25-036 Progress Update to Resolve Underpaid Claims

Date: 01/07/25

We are updating our system and making manual adjustments to resolve claims disruptions

Some behavioral health providers may have experienced an issue where non-Medicare claims that are priced based on a percentage of Medicare Allowable have been underpaid.

What claims are impacted?

This issue impacts Employer Group HMO/PPO and Medi-Cal behavioral health claims priced based on Medicare Allowable with dates of services on and after September 1, 2024, with the place of service (POS) code 02 (telehealth for patient that is not in their home). These claims have the facility rate reduction applied.

It does not affect claims billed with POS code 10 (telehealth for patients in their home/not in a facility). The facility rate reduction does not apply to claims billed with this POS 10 code.  

What are we doing to resolve the issue?

A system update is targeted to go live by February 2025 that will resolve this underpayment issue if POS 02 is used for impacted non-Medicare claims. Medicare claims are subject to the facility rate reduction for POS 02 and are not in scope in this update.

Until the system update is in place, we will monitor claims in our systems and make manual adjustments as needed.

Additional information

For questions regarding the information in this update, contact Behavioral Health Provider Services at 844-966-0298.

 

This information applies to Behavioral Health Providers.

For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.