23-811 Claims Submission Reminder: CCHS Submission Criteria is Required

Date: 08/07/23

Follow these tips to ensure your claim submission isn’t rejected

As a reminder, providers contracting with the Prison Health Care Provider Network (PHCPN) must follow guidelines established by the California Correctional Health Services (CCHCS) when treating California Department of Corrections and Rehabilitation (CDCR) patients.

Place of service codes for CMS-1500 forms

For all paper claims submitted on form CMS-1500, providers should submit separate claims for each place of service (POS). The specific location where the services were furnished should be entered on the claim form in Item 32. If multiple POS codes are submitted on the same paper claim, the claim will be rejected and returned to the provider.

Invalid POS codes

The CCHCS has reviewed the National Place of Service Code Set and determined that the POS codes listed on the chart below are invalid POS codes and will not be accepted for the submission of patient services. If claims are received with the invalid POS codes, the claim will be returned to the provider.

Billing instructions

When billing claims for CDCR patients, physicians and other providers must ensure the requirements are present and valid to avoid claims delays.

Patient name

• The patient’s full name must be included on the claim.
• The patient name and CDCR identification number can be verified by accessing the web-based tool located on the CDCR’s website at CDCR Inmate Locator.
• Incomplete claims, incorrectly formatted claims and claims considered ineligible during the adjudication process will be rejected and returned to the physician or other provider.

Coding for invalid POS codes

The POS codes below are considered invalid for patient services. For a list of POS codes for professional claims, please refer to the Centers for Medicare & Medicaid Services (CMS).

Code	Description	Code	Description
01	Pharmacy	35-40	Unassigned
03	School	43-48	Unassigned
04	Homeless Shelter	51	Inpatient Psychiatric Facility
05	Indian Health Service Free-standing Facility	52	Psychiatric Facility – Partial Hospitalization
06	Indian Health Service Provider-based Facility	53	Community Mental Health Center
07	Tribal 638 Free-Standing Facility	54	Intermediate Care Facility/Individuals with Intellectual Disabilities
08	Tribal 638 Provider-Based Facility	55	Residential Substance Abuse Treatment Facility
10	Telehealth Provided in Patient’s Home	56	Psychiatric Residential Treatment Center
12	Home	57	Non-Residential Substance Abuse Treatment Facility
13	Assisted Living Facility	58	Non-residential Opioid Treatment Facility
14	Group Home	59	Unassigned
16	Temporary Lodging	60	Mass Immunization Center
17	Walk-in Retail Health Clinic	63-64	Unassigned
18	Place of Employment – Worksite	66-70	Unassigned
25	Birthing Center	71	Public Health Clinic
26	Military Treatment Facility	73-80	Unassigned
27	Outreach Site/Street	82-98	Unassigned
28-30	Unassigned	99	Other Place of Service
34	Hospice

Additional information

If you have questions regarding the information contained in this update, contact the PHCPN Provider Services Center by email or by phone at 877-899-0561.

 

This information applies to Physicians, Hospitals, and Ancillary providers.