medi-Care/Medi-Cal crossover patient
  • Change in diagnosis

Note: ICD-10-CM coding must be three, four or five digits with the fourth and fifth digits included if present. The vertical line serves as the decimal point. Do not enter decimal point when entering this code.

Order current copies of the ICD-10-CM from:

PMIC
4727 Wilshire Boulevard, Suite 300
Los Angeles, California 90010

800-633-7467

Enter the amount requested for this billing. To compute the net amount, subtract patient liability and Other Coverage (if any) from the gross amount billed. If the net amount billed computes to $00.00, enter the amount as “0000”. Do not leave blank.

Enter the five-digit zip code of the facility if this information is not already pre-imprinted. Also include the Medi-Cal NPI number if it is not preprinted. Include all nine characters of the number. Do not submit claims using a Medicare provider number or state license number. Claims from providers and/or billing services that consistently bill with other than the 10-character Medi-Cal NPI number will be denied.
Field #DescriptionRequirement
1Claim Control NumberHPSM use only. DO NOT mark in this area. A unique 13-digit number, assigned by HPSM to track each claim, will be entered here when the claim is received by HPSM.
1AProvider Name, AddressEnter your name and address if this information is not preimprinted. Please confirm that this information is correct before submitting claims.
 Zip Code (Box 128)Enter the five-digit ZIP code of the facility if this information is not already pre-imprinted.
2Provider Number 
3DeleteIf an error has been made for a particular patient, enter an “X” in this space to delete both the upper and lower line. Enter the correct billing information on another line. When the Delete box is marked “X”, the information on both lines will be “ignored” by the system and will not be entered as a claim line.
4Patient NameEnter the patient’s last name, first name and if known, middle initial. Avoid nicknames or aliases.
5Medi-Cal ID #Enter the 10-character recipient ID number as it appears on the Benefits Identification Card (BIC).
6Year of BirthEnter the patient’s year of birth in a two-digit format (YY) from the BIC. If the recipient is 100 years of age or older, enter the recipient’s age and the full four-digit year of birth (CCYY) in the Explanations area (Box 126a).
7SexUse the capital letter “M” for male, or “F” for female. Obtain the sex indicator from the BIC.
8ARF Reference NumberFor services requiring an ARF, enter the nine-digit ARF Reference Number. It is not necessary to attach a copy of the ARF to the claim. Recipient information on the ARF must match the claim. Be sure the billed dates fall within the ARF authorized dates.
9Medical Record NumberThis is an optional field that will help you to easily identify a recipient. Enter the patient’s medical record number or account number in this field (maximum of five characters – either numbers or letters may be used). Whatever you enter here will appear on the RA.
10Attending M.D. Medi-Cal Number

Enter the physician’s nine-character Medi-Cal Provider Number. If the physician does not have a provider number, enter his/her state license number (not always nine characters). Be sure the attending physician’s ID number is entered on a(n):

  • Admit claim
  • Initial Medi-Cal claim for a Medi-Care/Medi-Cal crossover patient
  • Claim when there is a change in the attending physician’s provider number.
11Billing Limit ExceptionIf there is an exception to the six-month billing limitations from the month of service, enter the appropriate reason code number and include the required documentation. The appropriate documentation must be supplied to justify the exception to the billing limitation.
12/13Date of Service

Enter the period billed using a six-digit MMDDYY [Month, Day, Year] format for the FROM and THRU dates. Bill only one calendar month of service at a time. Be sure the authorization dates on the ARF cover the period billed. For example, September 1, 2003 is written 090103.

Note: When a patient is discharged, the through date of service must be the discharge date. When a patient expires, the thru date of service must be the date of death.

14Patient Status

Enter the appropriate patient status code from the list below. The patient status code must agree with the accommodation code (that is, if the status code indicates leave days, the accommodation code must also indicate leave days).

Code Patient Status:

  • 00 Still under care
  • 01 Admitted
  • 02 Expired
  • 03 Discharged to acute hospital
  • 04 Discharged to home
  • 05 Discharged to another LTC facility
  • 06 Leave of absence to acute hospital (bed hold)
  • 07 Leave of absence to home
  • 08 Leave of absence to acute hospital /discharged
  • 09 Leave of absence to home/discharged
  • 10 Admitted/expired
  • 11 Admitted/discharged to acute hospital
  • 12 Admitted/discharged to home
  • 13 Admitted/discharged to another LTC facility
  • 32 Transferred to TC status in same facility.
15Accommodation Code

Enter the appropriate accommodation code for the type of care billed, as listed in the Long-Term Care Accommodation Codes.

Note: HPSM does not require that a copy of Form LTC 231 (Certification for Special Program Services) be attached to the Payment Request for Long Term Care (25-1).

16Primary Dx (Diagnosis) Code 
17Gross AmountWhen billing for full Medi-Cal coverage, compute the gross amount by multiplying the number of days times the appropriate Medi-Cal daily rate for the accommodation code listed. When entering the gross amount, do not use symbols ($) or (.). The pre-imprinted vertical line serves as the decimal point. Use this method in entering all dollar amounts on the Payment Request form.
18Patient Liability/Medicare Deductible

Enter the recipient’s net Share of Cost (SOC) liability. The recipient’s net liability is determined by subtracting from the recipient’s original SOC shown on the Medi-Cal card, the amount expended by the recipient that qualifies under MediCal rules as expenditures which may be used to reduce the patient’s SOC liability. For continuing recipients, such qualifying expenditures will generally be those for necessary medical or remedial services or items “not covered” by MediCal.

The recipient’s net SOC liability is the amount billed to the recipient. This SOC is deducted from the Medi-Cal allowed amount.

The PATIENT LIABILITY entered in this box must agree with the “TOTAL SOC DEDUCTED FROM LTC CLAIM” entered on the DHS 6114 form, Item 15.

When billing the recipient for less than the SOC amount indicated by the Host, enter an explanation in the Explanations area on the claim form.

19Other Coverage

Enter the amount paid by other insurance carrier(s) for the period billed, if applicable. Other Coverage includes insurance carriers as well as Prepaid Health Plans (PHPs) and Health Maintenance Organizations (HMOs) that provide any of the recipient’s health care needs.

Note: If the Host indicates a coverage code “L” for the recipient, providers must bill other insurance carriers prior to billing Medi-Cal.

20Net Amount Billed 
21M.D. CertificationNot required
22Additional Claim Lines 
116 The Payment Request form may be used to bill services for as many as six patients. Bill only one month’s services on each line.
117Attachments

Enter an “X” if attachments are included with the claim. Leave blank if not applicable.

Note: If this box is not marked, attachments may not be seen by the examiner, which may cause the claim to be denied.

118Provider Reference NumberEnter any number up to seven digits to identify this claim form in your filing system. Any combination of alpha or numeric characters may be used. This number will be referenced by HPSM on any forms sent to you that pertain to the billing data on the form. It will not be included in the Remittance Advice.
119Date BilledIn six-digit format, enter the date the claim is submitted for HPSM payment.
120FI USE ONLYLeave it blank.
126 Not applicable.
126AExplanationsUse this area for procedures that require additional information or justification. It is essential to clearly indicate the billing line number in this area.
127Signature of Provider or Person Authorized by Provider (Representative)

The claim must be signed and dated by the provider or a representative assigned by the provider. Use black ball-point pen only. An original signature is required on all paper claims.

The signature must be written, not printed. Stamps, initials, or facsimiles are not acceptable. The signature does not have to be on file at HPSM.

127AAffix Label HereBIC cards do not have labels. Leave these boxes blank.

Timelines for Claims Submission

Medi-Cal Claims

Claims Submission from Date of ServiceReimbursement Policy
0-6 months100% of approved payment
7-9 months75%
10-12 months50%
> one year0% (without written justification)

Your claims must be submitted within 180 days from the date of service in order to qualify for the full approved payment amount.

Claims received beyond 180 days from the date of service will be pro-rated according to the guidelines listed in the table above and the member may not be balance billed. 

See Medi-Cal manual for acceptable billing delay reasons.

CareAdvantage and HealthWorx Claims

Your claims must be submitted within one calendar year from the date of service.

Additional Documentation

The following are common circumstances that will require additional documentation to be submitted with the claim:

  • LTC 25-1 form.
  • Non-specific injection codes (i.e., 90782): Indicate the name, NDC (National Drug Codes) number and dose of medication administered.
  • Same procedure performed multiple times on the same date of service.
  • Unlisted codes or codes that are “Not otherwise classified” usually ending in "99": Submit procedure, office or operative notes describing the procedure performed.
  • Special supplies: Submit description (e.g., 99070). All special supplies should be coded utilizing their HCPC Level II codes. Special supplies coded 99070 will require adequate documentation to ensure that usual and customary supplies over and above the general and accepted practice were used. These claims may be pended for reimbursement consideration.
  • DME and Medical supplies requiring invoice and/or MSRP for pricing purposes.
  • Services requiring consent.
  • Dental claims: Please refer to the Prior Authorization Required list (enter link to HPSM website).
  • Claims submitted to HPSM for secondary payment require the primary RA or reason for denial.

Important Billing Guidelines

It is especially important that your billing staff check their error reports to guarantee timely claims submission. A rejected claim will not be considered to have been submitted to HPSM.

Claims for services provided to members who are later determined to be retroactively eligible with HPSM must be submitted within 60 days of determination of eligibility with the corresponding Medi-Cal Delay Reason Code.

Note: To avoid a denied claim for late submission, please note in the remarks section the date that Proof of Eligibility (POE) was received by the Provider.

Claims for services provided to members who have Medicare and Other health insurance as primary coverage and HPSM as secondary coverage, claim and primary insurance remittance advice must be submitted to HPSM within six months of the date of service or 60 days of the primary RA date to avoid timely filing penalties.

Electronic Claims

Advantages

  • Cost-Efficiency. Handling of paper claims is eliminated.
  • Accuracy. Your claims are formatted and submitted directly into our host system. This prevents the original claim data from having to be re-keyed.
  • Expediency. Claims enter our system in real time and are processed faster.

Requirements

  • All existing claims data is still required.
  • All information that is currently submitted on your paper claims must also be included on all electronic claims (see, “Filing a Paper Claim”).

Electronic Claims Options

Clearinghouses

With the use of proprietary software or through integration of your current claims' software clearinghouses all needed information will be gathered and sent to HPSM electronically using a 837 file. HPSM currently partners with two different clearinghouses, Office Ally and Change Healthcare.

To get set up with a clearinghouse please contact the Provider Services department at 650-616-2106 or psinquiries@hpsm.org

eHEALTHsuite 

HPSM’s provider portal providers can submit an electronic CMS 1500 claim through eHEALTHsuite. The easy-to-use systemclaims are entered directly into HPSM’s claim system for processing.

 

To get set up in eHEALTHsuite visit the HPSM Provider Portal at www.hpsm.org/provider/portal and click on “New User Registration.”

Sign up for Electronic Funds Transfer/Electronic Remittance Advice

EFT and ERA are fast, secure and more accurate than paper checks.

Sign up for EFT/ERA

  • Electronic Funds Transfer (EFT) sends claims payments directly to your bank account
  • Electronic Remittance Advice (ERA) makes it easier to access and reconcile payment information

To get started, download the ERA/EFT Authorization Form

Claims Tips and Reminders

  • Be sure that you have a valid NPI number. This is extremely critical in the electronic process. It is imperative that your NPI number be included on all electronic claims. Please check with HPSM's Provider Services Department before initiating submission to verify your Medi-Cal or Medicare Provider ID.
  • Be sure to include both billing NPI and rendering NPI, particularly on claims for CareAdvantage enrollees.
  • Confirmation that HPSM received your claim. Electronic claims are acknowledged via e-mail within two working days. HPSM will reject claims with the following common errors:
    • Invalid Medi-Cal Provider ID Number, or no NPI number.
  • Dental electronic claims are acknowledged via EDI (Electronic Data Interchange) response within one working day.
  • Dental faxed claims are acknowledged via fax within one working day.

It is particularly important that your billing staff check their error reports to guarantee timely claims submission. A rejected claim will not be considered to have been submitted to HPSM.

All electronic claims must comply with the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The deadline for HIPPA compliance for electronic transactions and code sets for all covered entities was October 16, 2003.

For questions regarding electronic claim submission and testing, please call 650-616-2017.

Methods of Reimbursement

Please note: all practitioners should ensure that claim forms are submitted with appropriate CPT-4 procedure codes and/or Health Care Financing Administration Common Procedure Coding System (HCPCS) Level II codes for each service rendered at the time of the visit regardless of payment methodology (fee-for-service or capitation).

Fee-for-Service

Providers contracted under the fee-for-service reimbursement arrangement are paid for approved services based on the applicable HPSM fee schedule. All payments generated to fee-for-service providers are a direct result of claims submitted to HPSM. All claims must be submitted to HPSM within 365 days of the date of service to qualify for the payment. A pro-rated amount will be paid by the Medi-Cal plan if the claim is submitted more than 180 days to 365 from the date of service, without a valid Medi-Cal delay reason code, as per contract provisions.

Capitation

Providers contracted under a capitation payment arrangement are paid a monthly per member per month (PMPM) for each HPSM Medi-Cal member, including CareAdvantage members, on the monthly PCP Case Management List. This payment covers the cost of all capitated procedures performed and is received whether the patient is seen by the provider in any given month. Capitated providers are reimbursed on a fee-for-service basis for approved covered services not included in the capitation arrangement (See Primary Care Capitation Code List in the end of this section).

Claims for all fee-for-service covered services and encounter data for all capitated services must be submitted to HPSM within 365 days of the date of service unless a valid Medi-Cal delay reason code is provided, as per contract provisions. Encounter data for capitated services is submitted to HPSM using the same submission process(es) as fee-for-service claims.

Claims and encounter data reflective of services provided to patients cared for under capitated payment arrangements are used to inform utilization and service monitoring and state and federal regulatory reporting requirements including, but not limited to, annual Healthcare Effectiveness Data Information Set (HEDIS) and ongoing Encounter Data submissions. Complete and accurate submission of claims and encounter data will significantly reduce the need for on-site Medical Record review or requests for medical records to be mailed to HPSM (For more information about HEDIS, see, "Section 8").

HPSM Fee Schedule

Medi-Cal

For most services, HPSM reimburses providers the lesser of the billed amount or the maximum allowable fee based on the California Department of Health Care Services (DHCS) Medi-Cal rates. Reimbursement rates may change during the year. Any code listed may have a service limitation associated with it or need prior authorization.

To review current Medi-Cal rates, please see the Medi-Cal website at www.medi-cal.ca.gov. The HPSM Fee Schedule for PCPs, Specialists a.k.a. Referral Providers (non-OB), OB Specialists, Other Service Providers, Hospitals, and Pharmacies are described below.

HealthWorx

For HealthWorx, HPSM uses the Medi-Cal Fee Schedule as the base. The main differences are that PCPs are paid Fee-For Service under these programs, not at a capitated rate, and these programs have higher co-pays as well. Co-pay amounts are subtracted from the total Fee schedule amounts due before payment is released by HPSM.

CareAdvantage

For CareAdvantage, HPSM uses the Medicare Participating Fee schedule. To review current professional rates, please see the Noridian website at med.noridianmedicare.com/web/jeb/fees-news/fee-schedules/mpfs. All other claims are paid using the applicable Medicare fee schedule for the service or item provided.

 

Payment Policies, Rules, & Non-Standard Coding Methodologies

HPSM follows the payment policies and rules outlined in the Medi-Cal Provider Manuals for Medi-Cal and HealthWorx including modifier and diagnosis requirements. HPSM applies National Correct Coding Initiative (NCCI) edits. HPSM follows the current Medicare guidelines for the CareAdvantage line of business including NCCI edits.

The Center for Medicare and Medicaid Services (CMS) oversees Medicare and Medicaid plans on a national level. CMS requires health plan compliance programs to identify health care fraud, abuse, and waste. The goal of HPSM’s compliance program is to focus on areas of government concern, such as unbundling, upcoding, medically unnecessary services, duplicate billing, and billing for services not rendered.

HPSM has implemented Cotiviti as a technologically advanced tool for reviewing billing practices. Using nationally recognized payment and coding guidelines, Cotiviti allows HPSM’s claims system to pend, edit, or deny claim entries based on CMS and AMA guidelines.

Your HPSM RAs outline the nature of the coding and edits that have been identified by HPSM’s Claims Department. Please use this information as an instrument to review and improve your billing practices.

Vaccines for Children Medi-Cal Program

You must be a VFC provider to be reimbursed through VFC and to be reimbursed for eligible vaccines. The VFC program, operated by the California Department of Health Care Services, furnishes federally purchased pediatric vaccines to health care providers at no cost to serve children birth-18 years whose parents cannot pay out of pocket for vaccines. Vaccines are used for children covered by Medi-Cal, children without health insurance or whose insurance does not cover vaccine, and American Indian or Alaskan native children. For more information, contact the State toll free at 877-2-GET-VFC (877-243-8832).

Use SL modifiers to get reimbursed for the administrative fee from HPSM. For high-risk adults, use the SK modifier.

HealthWorx and CareAdvantage

Vaccines should be billed directly to HPSM.

Reimbursement Guidelines

Claims are required to have accurate and specific ICD-10 diagnosis codes and CPT-4 procedure codes and/or HCPCS codes. Dental claims are required to have accurate and specific CDT procedure codes. Claims are reviewed for the following items and reimbursement for covered services will be based on the most appropriate coding:

Evaluation and management services

Office visit codes for initial or new patients will be allowed for separate reimbursement, according to the CPT guideline, when billed in conjunction with a reimbursable procedure (see CPT-4 starred procedures).

Reimbursement will not be made when the services are considered part of the pre-operative and/or postoperative care provided as part of evaluation and management services of a major surgical procedure (global billing). Claims will be reviewed for claim history to determine appropriate Evaluation and Management visit codes in relation to initial versus established patient. In addition, reimbursement will not be made when the services provided are covered under a capitation arrangement.

Medical services after hours

After hours codes are not reimbursable when billed in conjunction with an Evaluation and Management Service.

Hospital discharge day

A hospital visit is not separately reimbursable when billed in conjunction with a reimbursable procedure and/or an Evaluation and Management Service performed on that same discharge date.

Incidental procedures

Incidental procedures will not be separately reimbursed when billed separately on a claim for the same date of service as a primary procedure.

Unbundling

When submitting surgical or laboratory claims, it is best practice to use the single most comprehensive CPT -4 Procedure Code that accurately describes the entire service. When two or more procedure codes are used where a single code (or primary code) includes those codes billed, all codes will automatically be re-bundled and payment will be made for the primary code only.

Mutually exclusive procedures

When two or more codes appear on a claim for procedures that are usually not performed at the same operative session on the same patient on the same date of service, or when two or more codes describing the same type of procedure are submitted on the same claim, they are considered mutually exclusive and only one code will be reimbursed.

Unlisted procedures

Unlisted procedures should not be billed unless a more specific and current CPT-4 procedure code is unavailable in the current CPT-4 reference for the year the procedure was performed. When billing with an unlisted code, a written description of the procedure must be submitted for consideration. Unlisted procedures may not be eligible for coverage under the Plan contract, and reimbursement will be based on the terms, limitations, and policies of the plan. Lack of documentation will result in denial for any unlisted procedure.

Cosmetic procedures

Cosmetic surgery can be described as any procedure performed to improve the general physical appearance, where a physical functional deficit is not documented, and medical necessity is not substantiated. Cosmetic surgery is not a covered benefit. In following CMS guidelines and CPT-4 coding rationale, clinical indication for possible cosmetic surgery must be substantiated with a detailed history and physical findings, previous unsuccessful medical treatment, functional impairment, or limitations following disease, infection, trauma or previous surgery. Psychological stress does not constitute medical necessity.

Special supplies

All special supplies should be coded utilizing the HCPCS Level II codes. Special supplies coded 99070 will require adequate documentation to ensure that usual and customary supplies over and above the general and accepted practice were used. These claims may be pended for reimbursement consideration.

Modifiers

Listed services may be modified under certain circumstances. When applicable, the modifying circumstance against general guidelines should be identified by the addition of the appropriate modifier code. Note that the utilization of modifiers will be reviewed and supporting documentation may be requested. Inappropriate use of a modifier or using a modifier when it is not necessary will result in denial or a delay in claim payment. Some CPT-4 codes, by nature of their description, are for the professional or technical component only. In these cases, a modifier will make the claim suspend unnecessarily.

Additional items

Claims will also be screened for the following: duplicate procedures, obsolete procedures, experimental procedures, age and sex discrepancies, and questionable necessity of an assistant surgeon.

Surgical reimbursements

The surgical fee for all therapeutic surgical procedures covers:

  • The pre-operative evaluation and care beginning with the decision to perform surgery.
  • The surgical procedure and intra-operative care.
  • Anesthesia, if used, whether it is local infiltration, digital or regional block and/or topical.
  • Normal uncomplicated follow-up care, including the routine post-operative hospital care and routine office visits within the post-operative period. Supplies that are considered usual and customary to the surgical procedure are not separately reimbursable.

Assistant surgeons

When an assistant surgeon is used for a procedure, it should be noted on the claim by adding an assistant surgeon modifier (80) to the procedure code. All claims are subject to review pursuant to any applicable state or federal laws or regulation or any requirements of California Department of Health Care Services, Department of Managed Health Care or CMS. The claim will then be reviewed to determine if there was a medical necessity for an assistant surgeon, consistent with Milliman Care Guidelines. A procedure which always requires the use of an assistant surgeon according to the Milliman Care Guidelines will automatically be approved for payment at a reduced rate. This is currently set at 20% of the fee payable to the primary surgeon.

Assistant surgeon fee may be payable for procedures which are not on the list of assistant surgeon allowed procedures. For these exceptions, a Treatment Authorization Request (TAR) will be required and documentation supporting the medical justification for an assistant surgeon must be submitted for preauthorization. The list of procedures for which an assistant surgeon is allowed is downloadable from the HPSM website or you may contact your Provider Services Representative for a hard copy.

Hospital discharge day

If the day of discharge or death occurs with an emergency or regular admission, it is not reimbursable except when the discharge/death occurs on the day of admission – even though the day may be covered by the accommodation quantity authorized on the TAR.

Long Term Care Reimbursement

Payment to Nursing Facility for Skilled Nursing Facility Services provided in accordance with 22 CCR § 51123 shall be as set forth below:

  • Provider shall furnish all equipment, drugs, supplies, and services necessary to provide nursing facility services except as provided in subsection (c) below. Such equipment supplies and services are, at a minimum, those which are required by law, including those required by federal Medicaid regulations and State licensing regulations.
  • Services included but not limited to the following are those which are not included in the payment rate and which are to be billed separately by the Nursing Facility thereof, subject to the utilization controls and limitations of Medi-Cal regulations covering such services and supplies:
    • Allied health services ordered by the Attending Physician; (ii) Physician services; (iii) legend drugs and Insulin; (iv) laboratory services; (v) alternating pressure mattresses/pads with motor and therapeutic air/fluid support systems/beds; (vi) atmospheric oxygen concentrators and enrichers and accessories, oxygen (except emergency), liquid oxygen system, and portable gas oxygen system and accessories; (vii) blood, plasma and substitutes; (viii) dental services; (ix) durable medical equipment as specified in 22 CCR § 51321(g) and medical supplies as specified in 22 CCR § 59998 and parts and labor for repairs of durable medical equipment if originally separately payable or owned by the Member; (x) prescribed prosthetic and orthotic devices for exclusive use by Member; and (xi) X-rays.
  • Not included in the payment rate nor in the Medi-Cal schedules of benefits are personal items such as cosmetics, tobacco products and accessories, dry cleaning, beauty shop services (other than shaves or shampoos performed by the facility staff as part of patient care and periodic hair trims) and television rental. The Member shall be responsible for reimbursement for any such personal items.
  • Payment to nursing facilities for inpatient services shall be the State’s prevailing allowable rate for the Nursing Facility as may be set forth in 22 CCR § 51511.

If Provider also renders intermediate care services, Provider shall be reimbursed as set forth in Attachment A.

Full Payment. The rates agreed to in this Exhibit 1, are to be the only payments made by PLAN to Nursing Facility for inpatient services provided to Members except where otherwise may be provided hereunder in the Agreement on in this Exhibit 1.

  • Notwithstanding (e) above, should the State, through an Operating Instruction Letter (OIL) or some other instrument, require PLAN to implement benefit changes that would result in reimbursement to Nursing Facility at a rate different than the rates set forth in (e) (ii) of this Exhibit 1 or, PLAN reserves the right, but does not have the obligation, to make said adjustments. In the event PLAN does elect to make such an adjustment, PLAN shall be obliged only to do so back to the beginning of the current fiscal year.
  • Based on valid Claims submitted by Nursing Facility, PLAN shall multiply the number of approved inpatient Days by the applicable rates, set out above, to determine the amount due. PLAN shall pay the amount due within thirty (30) Days of receipt of valid Claims.

Facility should submit UB 04 Claim forms and include Medi-Cal LTC accommodation codes.

The parties to this Agreement agree that Nursing Facility shall be reimbursed by PLAN when it receives Clean Claims for services billed with Medi-Cal accommodation codes at the per diem rate State Medi-Cal rate for the level of care provided.

Based on valid Claims submitted by Nursing Facility, PLAN shall multiply the number of approved ICF/LTC days at the rate set forth above to determine the amount due. PLAN shall pay the amount due within thirty 45 business days of receipt of valid claims.

Intermediate Care Services

Developmentally Disabled and Nursing Level-A Facilities

  • Intermediate Care Facilities (ICF) provide intermediate care services for the developmentally disabled shall furnish all equipment, drugs, services and supplies necessary to provide intermediate care services for the developmentally disabled except as provided in subsection (b) below. Such equipment, drugs, supplies, and services are, at a minimum, those which are required by law, including those required by federal Medicaid regulations and State licensing regulations.
  • Not included in the payment rate and to be billed separately by the ICF thereof, subject to the utilization controls and limitations of Medi-Cal regulations covering such services and supplies, are as follows:
    • Allied health services ordered by the attending physician; (ii) physician services; (iii) legend drugs and Insulin; (iv) laboratory services; (v) alternating pressure mattresses/pads with motor and therapeutic air/fluid support systems/beds; (vi) atmospheric oxygen concentrators and enrichers and accessories, oxygen (except emergency), liquid oxygen system, and portable gas oxygen system and accessories; (vii) blood, plasma and substitutes; (viii) dental services; (ix) durable medical equipment as specified in 22 CCR § 51321(g) and medical supplies as specified in 22 CCR § 59998 and parts and labor for repairs of durable medical equipment if originally separately payable or owned by the Member; (x) prescribed prosthetic and orthotic devices for exclusive use of patient; and (xi) X-rays.
  • Not included in the payment rate nor in the Medi-Cal schedules of benefits are personal items such as cosmetics, tobacco products and accessories, dry cleaning, beauty shop services (other than shaves or shampoos performed by the facility staff as part of patient care and periodic hair trims) and television rental. The Member shall be responsible for reimbursement for any such personal items.
  • Payment to ICF facilities for inpatient services for Developmentally Disabled shall be: (i) the State’s allowable rate for the ICF; or (ii) the rate charged to the general public, whichever is lowest. ICF must complete the information set forth in Attachment A, attached hereto, and submit it to the PLAN at the time the Agreement is signed.
DescriptionAccommodation Code
ICF Developmental Disability Program41
ICF/DD-H 4-6 beds 61
ICF/DD-H 7-15 beds65
ICF/DD-N 4-6 beds62
ICF/DD-N 7-15 beds66

Payment for inpatient services for Nursing Facility Level A as follows:

DescriptionAccommodation Code
Nursing Facilities Level A - Regular Services21
Nursing Facilities Level A - Leave Days- (developmentally disabled patient)22

Nursing Facility shall be reimbursed by PLAN when it receives Clean Claims for intermediate care services billed with accommodation codes 21 or 22 at the ICF’s daily State Medi-Cal rate.

Based on valid Claims submitted by Nursing Facility, PLAN shall multiply the number of approved ICF Days at the rate set forth above to determine the amount due. PLAN shall pay the amount due within thirty (30) Days of receipt of valid Claims.

Full Payment: The rates as set forth above for both Developmentally Disabled and Nursing Facility Level A services are to be the only payments made by PLAN to ICF for inpatient services provided to Members except where otherwise may be provided hereunder in this Exhibit 1 or any attachment thereto.

(e) Not withstanding (d) above, should the State, through an Operating Instruction Letter (OIL) or some other instrument, require PLAN to implement benefit changes that would result in reimbursement to ICF at a rate different than the rates set forth in (d) of this Exhibit 1, PLAN reserves the right, but does not have the obligation, to make said adjustments. In the event PLAN does elect to make such an adjustment, PLAN shall be obliged only to do so back to the beginning of the current fiscal year.

(f) Based on valid Claims submitted by ICF, if PLAN reimburses ICF at the Per Diem Rate, PLAN shall multiply the number of approved inpatient Days by the applicable rates, set out above, to determine the amount due. PLAN shall pay the amount due within thirty (30) Days of receipt of valid Claims.

Coordination of Benefits Billing Instructions

How to Submit Claims When HPSM is the Secondary Plan

Automatic Crossover Claims: Medicare uses a consolidated Coordination of Benefits Contractor (COBC) to automatically cross over to HPSM claims billed to any Medicare contractor for Medicare/Medi-Cal eligible recipients assigned to HPSM.

Note: Providers do not need to rebill to Medi-Cal on paper or electronically claims that automatically cross over. See Medi-Cal manual for exceptions to this process.

When HPSM is a secondary plan, and the claim is not eligible to automatically crossover, a copy of the primary payer’s EOB must be attached to the claim. Medicare Part A and B member claims must be submitted with the Explanation of Medicare Benefits (EOMB) form attached to the claim. If the primary plan denies services asking for additional information, that information must be submitted to that carrier prior to submitting to HPSM.

Standard timely filing limits may be exceeded if the claim is submitted within 60 days of payment on the primary payer's Explanation of Benefits (EOB) form.

HealthWorx

How to Define the Primary and Secondary Plans for HealthWorx: Once it has been determined that coordination of benefits applies, the following rules are used to define the primary and secondary plans.

  • Subscriber or dependent
  • Active or retired
  • Effective date
  • Dependent children of non-divorced parents (gender rule and birthday rule)
  • Children of divorced parents (parents who have remarried and parents who have not)
  • Medicare (Primary and Secondary payer)
  • Medi-Cal is the payer of last resort. Primary insurance must always be billed before billing HPSM Medi-Cal.

Subscriber or Dependent: The plan that covers the member as a subscriber pays before the plan that covers the member as a dependent.

Active or Retired: If one of the family members is retired and continues to hold group coverage through his or her previous employer, the subscriber vs. dependent rule holds true. The active plan is primary for all family members.

Medicare with HealthWorx Coverage

Medicare is the primary payer when:

  • Patient is 65 or older, retired, and/or disabled with no group health coverage from former employer or employer of family.
  • Patient is 65 or older, retired, and has a health plan from a former employer.
  • Patient is 65 or older, retired, and spouse is employed but does not have an employer group health plan.
  • Patient is eligible for Medicare solely because of end stage renal disease (ESRD) and health plan of the current or former employer of patient or family has been billed for the first 30 months of Medicare eligibility. This applies regardless of whether the patient is under or over 65.
  • Patient works for the military and is covered by the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). CHAMPUS will pay as secondary plan.
  • Patient is a veteran who rejects VA benefits.

Medicare is secondary payer to HealthWorx when:

  • Patient is 65 or older, is actively employed and has coverage under an employer group health plan;
  • Patient is 65 or older and is covered under an actively employed spouse;
  • Patient is disabled, under the age of 65 and is covered with 100 or more employees;
  • Patient is under 65 and eligible for Medicare solely because of end stage renal disease and the health plan of the current or former employer of the patient or family member has not yet been billed for the first 30 months of Medicare eligibility;
  • Patient is "Working Aged". Retired patient who is Medicare eligible returns to work, even temporarily, and receives employee health benefits;
  • Patient who is eligible for Medicare and has a retired spouse returns to work, even temporarily, and gets employee benefits that covers the patient services;
  • Patient who is eligible for Medicare has VA benefits that cover the services.

Effective Date

The effective date rule applies when one member has two active group coverages. This often occurs when a member has more than one job and has elected coverage through both employers or was offered two coverages from the same employer and elected to have both. When this happens, the plan with the earliest effective date is primary.

Dependent Children of Non-Divorced Parents

This rule states that the plan of the parent with the earlier birthday is primary and the plan of the parent with the later birthday is secondary. This applies only to the month and day of birth, not the year. The birthday rule is the most common rule that is used by health insurance plans today.

Children of Divorced Parents

When children of divorced parents are covered under both parents’ plan, and there is a custody/divorce decree that states one parent has primary responsibility for medical expenses, the plan of the parent with the primary responsibility is primary.

If there is no court decree assigning medical expenses responsibility, or parents hold joint medical expense responsibility, the plan of the parent with custody of the children is primary and the plan of the parent without custody is secondary.

If the children are covered under the plans of their natural parents and stepparents, the order of benefits is as follows:

  1. Plan of the parent with custody pays first.
  2. Plan of stepparent with custody pays secondary.
  3. Plan of parent without custody pays third.
  4. Plan of stepparent without custody pays last.

Medi-Cal is not liable for the cost of HMO-covered services if the recipient elects to seek services from a provider not authorized by the HMO. To establish Medi-Cal’s liability, the provider must obtain an acceptable denial letter from the HMO. For additional information, refer to “HMO Denial Letters” in the Other Health Coverage (OHC).

Please remember, Medi-Cal is the payer of last resort in all cases.

Balance Billing

As a Medi-Cal or Medicare provider with HPSM you are prohibited from billing HPSM members according to the terms of your contract and California State Law.

Please remember to obtain the member co-pays and or coinsurance indicated on the HPSM member ID card or co-insurance at the time of service for HealthWorx members.

Should you have any questions regarding billing HPSM members, please contact HPSM at 650-616-2106 or via email at claimsinquiries@hpsm.org.

Contacting the Claims Department

Providers should check HPSM’s website for member eligibility and claims status. Providers are encouraged to direct questions to the Claims Department via e-mail at claimsinquiries@hpsm.org. The Claims Department is available by phone 650-616-2106 Monday, Tuesday, Thursday and Friday from 8:00 a.m. to 5:00 p.m. (closed from 12-1:30), and Wednesdays from 8:00 a.m. to 12:00 p.m.

Claims Disputes

Please refer to “Section 5: Provider Disputes” for information.

Claims Status Inquiries via HPSM’s Web Claims System

Providers who are registered with HPSM’s Web Claims System may review the status of their claims by logging on with their user ID and password.

Providers who are interested in using the Web Claims System should contact the HPSM Claims Department at 650-616-2106 or by email at claimsinquiries@hpsm.org for assistance.