- Participating Physician Groups (PPG)
Coordination of benefits (COB) is required before submitting claims for members who are covered by one or more health insurers other than Medi-Cal. Medi-Cal is always the payer of last resort, including Medicare and TRICARE.
Submission of a COB Claim
Coordination of benefits (COB) claims must be submitted within 180 days following the date that the member and provider receive the other coverage's Explanation of Benefits (EOB).
When the provider learns that a Health Net Medi-Cal member has other group health coverage, the provider must:
- File the provider claim with the primary carrier first
- After the primary carrier has paid, submit a copy of the explanation of check or EOB with the claim to Health Net or the responsible capitated subcontractor, if one exists
As the payer of last resort, Health Net's Medi-Cal plan coordinates benefits. In order for Health Net to document records and process claims correctly, include the following information on all coordination of benefits (COB) claims:
- Name of the other carrier
- Subscriber identification number with the other carrier
How to bill Medi-Cal after billing other health coverage
The provider must present acceptable forms of proof to the Plan that all sources of payment have been exhausted, which may include:1
- A denial letter from the other health coverage (OHC) for the service.
- An EOB that shows the service is not covered by the OHC.
Prior authorization for out-of-network providers
Where a prior authorization is required, an out-of-network provider may leverage a letter of agreement (LOA) or similar mechanism. Without an LOA or similar agreement, the provider may be at risk for billed amounts exceeding the allowable FFS rate. 1
Follow these guidelines to bill Medi-Cal after OHC2
- Medi-Cal may be billed for the balance, including OHC copayments, OHC coinsurance and OHC deductibles. Medi-Cal will pay up to the limitations of the Medi-Cal program, less the OHC payment amount, if any.
- Medi-Cal will not pay the balance of a provider’s bill when the provider has an agreement with the OHC carrier/plan to accept the carrier’s contracted rate as payment in full.
- An EOB or denial letter from the OHC must accompany the Medi-Cal claim.
- The amount, if any, paid by the OHC carrier for all items listed on the Medi-Cal claim form must be indicated in the appropriate field on the claim. Providers should not reduce the charge amount or total amount billed because of any OHC payment. Refer to claim form completion instructions in the Medi-Cal provider manual for more information.
- When you bill, use Medi-Cal-approved HCPCS codes, CPT® codes and modifiers.
- Do not bill with HCPCS codes, CPT codes or modifiers where OHC paid, but which Medi-Cal does not recognize or allow.
- If services normally require a Treatment Authorization Request (TAR), the related procedures must be followed. Refer to the TAR Overview section of the Medi-Cal Other Health Coverage Provider Manual, Part 1, for details.
1Information taken or derived from Medi-Cal Managed Care Enrollment and What this Means for Members and Providers fact sheet. dhcs.ca.gov/services/Documents/MCQMD/OHC-and-MMCE-Fact-Sheet.pdf.
2Information taken or derived from Medi-Cal Provider Manual, Part 2. files.medi- cal.ca.gov/pubsdoco/Publications/masters-MTP/Part2/othhlth.pdf.
Dual Health Net coverage refers to members that are covered under two Health Net plans. Claims must be submitted to the primary plan first. The Health Net Medi-Cal plan is the secondary coverage under coordination of benefit (COB) rules. The secondary claim must be submitted with the primary Health Net remittance advice, identification and group numbers, indicating the primary Health Net identification number in the Other Coverage box.