Objective
Provide a flowchart on the county Mental Health Plans (MHPs) submission of claims for Medi-Cal reimbursement for Short-Doyle/Medi-Cal (SDMC) reimbursable specialty mental health services provided to beneficiaries eligible for both Medicare and Medi-Cal (dual eligibles) whose Medicare coverage is provided through a Medicare Advantage plan (also known as a Medicare Risk HMO or Medicare Part C plan).
References
Process Steps
1.
If dual eligibles with FFS Medicare, MHPs are not required to bill Fee-For-Service Medicare for reimbursement for services which DHCS has determined are not covered by Medicare because the service, the provider type, or the combination of the service, provider type, and place of service are not reimbursable by Medicare.
2.
All Mental Health Plans periodically access MedCCC website to verify if insurance carrier on the list.
3.
Mental Health Plan obtains the certification letter certifying that the plan provides no additional coverage for specialty mental health services beyond that which is provided by FFS Medicare. The certification letter must include the following information:
a.
The Medicare Advantage plan name;
b.
Federal contract number; and
c.
Calendar year(s) of service to which it applies, which must not include any year of service later than the year following the date of the letter.
4.
The MHP sends certification letter to MedCCC at Mental Health Services Division, County Customer Service Section at:
MedCCC@DHCS.CA.GOV using the subject line: “FFS-Equivalent Coverage Certification.”
5.
MedCCC ensures the SDMC system will treat the plan as a FFS-equivalent plan when adjudicating services for the service dates covered by the certification letter.
6.
MHPs with claims which were previously denied because the services were not first billed to the beneficiary’s Medicare Advantage plan may submit replacement claims for any such denied claims which include services which no longer require billing to the Medicare Advantage plan before billing Medi-Cal.
