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20-740 Avoid Post-Payment Collection by Ensuring Medi-Cal is the Payer of Last Resort

Date: 12/18/20

This information applies Participating Physician Groups (PPGs).

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

Requirements for Medi-Cal cost avoidance and post-payment recovery for other health coverage

Medi-Cal managed care plans (MCPs) are required to be the payer of last resort for services when a member has other health care coverage (OHC). On April 20, 2020, the California Department of Healthcare Services (DHCS) issued All Plan Letter (APL) 20-010 to ensure both providers and MCPs, like CalViva Health, Health Net and its delegated providers, are doing their part to correctly identify OHC and avoid unnecessary costs. APL 20-010 provides clarification and guidance regarding requirements for cost avoidance and post-payment recovery when a member has OHC.

To view APL 20-010 in its entirety, visit the DHCS website (PDF).

New guidelines for cost avoidance and post-payment recovery

DHCS new requirements include the following:

  • Use the Medi-Cal Eligibility Record for processing OHC claims.
  • Beginning January 1, 2021, on behalf of CalViva Health, Health Net and its delegated participating physicians groups (PPGs) must include OHC information in their notification to the provider when a claim is denied due to the presence of OHC. OHC information includes, but is not limited to:
    • The name of the OHC provider
    • The policy number
    • Contact or billing information
  • PPG’s may continue to direct providers to access the necessary member OHC information using the Automated Eligibility Verification System at 1-800-427-1295, or the Medi-Cal Online Eligibility Portal. Information pertaining to OHC carriers can be found in the Health and Human Services Open Data Portal at data.chhs.ca.gov/dataset/aevs-carrier-codes-for-other-health-coverage. Additional information on changes to the Medi-Cal Eligibility Reports will be coming from CalViva Health at a later date.
  • Health Net and its delegated PPGs must not process claims for payment for a CalViva Health member whose Medi-Cal eligibility record indicates OHC, other than a code of A or N, unless the provider presents proof that all sources of payment have been exhausted, or the provided service meets requirements for billing Medi-Cal directly.
  • CalViva Health must report new OHC information not found on the Medi-Cal eligibility record or OHC information that is different from what is found on the Medi-Cal Eligibility Record to DHCS within 10 calendar days of discovery.
  • CalViva Health is required to submit detailed information regarding their recoveries to DHCS on a monthly report no later than the 15th of each month.
  • On a monthly basis, CalViva Health must report and return all recovered monies that are 13 months or older from the date of payment of a service to DHCS using the monthly report.

Additional information

Providers are encouraged to access the provider portal online 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.



Last Updated: 12/18/2020