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Frequently Asked Questions: Medi-Medi Billing

Question: If a Medi-Medi beneficiary receives Inpatient services and Crisis Stabilization services within 72 hours of the inpatient stay, Medicare  requires all of these services to be claimed on one claim (837I).  The Medicare reimbursement is not itemized.  The MHP is paid the same Diagnostic-Related Group (DRG) rate whether or not Crisis Stabilization is provided when Crisis Stabilization occurs within 72 hours of the inpatient stay.  How should the MHP apply the Medicare reimbursement to the Medi-Cal claim?

• Answer: The MHP should claim Medi-Cal for the hospital Inpatient services on the 837I and Crisis Stabilization on the 837P.  All Medicare reimbursement should be applied to the Medi-Cal 837I for the hospital Inpatient services.

Question: If a Medi-Medi beneficiary receives Crisis Stabilization services with no inpatient services, or no inpatient services within 72 hours and the MHP claim portions of what DMH recognizes as Crisis Stabilization to Medicare (e.g., physician services), how should the MHP apply the Medicare reimbursement to the Medi-Cal claim?

• Answer: The MHP should claim Medi-Cal for the balance of the claim not paid by Medicare for Crisis Stabilization on the 837P.  The MHP must submit the Medicare reimbursement as a Coordination of Benefits (COB) amount so it can be applied to the SDMC payment.

Question: Is procedure (HCPCS) code "H2017" to be used for all specialty mental health services under the Federal Rehabilitation State Plan Option ("Rehab Option")?

• Answer: No. H2017 is only to be used for claiming the service activity Rehabilitation under Mental Health Services.  Rehabilitation is a service activity under Mental Health Services that is not Medicare reimbursable regardless of where it is provided.  Some “Rehabilitation Option” services under California’s Medicaid State Plan are Medicare reimbursable.

Question: How is billing coded for services provided in the community?

• Answer: Specialty mental health services provided in the community are not Medicare reimbursable and should be claimed directly to Medi-Cal.  When a service is provided in the “community” and no other appropriate place of service code applies, the place of service code should be indicated as 99 (other) and the modifier “HQ” should be used with procedure codes H2010 and H2015 to specify that the service was provided in the community.  Medi-Medi claims with place of service code 99, but no modifier will be denied as requiring coordination of benefits.  Similarly, Medi-Medi claims for procedure codes H2010 or H2015 services with the procedure modifier “HQ” that do not include place of service 99 will be denied.

• Answer: Services provided by telephone differ from telemedicine services.  Telemedicine benefits are Medicare reimbursable when provided from a clinic through interactive voice and visual interface between the provider and the client and when provided in specific, eligible geographic regions.  Services provided via telemedicine should be claimed to Medicare prior to Medi-Cal unless another exception to prior Medicare claiming exists.

Services provided by telephone differ from telemedicine services.  Telemedicine benefits are Medicare reimbursable when provided from a clinic through interactive voice and visual interface between the provider and the client and when provided in specific, eligible geographic regions.  Services provided via telemedicine should be claimed to Medicare prior to Medi-Cal unless another exception to prior Medicare claiming exists.

Question: How is place of service "03" (School) defined?

• Answer: A facility whose primary purpose is education.                                                                                                                

Question: How is place of service "15" (Mobile Unit) defined?

• Answer: A facility/unit that moves from place-to-place and equipped to provide preventive, screening, diagnostic, and/or treatment services.

Question: How should the service activity "Plan Development” under "Mental Health Services" be billed for Medi-Medi claims?

• Answer: Plan Development is a service activity under Mental Health Services that is not Medicare reimbursable regardless of where it is provided, or who provides it.  When claiming the service activity Plan Development under Mental Health Services, Mental Health Plans (MHPs) may use procedure code H0032 to bill Medi-Cal directly for Medi-Medi clients. 

• Answer: These must be claimed to Medicare prior to Medi-Cal, using procedure code H2015, unless an exception to Medicare billing exists (for example, the service is provided over the telephone or in the community, it is provided by a non-Medicare reimbursable provider, or in a non-Medicare reimbursable place of service).

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