20-021 Change to Capiatated Claims Encounter Duplicate Logic

Date: 01/07/20

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.

Capitated claims encounter system logic for duplicates now includes NDC codes

On November 25, 2019, the capitated claims (encounters) duplicate logic was changed to accommodate the new National Drug Code (NDC) requirement. The table below explains the criteria previously used to determine if an encounter claim is a duplicate and the changes that were made to the criteria as of November 25, 2019.

Encounter capitated claims impacted

This change impacts capitated claims for professional services.

Duplicate logic	Description
Previous	The previous logic for duplicate services validated the: Same member Provider (either billing provider or rendering provider) Date of service Procedure code Modifier 1-4 Frequency code Check/processed date
New	The new logic for duplicate services validates the: Same member Provider (either billing provider or rendering provider) Date of service Procedure code Modifier 1-4 Frequency code Check/processed date NDC code1

¹If the same procedure and NDC code are submitted more than once, the encounter data will be rejected. The procedure and NDC code combination must be unique in order to be accepted.

Additional information

If you have questions regarding the information contained in this update, contact the Encounter group via email at enc_group@healthnet.com. For all other questions, please contact CalViva Health at 1-888-893-1569.