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23-674m Get Paid Faster: Bill Correctly When Members Have Other Health Coverage

Date: 07/14/23

Bill other health coverage first, as Medi-Cal is the payer of last resort

What is OHC?

OHC refers to private health insurance. Services may include medical, dental, vision, pharmacy and/or Medicare supplemental plans (Part C & D). The following are not OHC: Medi-Cal managed care plans, Medicare Part A & B, Institutionalized (OHC Code “I”) or Medi-Cal.1

How mandatory managed care enrollment affects billing for members with OHC

Medi-Cal beneficiaries who have other health coverage (Commercial health insurance, Medicare, Tricare, etc.) can keep their OHC when they become mandatorily enrolled into managed care.2

How to bill

Medi-Cal is the payer of last resort, which means in most cases Medi-Cal will be secondary to the OHC, covering allowable costs not paid by the primary insurance (typically wrap payments or co-pays) up to the Medi-Cal rate.2

Physicians and other providers enrolled as Medi-Cal fee-for-service (FFS) providers or as Medicare providers do not need to be contracted with the Plan in order to see the Plan member and bill the Plan for a member who is dual-eligible or has OHC.2

To bill Medi-Cal after billing the OHC, the provider must present acceptable forms of proof to the Plan that all sources of payment have been exhausted, which may include:2

  • A denial letter from the OHC for the service.
  • An EOB that shows the service is not covered by the OHC.

Prior authorization for out-of-network providers

Where a prior authorization is required, an out-of-network provider may leverage a letter of agreement (LOA) or similar mechanism. Without an LOA or similar agreement, the provider may be at risk for billed amounts exceeding the allowable FFS rate.2

Follow these guidelines to bill Medi-Cal after OHC3

  1. Medi-Cal may be billed for the balance, including OHC copayments, OHC coinsurance and OHC deductibles. Medi-Cal will pay up to the limitations of the Medi-Cal program, less the OHC payment amount, if any.
  2. Medi-Cal will not pay the balance of a provider’s bill when the provider has an agreement with the OHC carrier/plan to accept the carrier’s contracted rate as payment in full.
  3. An EOB or denial letter from the OHC must accompany the Medi-Cal claim.
  4. The amount, if any, paid by the OHC carrier for all items listed on the Medi-Cal claim form must be indicated in the appropriate field on the claim. Providers should not reduce the charge amount or total amount billed because of any OHC payment. Refer to claim form completion instructions in the Medi-Cal Provider Manual for more information.
  5. When you bill, use Medi-Cal-approved HCPCS codes, CPT® codes and modifiers.
  6. Do not bill with HCPCS codes, CPT codes or modifiers where OHC paid, but which Medi-Cal does not recognize or allow.
  7. If services normally require a Treatment Authorization Request (TAR), the related procedures must be followed. Refer to the TAR Overview section of the Medi-Cal Other Health Coverage Provider Manual, Part 1, for details.

Resources

Refer to these resources on the Department of Health Care Services website for more information.

Additional information

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 on the provider portal> Provider Library under Quick Links.

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.

1 Information taken or derived from Other Health Coverage.

2 Information taken or derived from Medi-Cal Managed Care Enrollment and What this Means for Members and Providers fact sheet. 

3 Information taken or derived from Medi-Cal Provider Manual, Part 2. 

 

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.



Last Updated: 07/11/2023