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
- For days of service during an inpatient hospital stay, the following benefits apply for services provided to Plan Medi-Cal members with a CCS-eligible condition: If the member is admitted to the hospital for a CCS-eligible condition, the entire stay will require a CCS SAR from the date of admission and is to be billed by the hospital to Medi-Cal Fee For Service (FFS), regardless of whether any services provided during that stay are Medi-Cal covered services. NOTE: The hospital will receive one payment for the entire stay based on Medi-Cal’s FFS DRG for that stay. Hospitals are disallowed from billing the Plan (APL16-008).
- If the member is admitted to the hospital for a non-CCS-eligible condition, and subsequently receives services during the stay for a CCS-eligible condition, the entire stay will require a CCS SAR from the date of admission and is to be billed to Medi-Cal FFS. The full stay is to be billed to Medi-Cal FFS. NOTE: DHCS advises that a SAR will be authorized back to the day of admission. The hospital will receive one payment for the entire stay based on the Medi-Cal FFS DRG for that stay. Hospitals are disallowed from billing the Plan (APL 16-008).
- When a member’s stay includes delivery and well-baby coverage, the entire claim is the responsibility of the Plan. If, during the stay, a CCS-eligible condition is identified, the entire stay for the baby will require a CCS SAR from the date of admission and is to be billed to Medi-Cal FFS. The Plan is not to be billed for the baby’s CCS-eligible condition stay. In this case, the hospital will receive two payments: one (1) for the delivery and well-baby stay from the Plan, and one (1) for the baby under the Medi-Cal FFS DRG.