Claims and Provider Reimbursement

When submitting claims for assistant surgeon services, providers must include documentation supporting the role of the assistant surgeon. If the information is not included in the operative report, providers must attach a separate report justifying the need for an assistant surgeon for the surgical procedure billed.

When the Centers for Medicare and Medicaid Services (CMS) makes any coding edits or changes to reimbursement rates, Network Providers, LLC (NPLLC) updates its systems accordingly. NPLLC implements the modifications within 90 days of receiving the changes from CMS.

The provider and NPLLC agree that, in the event such coding modifications change a payment amount in the NPLLC Prison Health Care agreement, the resulting payment amount change is effective on a prospective basis from the date the CMS change was implemented.

Providers must bill on the 02/12 version of the CMS-1500 claim form or its successor.

The following information must be included on every claim.

If a field is not mentioned, there is no specific format required.

*As of June 30, 2023, all Divisions of Juvenile Justice (DJJ) are closed. Juvenile offenders are no longer committed to the DJJ as of this date. Effective July 1, 2023, claims for health care services rendered to the DJJ youth should be directed to the county where the patient is located. Claims for services rendered on or prior to June 30, 2023, will continue to be the responsibility of California Department of Corrections and Rehabilitation (CDCR).

Coordination of benefits does not apply to patients or youths. All eligible claims are processed by California Correctional Health Care Services (CCHCS) and paid by the State Controller's Office (SCO).

Patients are not responsible for copayments, coinsurance or deductibles. Participating providers agree to accept Network Providers, LLC (NPLLC) contracting rates for services as payment in full.

CorrectCare Integrated Health (CCIH), the third-party administrator, uses an automated payment processing system, consistent with current industry standards, to process claims. The utilization of the automated processing system reduces billing and processing errors and expedites payments. To expedite payment under the automated payment system, it is important for participating providers to adhere to the following billing requirements:

• Fill out billing forms correctly and include all required information. Incorrect or incomplete claim forms cause processing delays or rejection of claims.
• Do not mail cover sheets. The automated processing system is limited to reading standard claim forms. Cover sheets and any information on them are no longer considered.

Providers must submit all claims, using the UB-04 (CMS-1450) or CMS-1500 form, HIPAA 5010 standard 837I (institutional claim) or 837P (professional claim) transaction, to CCIH within 120 days from the date services were rendered.

With the exception of emergency care, claims must contain the prior written authorization number issued by the requesting CDCR Institution or DJJ* Facility, which coincides with the dates of services.

CCIH performs claims adjudication, which includes, at a minimum, eligibility verification, duplication validation, prior authorization validation, and NCCI/Medicare editing.

*As of June 30, 2023, all Divisions of Juvenile Justice (DJJ) are closed. Juvenile offenders are no longer committed to the DJJ as of this date. Effective July 1, 2023, claims for health care services rendered to the DJJ youth should be directed to the county where the patient is located. Claims for services rendered on or prior to June 30, 2023, will continue to be the responsibility of California Department of Corrections and Rehabilitation (CDCR).

Claims corrections due to minor billing errors or omissions do not need to be submitted as provider disputes or appeals. Providers may submit the corrected claim to CorrectCare Integrated Health (CCIH) in the same manner as the original claim. Providers must submit corrected claims within the timely filing period and follow Centers for Medicare and Medicaid Services (CMS) billing and coding guidelines.

When submitting corrected claims, providers must enter Corrected Claim in box 19 on the CMS-1500 claim form.

For EDI submission, box 19 translates to Loop 2300 and segment NTE01 = ADD, then segment NTE02 = CORRECTED CLAIM.

CorrectCare Integrated Health (CCIH) contracts with Availity, LLC for the electronic data interchange (EDI) claim submission process. For successful EDI claim submission, participating providers must register with Availity. To register, providers may visit Availity's website at www.availity.com or contact Availity by phone.

Before registering, providers must review Availity's connection requirements and instructions for EDI claims submission online at www.availity.com.

Providers submitting claims electronically must follow standard Health Insurance Portability and Accountability Act (HIPAA) requirements. The following information must be included in the EDI file:

• Payer ID "CCIH" (in capital letters).
• Patient's or Division of Juvenile Justice (DJJ*) youth's full name.
• Patient's California Department of Corrections and Rehabilitation (CDCR) identification (ID) or DJJ* youth number.
• Patient relationship to Insured field must always indicate "Self".
• CDCR institution abbreviation (PDF) or DJJ* facility abbreviation, city, state, and ZIP code (do not list a street address).

To verify the patient name and CDCR ID number, access the Inmate Locator on the web-based tool maintained by the CDCR.

Incomplete claims, incorrectly formatted claims and claims considered ineligible during the adjudication process are rejected and returned to the provider.

Additional documentation for EDI claims

To submit additional documentation for EDI claims, use the process outlined below and a Paperwork (PWK) Fax Cover Sheet to fax the documentation to 844-836-7475.

The provider must populate the following PWK elements in Loop 2300 of the ASC X12 submission:

Submit supporting claim documentation with the PWK Fax Cover Sheet as follows:

• Download the PWK Fax Cover Sheet available online at the CCIH provider website at https://tpa.correctcare.com/pp_reg/portal/ca_index/, under User Reference.
• Complete the fax cover sheet, place it on top of the supporting documentation and fax all pages to CorrectCare Integrated Health. Note: If an attachment is required to adjudicate the associated claim, CCIH must receive it within 10 calendar days of the electronic claim’s submission date; otherwise, CCIH may reject the claim.
• Attachments associated with incomplete cover sheets may be discarded.
• Use only one cover sheet for each electronic claim, regardless of the number of attachments.

*Effective July 1, 2023, claims for health care services rendered to DJJ youth should be directed to the county where the patient is located. Juvenile offenders are no longer committed to DJJ. Claims for services rendered on or prior to June 30, 2023, will continue to be the responsibility of CDCR.

The following information applies only to Hospital providers.

Facility claims that span two fiscal years are not required to be split into two separate claims. Claims should be billed according to the Centers for Medicare and Medicaid Services (CMS) Medicare billing and compensation guidelines.

There are instances when the Centers for Medicare and Medicaid Services (CMS) does not apply reimbursement rates for Medicare-accepted and approved procedure codes. Eligible complete claims billed with Medicare-approved procedure codes that do not have associated CMS rate fees, which are authorized and reimbursable, are reimbursed at a percentage of the provider's billed charges, as stated in the contract agreement.

The following information applies only to Physician providers.

Oral and maxillofacial surgeons should use the most current American Dental Association (ADA) Claim Form to submit claims. Providers can view a sample of the ADA Dental Claim Form or access completion instructions on the ADA website.

The ADA claim form includes several fields related to patient identification that require unique entries for California Department of Corrections and Rehabilitation (CDCR) patient and Division of Juvenile Justice (DJJ*) youth claims. Providers must enter the information in the table below for the identified fields. If a field is not mentioned, there is no specific format required.

If a provider is aware of receiving an overpayment, including but not limited to, overpayments caused by incorrect or duplicate payments, errors on or changes to the provider billing, the provider must promptly refund the overpayment amount to California Correctional Health Care Services (CCHCS) with a copy of the applicable Remittance Advice (RA) and a cover letter indicating why the amount is being returned. If the RA is not available, provide patient name, date of service, payment amount, provider tax ID number, and provider ID number.

When CCHCS determines that an overpayment has occurred, CCHCS notifies the provider in writing regarding the overpaid claim through a separate notice that usually includes the following information:

• Patient name and California Department of Corrections and Rehabilitation (CDCR) identification (ID) number.
• Claim identification number.
• Clear explanation of why CCHCS believes the claim was overpaid.
• The amount of overpayment.
• Copy of claim and explanation of benefits.

The provider has 30 business days to submit a written dispute to CCHCS if the provider does not believe an overpayment has occurred. In this case, CCHCS treats the claim overpayment issue as a provider dispute.

If the provider does not dispute the overpayment, the provider must reimburse CCHCS within 30 calendar days from of CCHCS notice. To reimburse CCHCS, providers must:

• Include a copy of the RA that accompanied the overpayment or the refund request letter to expedite CCHCS adjustment of the provider's account. If neither of these documents is available, the following information must be provided: patient name, date of service, payment amount, vendor name and number, provider tax ID number, provider number, claim number, invoice number, and reason for the overpayment refund.
• Make overpayment refund payable to the California Department of Corrections (CDCR) and send the overpayment refund and applicable details to CCHCS.
• If a provider is contacted by a third-party overpayment recovery vendor acting on behalf of CCHCS, such as Performant, the provider must follow the overpayment refund instructions provided by the vendor.

Overpayment and offsets

In order to correct an overpayment, the California Correctional Health Care Services (CCHCS)/California Department of Corrections and Rehabilitation (CDCR) may offset any overpayment, incorrect payment or improper payment to a provider by withholding an amount from the next payment or several payments (as necessary) to recover the overpayment.  

When an overpayment to a provider is identified, the CCHCS/CDCR will:

• Issue a written notice to the provider when an overpayment is discovered. The notice will be issued at least 30 calendar days prior to seeking recovery. The notice will provide an explanation of the overpayment and the recovery process.   
• Not offset an overpayment if there is an appeal pending. The appeal must be filed under the Dispute and Resolution process, as set forth in the provider’s contract agreement.
• If recovery of the full amount at one time imposes a financial hardship on the provider, the CCHCS/CDCR, at its sole discretion, may grant a provider’s request to repay the recoverable amount in monthly installments over a period of consecutive months, not to exceed six (6) months. 

Providers must use correct coding and follow the Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI) billing and coding guidelines to ensure prompt, accurate processing of claims. Physicians should use the correct version of the CMS-1500 form and CPT and HCPCS coding, as indicated in the Provider Participation Agreement (PPA). Hospitals use the UB-04 (CMS-1450) form and current UB coding, including CPT, DRG, HCPCS, and ICD-10.

If the provider has more than one tax identification number (TIN), use the TIN under which the PPA has been signed and include the National Provider Identifier (NPI). Claims cannot be processed without these identifying numbers.

Providers must include the California Department of Corrections and Rehabilitation (CDCR) or Division of Juvenile Justice (DJJ)* identification (ID) number, and the CDCR institution abbreviation or DJJ* facility abbreviation  on each claim. Claims may be denied if the number is missing. To verify the patient name and CDCR ID number, access the Inmate Locator on the web-based tool maintained by the CDCR.

All claims billed for CDCR a patient or DJJ* youth must include the institution abbreviation, as well as the city, state and ZIP code of the institution responsible for the CDCR patient or DJJ* youth on the date of service. Place the abbreviation and address in box 5 on the CMS-1500 and box 9 on the CMS-1450.

Submit paper claims to CorrectCare Integrated Health (CCIH) within 120 calendar days from the date of service. Participating providers submit claims directly to CCIH. The State Controller's Office (SCO) reimburses the provider. 

*Effective July 1, 2023, claims for health care services rendered to DJJ youth should be directed to the county where the patient is located. Juvenile offenders are no longer committed to DJJ. Claims for services rendered on or prior to June 30, 2023, will continue to be the responsibility of CDCR.

An explanation of payment (EOP) detailing the provider reimbursement is available on the CorrectCare Integrated Health (CCIH) website. The EOP displays amounts that were paid under the Network Provider, LLC (NPLLC) contract terms.

If coverage is denied, the claim and denial letter are mailed to the providers.

Providers must report mileage on ambulance claims in fractional units as follows:

• For trips less than one mile, enter 0 before the decimal, such as 0.9.
• For trips totaling up to 100 covered miles, round the total miles up to the nearest tenth of a mile and use the appropriate HCPCS code for ambulance mileage.
• For trips totaling 100 covered miles and greater, round up to the next whole number without the use of a decimal.

According to Medicare billing guidelines, ambulance providers only need to enter one service line when reporting rural or super-rural (rural areas with the lowest population density) mileage. Reimbursement for rural or super-rural mileage, which qualifies for a higher reimbursement rate, is based on the ZIP code where the patient is picked up.

The Centers for Medicare & Medicaid Services (CMS) implemented a Medically Unlikely Edit (MUE) for HCPCS code A0425 (ground mileage, per statute mile). California Correctional Health Care Services (CCHCS) requires providers to submit a trip report along with the claim when billing claims with HCPCS code A0425 for one-way trips greater than 250 miles. Claims without the trip report may result in a claims processing delay.

Physicians and practitioners must submit professional telemedicine claims using the place of service (POS) code 02, the appropriate HCPCS procedure code for telemedicine services, and modifier GT (via interactive audio and video telecommunication systems).

Facility claims for telemedicine services must be submitted with revenue code 780 and HCPCS code Q3014.

Modifiers GT (via interactive audio and video telecommunications systems) and GQ (via an asynchronous telecommunications system) are still required when billing for telehealth services. If providers bill telehealth services with POS code 02, but without the GT or GQ modifier, there will be delays in processing the claims.

Conversely, if providers bill telehealth services with modifiers GT or GQ, but without POS code 02, there will be delays in the processing of the claim.

Claims for outpatient rehabilitation services submitted on a UB-04 form must include appropriate revenue codes and therapy modifiers. Outpatient rehabilitation services include physical, occupational and speech therapy. Revenue codes and modifiers must be reported in the following combinations:

• Revenue code 042X (physical therapy) must be billed with modifier GP.
• Revenue code 043X (occupational therapy) must be billed with modifier GO.
• Revenue code 044X (speech therapy) must be billed with modifier GN.

Claims with revenue codes 042X, 043X and 044X without the appropriate therapy modifier are returned to the provider. Additionally, claims with more than one therapy modifier on the same service line are returned to the provider for correction.

If a claim is denied for timely filing, but the provider can demonstrate good cause for the delay, CorrectCare Integrated Health (CCIH) accepts and adjudicates the claim as if it were submitted in a timely manner. California Correctional Health Care Services (CCHCS) considers and makes the determination of whether or not there is a good cause for the delay.

Submission of one of the following is usually sufficient demonstration of good cause:

• Electronic Data Interchange (EDI) confirmation that the claim was received and accepted.
• Delivery confirmation evidence (registered receipt or certified mail receipt to CCIH or CCHCS).
• Screen print from provider's accounting software to show date the claim was submitted.