Calduals.org



Under the Coordinated Care Initiative (CCI), certain beneficiaries who choose not to enroll in Cal MediConnect will still be mandatorily enrolled in Medi-Cal plans for long-term supports and services (MLTSS). This document explains how to seek the Medi-Cal payment portion for MLTSS beneficiaries in Medicare Fee-For-Service.

For such beneficiaries Medicare should be billed and will pay 80% of the Medicare fee schedule. The 20% copay cannot be billed to dual eligible patients. Instead, these “crossover claims” must go to the patient’s Medi-Cal plan, which will pay any amount owed.

The CMS Coordination of Benefits Agreement (COBA) Program allows these crossover claims to go directly to the Medi-Cal plan through a Coordination of Benefits Contractor (COBC) after the claims have been submitted to Medicare. As not all Medi-Cal plans are yet participating in this automated process, the chart below outlines how Medicare providers should submit their Medi-Cal claims to each plan.

Please note that since 1982, state law has limited Medi-Cal’s reimbursement on Medicare claims to an amount that, when combined with the Medicare payment, does not exceed Medi-Cal’s maximum payment for similar services. Consequently, if the Medi-Cal rate is 80% or less than the Medicare rate for the service rendered, Medi-Cal will not reimburse anything on these crossover claims.

Physicians do not need to be in a plan’s network to submit a crossover claim.

|Health plan |CCI County participation |If a provider needs to submit a Medi-Cal crossover claim, how should they do that? |

|Alameda Alliance |Alameda |Providers need to submit crossover claims on paper with Medicare’s EOB attached. Send to: |

| | | |

| | |Alameda Alliance Claims Dept |

| | |PO Box 2460 |

| | |Alameda, CA  94501 |

|Anthem/ Wellpoint |Alameda and Santa Clara |Providers would submit a Medi-Cal claim via paper with a copy of the EOP from the other carrier. |

| | | |

| | |Anthem Blue Cross |

| | |P.O. Box 60007 |

| | |Los Angeles, Ca. 90060-0007   |

| | |  |

| | |Crossover Claims Procedures: In most cases, when a resident has met the criteria for a |

| | |Medicare-qualified stay in a certified Medicare bed, the Medicare cost share will be relayed to Anthem |

| | |via a crossover file provided to Anthem. We will then process and adjudicate the crossover claim. No |

| | |further action should be necessary by the provider. Should Anthem not receive a crossover claim, then a |

| | |claim can be submitted by the provider with a copy of the EOP from the other carrier for processing. |

|CalOptima |Orange |Cal Optima receives CrossOver claims for Part A and Part B electronically through DHCS proprietary |

| | |files. Providers should submit all other claims as paper claims: |

| | | |

| | |CalOptima CMC Crossover Claim |

| | |P.O. Box 11070 |

| | |Orange, CA 92856 |

|Health plan |CCI County participation |If a provider needs to submit a Medi-Cal crossover claim, how should they do that? |

|Care1st |San Diego and Los Angeles |Medicare EOB must be submitted with the claim. |

| | | |

| | |Paper claims can be mailed to: |

| | | |

| | |Care1st Health Plan |

| | |Mail Stop: CL005 (COB) |

| | |601 Potrero Grande Drive |

| | |Monterey Park, CA 91755 |

|CareMore (Anthem ) |Los Angeles |Providers should submit a Medi-Cal claim via paper with a copy of the EOP from the other carrier. |

| | | |

| | |CareMore Health Plan |

| | |Attn: Claims Dept – Duals |

| | |MS-6110 |

| | |P.O. Box 366 |

| | |Artesia, CA 90702 |

| | |  |

| | |Phone: 1-877-211-6553 |

| | |Fax: 1-562-741-4403 |

| | |  |

| | |Crossover Claims Procedures: In most cases, when a resident has met the criteria for a Medicare |

| | |qualified stay in a certified Medicare bed, the Medicare cost share will be relayed to CareMore via a |

| | |crossover file provided to CareMore. We will then process and adjudicate the crossover claim. No further|

| | |action should be necessary by the provider. |

|Community Health Group |San Diego |Providers should send to: |

| | | |

| | |Community Health Group |

| | |Claims Payment |

| | |2420 Fenton street |

| | |Suite 100 |

| | |Chula Vista CA 91914 |

|HealthNet |San Diego and Los Angeles |Providers would need to submit their claims with the Medicare EOB via paper to the following addresses: |

| | | |

| | |Health Net Medi-Cal Claims |

| | |P.O. Box 14598 |

| | |Lexington, KY 40512 |

| | | |

| | |Health Net Medicare Claims |

| | |P.O. Box 14703 |

| | |Lexington, KY 40512 |

| | | |

| | |If a crossover claim is submitted where the member has Health Net coverage for Medicare and for |

| | |Medi-Cal, the claim is routed internally for processing. If the member has another Plan for their |

| | |Medicare the provider would bill them first. Then if that claim needs to come to Health Net to be paid |

| | |under the Medi-Cal benefit it would be as a paper claim. |

|Health plan |CCI County participation |If a provider needs to submit a Medi-Cal crossover claim, how should they do that? |

|Health Plan of San Mateo |San Mateo |Providers should submit on paper with the payment information (EOB) of the primary payer. Crossover |

| | |claims billed with a copy of the EPMB from Medicare to: |

| | |  |

| | |HPSM |

| | |701 Gateway Blvd., Ste 400 |

| | |South San Francisco, CA 94080 |

|LA Care |Los Angeles |Providers should submit paper claims and EOMBs. Once the implementation is complete no paper claim is |

| | |required. |

| | | |

| | |Providers can mail the paper claim and the EOMB to: |

| | | |

| | |L.A. Care Claims Department |

| | |P.O. Box 811580 |

| | |Los Angeles, CA 90081 |

|Molina |Riverside, San Bernardino, |Molina currently accepts both paper and electronic claims. |

| |and Los Angeles | |

| | |Providers should send paper claims to: |

| | | |

| | |P.O. Box 22702 |

| | |Long Beach, CA 90801 |

| | | |

| | |Send EDI to: |

| | |P.O. Box 22807 |

| | |Long Beach, CA 90801 |

| | | |

| | |Electronic EDI Submission: |

| | |EDI Vendor: EMDEON |

| | |Emdeon Payer ID: 38333 |

|Santa Clara Family Health |Santa Clara |Providers must attach the EOB or RA of the primary insurance to allow SCFHP to coordinate benefits under|

|Plan | |Medi-Cal. Providers can mail paper claims (UB-04 and CMS 1500) to:  |

| | | |

| | |SCFHP, P.O. Box 5550 |

| | |San Jose, CA 95150-5550.  |

| | |  |

| | |Providers can electronically submit their claims as HIPAA compliant X12 837 5010 P/I transactions to our|

| | |clearinghouse—Office Ally.  Providers must attach the EOB or RA of the primary insurance to allow SCFHP |

| | |to coordinate benefits under Medi-Cal.  |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download