Billing Inpatient Services for Members with CCS-Eligible Conditions

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Inpatient services at private hospitals and non-designated public hospitals for Medi-Cal members who have California Children's Services (CCS)-eligible conditions are reimbursed using diagnosis-related group (DRG) methodology, which reimburses hospitals for the member's entire stay, with payments based on acuity and not length of stay.

Inpatient services at designated public hospitals (DPHs) are reimbursed based on the applicable DPH Medi-Cal inpatient interim per diem rate. 

Billing policies

Providers must adhere to the following billing policies:

  • If a member is admitted to a hospital for a CCS-eligible condition, the entire stay should be billed to CCS, regardless of whether any services provided during that stay are covered by Health Net. Providers should not bill Health Net for these services.
  • If a member is admitted to a hospital for a non-CCS-eligible condition, and subsequently receives services during the stay for a CCS-eligible condition, the full stay should be billed to CCS. A Service Authorization Request (SAR) is authorized by CCS retroactive to the day of admission. Providers should not bill Health Net for these services.
  • When a member's hospital stay includes delivery and well-baby coverage, the entire claim should be billed to Health Net. If, during the stay, the baby develops a CCS-eligible condition, the entire stay for the baby requires a SAR from CCS from the date of admission and the claim should be billed to CCS. Health Net is responsible for the delivery and well-baby claim and CCS is responsible for the baby's claim with the CCS-eligible condition.

Claims for inpatient services for members with CCS-eligible conditions, whether due to the admission or subsequently received during the admission, must always be billed to CCS, regardless of who initiated the authorization. Hospitals must ensure they have a SAR from CCS.