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Claims and Provider Reimbursement

Provider Type

  • Physicians 
  • Hospitals
  • Ancillary

Select any subject below:

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.

The following information must be included on every claim.

CDCR Patient or Ward Name

Enter California Department of Corrections and Rehabilitation (CDCR) patientor Division of Juvenile Justice (DJJ) ward's full name in box 2 on CMS-1500 or box 8 on CMS-1450

CDCR or DJJ Ward Number

Enter patient's CDCR identification (ID) or DJJ ward number in box 1A on CMS-1500 or box 60 on CMS-1450

All claims must include the patient's CDCR ID or DJJ ward number. These numbers consist of six digits for patients (one letter followed by five numbers or two letters followed by four numbers) and five digits for wards (five numbers or a combination of letters and numbers)

Institution Address

Enter institution abbreviation and address in box 5 on CMS-1500 or box 9 on CMS-1450

All claims must include only the CDCR institution abbreviation or DJJ facility abbreviation, city, state, and ZIP code of the institution responsible for the patient or ward on the date of service (do not list a street address)

HNET Identifier

Enter HNET in Box 26 on CMS-1500 or Box 3a on CMS-1450.

National Provider Identifier (NPI)

Enter the provider's NPI in box 24J on CMS-1500 or box 56 on CMS-1450

Tax ID Number

Enter provider's tax ID number in box 25 on CMS-1500 or box 5 on CMS-1450

Use the contracting entity's ID number. For example, if a physician provides medical services as part of participating physician group (PPG) that contracts with Network Providers, LLC (NPLLC), provide the PPG's tax ID number (TIN), not the physician's

Ambulance Providers

Enter the number of miles traveled in box 24G on CMS-1500

Enter the ZIP code for the location of the point of pickup in box 23

Enter pick-up and drop-off addresses, including ZIP codes, in box 32

Telemedicine Services

Professional Services - As of January 1, 2017, PHCPN providers are required to use place of service (POS) code 02 in box 24B on CMS-1500. Use the appropriate HCPCS code with modifier GT in box 24D

Originating Site Facility Services - Enter revenue code 780 in box 42 and HCPCS code Q3014 in box 44 on CMS-1450

Anesthesia Providers

Enter the number of anesthesia minutes, as well as start and stop times, in box 19 on CMS-1500

Show the elapsed time (minutes) in box 24G. Convert hours into minutes and enter the total minutes required for this procedure

MS-DRG Code

Enter the three-digit MS-DRG code in box 71 on CMS-1450 for all inpatient hospital claims or they may be rejected. Physician claims and outpatient hospital claims do not need this code

HCPCS/CPT Codes

Both hospital and physician claims must include all appropriate modifier codes after each HCPCS/CPT code billed

Administrative Days

Hospital providers approved to bill for administrative days must use revenue code 169

Providers who bill administrative days must attach required documentation to the claim form. When requesting reimbursement for administrative days, providers must complete and submit the Administrative Day Justification Form (PDF).

Corrected Claims

Enter Corrected Claim in box 19 when submitting a corrected claim.

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

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

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.

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 telephone.

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) ward's full name
  • Patient's California Department of Corrections and Rehabilitation (CDCR) identification (ID) or DJJ ward 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 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.

The following information applies only to Hospital providers.

As of fiscal year 2013, 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 American Dental Association (ADA) Claim Form (J340D) 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.

Field Number

Field Name

Required Information

15

Policyholder/Subscriber ID

(SSN or ID#)

CDCR or DJJ ward number

17

Employer name

CDCR institution abbreviation or DJJ facility abbreviation

20

Name (Last, First, Middle Initial, Suffix), Address, City, State, ZIP Code

Patient or ward name and institution or facility address

23

Patient ID/Account #

(Assigned by dentist)

Health Net identifier HNET

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 Equiclaim or Change HealthCare, the provider must follow the overpayment refund instructions provided by the vendor

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 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.

If the provider has more than one tax identification 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 Web-based tool maintained by the CDCR.

All claims billed for CDCR patient or DJJ wards must include the institution abbreviation, as well as the city, state and ZIP code of the institution responsible for the patient or DJJ ward 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 Controllers Office (SCO) reimburses the provider. 

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 code (POS) 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.

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 Date 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 
Last Updated: 01/22/2020