21-518m Reminder: Submit Claims with Correct Coding to Avoid Rejections

Date: 07/16/21

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.

How the health plan processes Medi-Cal claims with an NDC and HCPCS code

When the health plan receives a Medi-Cal claim with both a National Drug Code (NDC) and a HCPCS code, the plan applies line-level claim edits to determine:

• Is the NDC valid?
• Is the HCPCS code valid?
• Is the NDC/HCPCS code combination valid?

If the response to any of the above questions indicates an invalid code or invalid code combination, the plan will contest the claim to ask for corrected billing.

Additional information

To better reflect current processes, relevant sections of the provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library, located on the provider website.

Access information about billing NDCs in the Provider Library. Select Medi-Cal > Provider Manual > Claims and Provider Reimbursement > Billing and Submission > National Drug Codes for Medi-Cal Claims.

Providers are encouraged to access the provider portal 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 888-893-1569.