Family PACT Claims Erroneously Denied with RAD Codes 0169, 9515 and 9516
The Department of Health Care Services (DHCS) has identified a claims processing issue that occurred on or after January 1, 2018, causing Family Planning, Access, Care and Treatment (Family PACT) claims to erroneously deny with Remittance Advice Details (RAD) codes 0169: This service is not payable when billed with this diagnosis, 9515: The procedure code is not a benefit of the Family PACT (Planning, Access, Care and Treatment) program and 9516: The secondary diagnosis code is missing or invalid for the procedure code. DHCS and the DHCS Fiscal Intermediary (FI) are working to resolve this issue.
Providers should continue to submit claims in a timely manner and are encouraged to check the Medi-Cal website regularly for updates regarding this issue.
ICD-10-CM Diagnosis Codes for Postprocedural Hematoma Erroneously Denied
An article published in the September 2017 Family Planning, Access, Care and Treatment (Family PACT) Update titled “Family PACT Adds ICD-10-CM Diagnosis Codes for Postprocedural Hematoma” informed providers that, effective for dates of service on or after November 1, 2017, ICD-10-CM diagnosis codes for postprocedural hematoma, L76.32 and N99.840, are reimbursable for the Family PACT Program.
The system was not updated in time for the November 1, 2017, effective date; therefore, the effective date was revised to January 1, 2018. Claims with ICD-10-CM diagnosis codes L76.32 and N99.840 for dates of service from November 1, 2017, through January 1, 2018, may be denied. An Erroneous Payment Correction will be issued to reprocess affected claims. Providers should continue to submit claims in a timely manner.
Select Comprehensive Family Planning Services Policy Update
The Family Planning, Access, Care and Treatment (Family PACT) program will provide time-limited supplemental payments, to Family PACT providers for Evaluation and Management (E&M) office visits rendered for comprehensive family planning services for the period of July 1, 2017 through June 30, 2018. These supplemental payments are equal to 150 percent of the reimbursement amount for procedure codes 99201, 99202, 99203, 99204, 99211, 99212, 99213, and 99214. Claims submitted for dates of service beginning January 1, 2018 will include the 150 percent supplemental payment. An Erroneous Payment Correction will be initiated in January 2018 to address retroactive payments for dates of service July 1, 2017 through December 31, 2018. This payment increase was mandated by Assembly Bill no. 120 (Stats. 2017, ch. 22, § 3, Item 4260-101-3305), which amended the Budget Act of 2017 to appropriate Prop. 56 funds for specified DHCS health care expenditures during the 2017–18 state fiscal year.
Accuracy and Correction of Claims or Payments
Family PACT providers are responsible for all claims submitted regardless of who completes the claim on behalf of the provider. Family PACT providers are responsible for the review and verification of the accuracy of claims payment information promptly upon the receipt of any payment. The Family PACT provider agrees to seek correction of any claim errors through the appropriate processes as designated by the Department of Health Care Services or its fiscal intermediary (Source: Medi-Cal Provider Manual, Part I and your signed Form DHCS 6153, Medi-Cal Telecommunications Provider and Biller Application/Agreement).
ACA's Nondiscrimination Policy Applies to Family PACT
Section 1557 of Patient Protection and Affordable Care Act (ACA) prohibits discrimination on the basis of race, color, national origin, sex, age or disability in certain health programs or activities. In effect since 2010, Section 1557 builds on long-standing federal civil rights laws: Title VI of the Civil Rights Act of 1964; Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973 and the Age Discrimination Act of 1975.
Effective July 18, 2016, the Health and Human Services (HHS) Office for Civil Rights issued its final rule implementing Section 1557 at Title 45 Code of Federal Regulations (CFR) Part 92. The rule applies to any health program or activity, any part of which receives federal financial assistance, an entity established under Title I of the ACA that administers a health program or activity, and HHS. In addition to other requirements, Title 45 CFR Part 92.201, requires:
For more information about the application and requirements of the final rule implementing Section 1557, providers should contact their representative professional organizations. They may also visit the Section 1557 of the Patient Protection and Affordable Care Act page of the HHS website to find sample materials and other resources.
Information Related to Insurance Affordability Programs
An informational video for providers ACA Requirements for ORP Providers Available on ORP Web Page. Read more...
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