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Medical Oncology
Association of So. California
Medi-Cal Program Updates for
Oncology Providers
Presented by: Remy Turner
Objective
The purpose of this presentation is to provide Oncology providers with the
following information:
•Medi-Cal Resources
•What is New with Medi-Cal
•Claim follow-up options
•Top 10 denials for Oncology providers
•MOASC Questions
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November 5, 2014
Resources
•Telephone Service Center (TSC) 1.800.541.5555
•Medi-Cal Learning Portal: www.learn.medi-cal.ca.gov
•Regional Representative
•Provider Training Seminars\Webinars
•Claims Assistance Room (CAR)
•Small Provider Billing Unit (SPBU)
•Medi-Cal Subscription Services (MCSS)
•Medi-Cal website: www.medi-cal.ca.gov
• Provider Manuals
• Provider Bullets
• Newsflashes
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Resources
•Medi-Cal Learning Portal: www.learn.medi-cal.ca.gov
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Resources
•Regional Representative
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Resources
•Regional Representative
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Resources
•Medi-Cal Subscription Services (MCSS)
Sign up for MCSS by
“clicking” here
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What is new with Medi-Cal
• Effective 09\22\14 Medi-Cal requires an ICD indicator
•Medi-Cal will be ICD-10 effective 10\01\2015
•New Provider Enrollment system PAVE
•Medi-Cal promoting eTAR
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What is new with Medi-Cal
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What is new with Medi-Cal
• Medi-Cal will be ICD-10 effective 10\01\2015- The Centers for Medicare
and Medicaid Services (CMS) issued a final rule on July 31, 2014, finalizing
October 1, 2015 as the new compliance date for health care providers, health
plans and health care clearing houses to transition to ICD-10, the tenth revision of
the International Classification of diseases.
•PAVE (Provider Application and Validation for Enrollment) SystemThe Department of Health Care Services is implementing PAVE in 2015. PAVE
will transform provider enrollment activities from a manual process to a web-based
portal that providers can use to complete and submit their applications,
verifications and report changes.
•eTAR service- DHCS will be mandating all provider’s to convert over from
paper TAR to electronic TAR some time in 2016. O&E is working on an outreach
project to contact provider’s to train and sign them over to the eTAR system.
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Claim Follow-Up Options
Return a Resubmission Turnaround Document (RTD)
Rebill the claim - 6 months from the end of month of service
Submit an Appeal for (90-1) - 90 days from the denial date
(date on RAD)
Submit a Claims Inquiry Form (CIF)- 6 months from the denial
date (date on RAD)
Write to the Correspondence Specialty Unit (CSU)
Xerox/FI
Attention: CSU
P.O. Box 13029
Sacramento, CA 95813-4029
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November 5, 2014
Top 10 denials for Oncology
Providers
Denial #
1
RAD Code Message
1
0010
2
0037
3
0314
4
0031
5
0095
November 5, 2014
This service is a duplicate of a previously paid
claim.
Health Care Plan enrollee, capitated service not
billable to Medi-Cal.
Recipient is not eligible for the month of service
billed.
The provider was not eligible for the services
billed on the date of service.
This service is not payable due to a procedure, or
procedure and modifier previously reimbursed.
Top 10 denials for Oncology
Providers
Denial #
1
RAD Code Message
6
0036
7
0021
8
0002
9
0012
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0196
November 5, 2014
RTD(Resubmission Turnaround Document) was
either not returned or was returned uncorrected;
therefore, your claim is formally denied.
This claim was received after the one year
maximum billing limitation
Recipient not eligible for benefits under Medi-Cal
program or other special programs.
Medi-cal benefits cannot be paid without proof of
payment/description of the denial from Medicare
This procedure requires a modifier; modifier is not
present.
MOASC Questions
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