22-614 Simplified Capitation Eligibility Report
Date: 08/05/22
This information applies to Participating Physician Groups (PPGs) and Hospitals.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.
Other health coverage (OHC) information removed from the report
Effective with the June 1, 2022 report, we are simplifying the Eligibility Report (BRM 42) for capitated/delegated participating physician groups (PPGs) and hospitals. For additional information refer to Eligibility Report OHC Frequently Asked Questions below.
The following items are removed from the Eligibility Report (BRM 42):
- D – Medicare Part D Prescription Drug Coverage
- E – Vision Plans
- L – Dental only policies
- Q – Commercial pharmacy plans
- OHC Code 1 month ago 436-436 X(1) OHC Code in effect for previous month
- OHC Code 2 months ago 437-437 X(1) OHC Code in effect two months ago
- OHC Code 3 months ago 438-438 X(1) OHC Code in effect three months ago
- OHC Code 4 months ago 439-439 X(1) OHC Code in effect four months ago
- OHC Code 5 months ago 440440 X(1) OHC Code in effect five months ago
- OHC Code 6 months ago 441-441 X(1) OHC Code in effect six months ago
For monthly reports:
- Log into Provider Portal.
- Select Provider Reports under Welcome.
- A pop-up will notify you to log in to Healthnet.com. If you already have an account on Healthnet.com, select the green button to Go To Healthnet.com.
- Log in with your Healthnet.com email and password.
- Under Provider Reports > Available Reports.
Eligibility Report OHC Frequently Asked Questions
Where can I locate the other health coverage (OHC) carrier contact information on the eligibility reports?
The OHC carrier contact information is located at the bottom of the eligibility reports in the record type 3 section. A sample report key showing the OHC information in the record type 3 section may be accessed in the Eligibility Reports section of the provider operations manuals available online in the Provider Library.
Where can I find additional information regarding the member’s Medi-Cal eligibility?
Refer to the Eligibility and Eligibility Reports sections of the provider operations manuals available online in the Provider Library for additional information.
What is the minimum OHC information to be included on the Explanation of benefits (EOB) or Remittance advice (RA)?
When a claim is denied due to the presence of OHC, the minimum OHC information in the notification to providers must include, but is not limited to, the name of the OHC provider (COB Carrier Name on the eligibility report), and the contact or billing information.
How does a participating physician group (PPG) report more current member OHC information to the plan?
The updated OHC information should be included as part of the encounter reporting submissions to the plan. Refer to the Encounters section of the provider operations manuals available online in the Provider Library for additional information.
For Medi-Cal, do we process claims with a code other than “A” or “N” as OHC primary?
Do not process claims for a member whose Medi-Cal eligibility report indicates OHC, other than an OHC code of A or N, you would contest for OHC unless the provider presents proof that all sources of payment have been exhausted, or the provided service meets the requirement for billing Medi-Cal directly.
How do I identify the OHC carrier information in the eligibility reports?
Identify the COB ID showing in position 064-071, and then find that ID at the bottom of the eligibility report for the OHC carrier information. A sample report key is available in the Eligibility Reports section of the provider operations manuals available online in the Provider Library.
How do I find the contact information when the COB information is noted as “Any Carrier” in the eligibility report?
Any carrier means the member may have multiple coverage. DHCS requires the claim to be processed and for the plan and/or PPG to chase (i.e., A = pay and chase) the OHC information from the member or provider.
Who is considered the primary payor when an OHC code is showing as an F on the eligibility report?
The OHC code “F” identifies Medi-Cal recipients who have health insurance coverage through a Medicare Part C health plan in lieu of traditional Medicare fee-for-service. The claim should be processed as Medicare being primary.
Addition information
If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.