23-819 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, 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 on 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
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by telephone or through the Health Net provider portal.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.
For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.