EPC Letters: June 6, 2019 Reprocessing of Erroneously Paid and Denied Claims for Laboratory Services

The Department of Health Care Services (DHCS) identified a claims processing issue affecting claims billed with CPT and ICD-10-CM diagnosis codes listed in the Pathology: Billing and Modifiers section in the appropriate Part 2 manual. This issue caused some claims to erroneously pay and other claims to erroneously deny with one of the following Remittance Advice Details (RAD) codes:

• 0169: This service is not payable when billed with this diagnosis.
• 9109: This service is not payable for the diagnosis billed.
• 9516: The secondary diagnosis code is missing or invalid for the procedure code.

The issue affected claims for dates of service from October 1, 2015, through July 19, 2018.

No action is required on your part. The California Medicaid Management Information System (MMIS) Fiscal Intermediary, Conduent State Healthcare, LLC, will void erroneously paid claims and resubmit erroneously denied claims. These voids will appear on RAD forms beginning June 27, 2019, with RAD code 0821: Void of claim non-payable on date of service. Resubmissions of denied claims will appear on RAD forms beginning June 13, 2019, with Claim Control Number (CCN) roll number 55 (Resubmit). The roll number is the fifth and sixth digits of the CCN. Additionally, some erroneously paid claims will be voided and resubmitted. These voids will appear on RAD forms beginning June 27, 2019, with RAD code 0819: Void and resubmit of claims processed in error. Corresponding resubmissions will appear on RAD forms beginning July 5, 2019, with CCN roll number 55 (Resubmit).