CCS Outreach Presentation: Provider Relations Unit (PRU) Module
CCS Outreach Presentation: Provider Relations Unit (PRU) Module Last update: 09.2016 by LA County CCS Department of Public Health Disclaimers (2) Disclaimer The purpose of this module is to provide healthcare providers, Managed Care Plans, and clients and their families with an overview of the CCS Provider Relations Unit (PRU) process. It will provide you with useful
information and resources to understand the role of the PRU and how we can assist you. The information contained in this module is solely for the purpose of education and2 PROVIDER RELATIONS UNIT 3 Provider Relations Unit (PRU) Assists providers/clients with general claim inquires related to:
Claim Adjudication Challenges and Prevention Fiscal Intermediary Share-of-Cost (SOC) Adjudication Recommendations 4 CLAIM CHALLENGES AND PREVENTION 5 Claim Challenge Prevention PRU Responsibility: Preliminary research and
Identification of issue Remittance Advice Detail (RAD) code definition and interpretation Link to the complete list of RAD codes can be found in the resource section Limited access on claim history (12 week window) 6 Claim Challenge Prevention In order to avoid claim denials, the following items require a SEPARATE SAR: Diabetic Supplies Restricted, Brand, Compound
Drugs. DMEs or Medical Supplies If product/service exceeds M/C thresholds 7 Claim Challenge Prevention Helpful Hints to Avoid Claim Challenges: BIC number submitted on claim must match the SAR Date of service must fall within the approved dates authorized on the SAR Inpatient SARs are restricted to
hospitals to bill for inpatient stays 8 Claim Challenge Prevention Helpful Hints to Avoid Claim Challenges: The service billed must be authorized either by SCG or individually. When sharing a SAR, the referring providers NPI must be documented in the appropriate field on the claim form 9
Claim Challenge Prevention Helpful Hints to Avoid Claim Challenges cont.: Verify Medi-Cal PriorEligibility to Rendering service; verify eligibility, Every time!!! 10 Claim Challenge Prevention SAMPLE: MEDI-CAL/CCS ELIGIBLE MOPI
11 Claim Challenge Prevention Helpful Hints to Avoid Claim Challenges cont.: Potential Risk Of Nonpayment! 12 Claim Challenge Prevention Proper sharing of a SAR CMS1500 X
90000000A95 001 DUE, JANE 1234 MAIN STREET LOS ANGELES CA 90001 If the services provided were from a REFERRING PHYSICIANS SAR, then
include both the Name of Referring Provider or Other Source field (field 17) and NPI (field 17b). 323 555-5555 SAR number field 23 JOHN SMITH, M.D.
1 250000 John Smith DOWNTOWN DOWNTOWN HOSPITAL HOSPITAL 102 102 FIRST FIRST STREET, STREET, LOS ANGELES, LOS ANGELES, CA
CA 900015555 900015555 2345678901 2345678901 250000 JANE JANE DOE DOE 1027 1027 MAIN MAIN STREET, STREET, LOS ANGELES,
LOS ANGELES, CA CA 900015555 900015555 3456789012 3456789012 If the rendering provider is billing with a referring physicians SAR, enter the NPI number of the rendering provider in the Rendering Provider ID Number
Claim Challenge Prevention Proper sharing of a SAR UB04 Rendering providers NPI # goes in field 56 SAR number field 63 Referring providers NPI # goes in field 76 14
FISCAL INTERMEDIARY 15 Medi-Cals Fiscal Intermediary Call Medi-Cals Telephone Service Center (TSC) for assistance with general inquiries: M/C TSC at 1 800-541-5555 Calling from OUTSIDE of California 1 916-636-1960 16
Medi-Cals Fiscal Intermediary M/C Regional Representative Responsibility: In-depth claim adjudication research Assists with Medi-Cals Fiscal Intermediary internal process Full access to adjusted claim history 17 Access & Utilize Regional Representative 1. Please go to Medi-Cals website at:
www.medi-cal.ca.gov 2. Hover the cursor over the Education tab. 3. Click on Find Regional Representative. 18 Access & Utilize Regional Representative 4. Enter zip code of the service address. 5. Click on Enter Zip Code button. 6. Call TSC and ask to leave a message for your regional representative. 19
Access & Utilize Regional Representative 7. Give a brief description of your challenge 8. Obtain a Service Request Number 9. Document the time and date of your service request 10. If you do not receive a call back within 10 business days, contact CCS PRU 11. When you are contacted by your regional representative, have your Remittance Advice Detail (RAD) available to provide any information they may need in order to assist you with resolution of your challenge
20 Medi-Cals Fiscal Intermediary If you submit hard copy claims, please note the following addresses: CMS 1500 and Pharmacy- Xerox PO Box 15700 Sacramento, CA. 95852-1700 UB04 Inpatient 95852-1500 UB04 Outpatient -
Xerox PO Box 15500 Sacramento, CA. Xerox PO Box 15600 Send to local Sacramento, CA. IMPORTANT! DO NOT 95852-1600 CCS office!
21 Medi-Cals Fiscal Intermediary Computer Media Claims (CMC): https://files.medi-cal.ca.gov/pubsdoco/CTM_manua l.asp Advantages of CMC: 1-2 Weeks Adjudication vs. up to 8 weeks Immediate Confirmation
Avoid LOST in transit, delay and/or wrong address 22 Medi-Cals Fiscal Intermediary Timeliness Requirement For Claim Reimbursement 0-6 Month = 100% 7-9 Month = 75%
10-12 Month = 50% Over One Year = Claim Denial for over 1 year RAD code 021 * The Only Exception Claim submission delays due to CCS eligibility or authorization updates OVER ONE YEAR CLAIM UNIT XEROX PO Box 13029 23 Medi-Cals Fiscal Intermediary For Pharmacy Assistance Please Call: LAC CCS-PRU:
1 800-288-4584, option #3 or Medi-Cal Point of Service (POS) Help Desk: 1 800-427-1295 24 SHARE OF COST 25 Share of Cost CCS Policy & Procedure states: Los Angeles County CCS will reimburse the SOC for any CCS client when the Total Cost of the billed services are
four times (4X) greater than the clients SOC amount for each qualified month of service NOTE: SOC certification gives Full-Scope M/C benefits to clients for the month of service(s) 26 Share of Cost Call the CCS-Provider Relations Unit: 1. Verify straight CCS Eligibility 2. If not eligible, case will be forwarded to FEU for screening
27 Share of Cost 3. Verify claim amount qualifies for CCS reimbursement on behalf of the client Qualified: CCS-PRU will work with you to process SOC reimbursement (Claim $ = 4X > SOC $) Not Qualified: Call CCS-PRU office to verify eligibility for straight CCS and 28 Recommendations For any claim or billing issues
contact PRU @ 1 800-288-4584, option #3 before sending to collections REMEMBER: DO NOT bill patients Per Medi-Cal & CCS Regulations and Contracts! 29 End of Module Thank You 30
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