Medi-Cal Upcoming Changes to Retroactive Medicare Claim Business Process

Medicare is typically the primary payer for services rendered to beneficiaries enrolled in both Medicare and Medi-Cal (dual-eligible beneficiaries). When the Department of Health Care Services (DHCS) discovers Medicare coverage after a Medi-Cal payment has been issued, DHCS establishes an accounts receivable transaction and the provider receives a billing notice with instructions to bill Medicare and return the Medi-Cal payment. This requires providers to contact DHCS to obtain the necessary information to bill Medicare, which often causes delays resulting in timeliness issues and lost opportunities to receive higher reimbursement rates. Effective January 1, 2014, Xerox State Healthcare, LLC will offset the associated Medi-Cal payment from the provider’s next Medi-Cal checkwrite when Medicare coverage is retroactively identified. The provider will receive a Remittance Advice Details (RAD) with RAD code 0563: Void Due to Recipient Medicare Retroactive Eligibility, identifying recouped payments and their associated services, as well as instructions for submitting documentation to Medicare for reimbursement.