23-818 Bill Correctly to Get Paid - New Payment Edits to Be Added
Date: 08/15/23
New payment edits will ensure compliance with state guidelines.
Effective October 19, 2023, Health Net, on behalf of CalViva Health, will implement new edits described below on claim payments to ensure compliance with state guidelines.
Claim edits
- Procedure for Required Diagnosis Mismatch (PRDM) – Review procedures and diagnosis codes at the claim level to ensure California Medi-Cal rules allow the codes to be billed together.
- Procedure for Excluded Diagnosis Mismatch (PEDM) – Review procedures and diagnosis codes at the claim line level to ensure the diagnosis code is not disallowed in California Medi-Cal rules to be billed with the procedure code.
These claim edits are supported by Medi-Cal billing guidelines. A list of procedure codes which may be affected by this change is available below.
Procedure codes
Below is a list of procedure codes which may be affected by claim edits PRDM and PEDM. This is not an all-inclusive list.
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Edit source group: State Medicaid Guidelines California CPT codes | ||||
|---|---|---|---|---|
59025 | 80235 | 81246 | 81298 | 84703 |
76802 | 80280 | 81256 | 81300 | 86304 |
76810 | 81201 | 81265 | 81311 | 87338 |
76815 | 81206 | 81267 | 81314 | 87339 |
76816 | 81207 | 81268 | 81317 | 92201 |
76819 | 81208 | 81270 | 81319 | Q5106 |
76820 | 81210 | 81272 | 81435 | 84703 |
76821 | 81218 | 81273 | 81436 | 86304 |
76825 | 81219 | 81275 | 82607 |
|
76826 | 81220 | 81276 | 82731 |
|
76827 | 81235 | 81292 | 83001 |
|
76828 | 81243 | 81294 | 83002 |
|
78452 | 81244 | 81295 | 83013 |
|
78454 | 81245 | 81297 | 83014 |
|
Additional information
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.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.