20-203 Submit Data by May 15, 2020, for Supplemental Payment

Date: 03/03/20

This information applies to Hospitals.

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

Step-by-step instructions to help hospitals send in claims and encounters for payment programs

Health Net*, on behalf of CalViva Health, will be reviewing the files from the Department of Health Care Services (DHCS) to identify claims and encounters received for the State Fiscal Year (SFY) 2018–2019 Phase 2 service period of January 1, 2019, through        June 30, 2019. Health Net will identify claims and encounters on file with the plan but not on the DHCS file.

The plan will create files that will include the paid/accepted claims and encounters “Not on DHCS” file with DHCS status codes as well as “Denied” with denial codes. The information will be available for participating hospitals via an Excel file for appropriate reconciliation.

Upcoming events that require your action

Hospitals can expect:

• Health Net will send an Excel file of claims and encounters via secure email with details on how to reconcile the claims and encounters. Health Net will update the reconciliation files as new files from DHCS get released to us prior to the final submission date.
• Hospitals must submit any missing data or corrected information on the claims and encounters back to Health Net through the standard claims and encounters submission process, as well as submit the Excel file back by May 15, 2020.
• To ensure any claims paid by capitated provider groups that are not on the    Health Net list get submitted to DHCS, it is recommended that the hospital reach out to them as soon as possible, so they can submit the encounters to Health Net by May 15, 2020.

Instructions for the encounter reconciliation file

Participating hospitals must submit any missing data or corrected information back to Health Net through the standard file processing submission method.

All claims and encounters submissions must be sent to Health Net through the standard claims and encounters submission process no later than May 15, 2020. Health Net cannot guarantee that any claims and encounters received after May 15, 2020, will make the final June 30, 2020, DHCS deadline.

1     Review the “DHCS” tab, “Not in DHCS” tab and “Denied” tab.

A     DHCS tab: all of the encounters already accepted by DHCS. No action needed.

B     Not in DHCS tab: all of the claims/encounters that have been paid/accepted by Health Net and submitted to DHCS.

See “DHCS status” column for status of submission to DHCS.

·       Accepted – DHCS has accepted encounter. Should be on next DHCS contract flagging release file.

·       Rejected – DHCS has rejected the encounter. See “DHCS_Reason” for the reject reason and resubmit with correction prior to May 15, 2020.

·       No status and Not Sent – is pending submission to DHCS. The Health Net team is working on submission, so no action needed at this time.

C     Denied tab: Review the claims for remediation if possible. Corrected claims and encounters must be resubmitted through normal claims processing guidelines for appeals.

2     Review the file against the hospital’s records of claims/encounter submissions for Health Net.

A     Hospitals should identify any fee-for-service (FFS) claims not on the tabs and submit them to Health Net before
May 15, 2020.

B     Hospitals should identify any capitated encounters not on the tabs and reach out to the capitated entity to request submission to Health Net. To help support the submission of missing encounters, the hospital should send      Health Net the list with the submitter/capitated group who made payment listed as soon as possible so Health Net can reach out to them for the encounter submission before May 15, 2020.

Help is available

For questions about these instructions, hospitals can contact:

Health plan contact for questions about claims and encounters	Email
Dianna Bailey, Direct Pay Business Process Consultant	Dianna.Bailey@Centene.com
Direct Pay Team	HNCA_DirectPay@healthnet.com

More help and information about this program

DHCS implemented the Designated Public Hospital (DPH) Enhanced Payment Program (EPP) and Private Hospital Direct Payment Program (PHDP).

DPH-EPP and PHDP provide supplemental reimbursement to participating hospitals based on the actual utilization of qualifying services for eligible members covered under managed care organizations (MCOs), as reflected in Medi-Cal claims and encounters reported to DHCS.

For additional information, visit DHCS at the following websites:

• DPH-EPP – www.dhcs.ca.gov/services/Pages/DP-DPH-EEP.aspx
• PHDP – www.dhcs.ca.gov/services/Pages/DP-PHDP.aspx

Additional information

Providers are encouraged to access the provider portal online at provider.healthnet.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact CalViva Health at 1-888-893-1569.