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Ensuring Your Medi-Cal Reimbursement

SM. We’re advocates that get results!. Ensuring Your Medi-Cal Reimbursement. HFMA Geographic Program St. Bernardine Medical Center October 25, 2007. SM. Agenda. I. Introduction Identifying The Medi-Cal Patient Early Medi-Cal Linkage Factors: A. Basic linkage factors

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Ensuring Your Medi-Cal Reimbursement

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  1. SM We’re advocates that get results! Ensuring Your Medi-Cal Reimbursement HFMA Geographic Program St. Bernardine Medical Center October 25, 2007

  2. SM Agenda I. Introduction • Identifying The Medi-Cal Patient Early • Medi-Cal Linkage Factors: A. Basic linkage factors B. Parents with minor children in home, deprivation must exist. C. Disability 1. DAPD process (Time Line) 2. Presumptive disability IV. Full Scope Benefits vs. Restricted Benefits V. PRUCOL • Providing Necessary Documentation • How Do You Save That Really Old Account? • Social Security vs. BIC Numbers • Adjudication Response

  3. SM Identifying the Medi-Cal Patient Early Where? • Pre Admission/Pre Registration • Emergency Room • Admitting • Clinic/ Doctor’s office Who? • Financial Counselor • Admitting Clerk • Social Workers • Outside Vendor

  4. SM Medi-Cal Linkage Factors Basic Linkage • Under 21 yrs of age • 65 yrs of age or older • Pregnancy • Deceased

  5. SM Medi-Cal Linkage Factors Deprivation When there are children in the home, DEPRIVATION must exist. • Absent from the home • Deceased • Temporarily incapacitated for a minimum of 30 days or longer (MC61) • Primary wage earner is unemployed or worked less than 100hours.

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  7. SM Medi-Cal Linkage Factors DAPD (Disability and Adult Programs Division) • Patient must have a medical/physical disability that is expected to last for 12 months or longer • Must apply for SSDI and SDI.

  8. SM Medi-Cal Linkage Factors DAPD/Medi-Cal Time Line • Medi-Cal disability packet submitted to county. • County forwards disability packet to DAPD within 10 days • DAPD assigns case to disability analyst for evaluation. * 3-4 months for case to be assigned • Analyst will often: * Request medical records * Mail patient questionnaires for completion * Schedule consultative exam for patient with a state doctor

  9. SM Medi-Cal Linkage Factors DAPD/Medi-Cal Time Line • Analyst determines if patient is disabled. * 2-12 months to review medical evidence • DAPD makes disability determination, state closes case and forwards determination to the county. • Eligibility worker processes case accordingly. * Disabled; approval Notice of Action issued * Not disabled; denial Notice of Action issued

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  11. SM Full Scope vs. Restricted Benefits • Any legal resident or US citizen who is eligible for Medi-Cal can be entitled to full scope benefits. • Anyone who is undocumented is entitled to restricted benefits only.

  12. SM PRUCOL(Permanent Resident Under the Color of Law) Undocumented applicants eligible for restricted benefits only: • Emergency services, and/or • Pregnancy related services Full scope benefits for the applicant if: • Severe or life threatening medical condition • Separate application must be submitted to INS

  13. SM What Documents are Required? • Income Verification • Property Verification • Birth Certificate • Social Security Card • Proof of Residency, if Necessary

  14. SM What Can You Do When Documents Are Unavailable? • County Recorder’s Office • Birth Certificate • Death Certificate • Form SS5 • SSN • Financial Release Form • Bank Statements

  15. SM How Do You Save That Really Old Account? How Far Back Can Benefits be Granted? • 3 months prior to the month of application • One year from the month benefits requested • Application date of any previously filed welfare based program application.

  16. SM Social Security vs. BIC Numbers • Transmittal regarding TAR changes beginning May 1, 2007 * Paper TARs * Incomplete TARs deferred * SSN removed on deferred TARs • Notice to submitters regarding claims changes effective February 1, 2008   * AB 3029 and use of SSN * Changes in real-time eligibility response messages effective September 1, 2007 * Batch eligibility messages in January 2008 (limited time)

  17. SM AdjudicationResponse • Adjudicated paper TARs replaced with Adjudication Response (AR) * Status of requested services * Reason(s) for decision(s) * Adjudicator’s request for additional information, if necessary • Payment Indicator (PI) – Include at end of TAR Control Number

  18. SM Resources Medi-Cal website http://medi-cal.ca.gov/ Medi-Cal Forms http://www.dhcs.ca.gov/formsandpubs/forms/Pages/MCEBbyNumber.aspx The Health Consumer Alliance http://healthconsumer.org/ Overview of the Medi-Cal System http://www.healthconsumer.org/Medi-CalOverview.pdf SSA Disability Bluebook/Adult Listings http://www.ssa.gov/disability/professionals/bluebook/AdultListings.htm

  19. SM HOW TO CONTACT US: Corporate Office: 1508 Brookhollow Drive Suite 360 Santa Ana, CA 92705 (714) 415-3000 (714) 434-3788 fax Toll Free Number:(800) 494-4257 Website: www.hclscorp.com

  20. SM HOW TO CONTACT US: Greg Labow, President glabow@hclscorp.com Bennie-Lynne Flores, Government Program Manager bflores@hclscorp.com

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