21-418 New Reporting Requirements for Third-Party Liability
Date: 06/04/21
Use the new reporting requirements for third-party liability cases
On April 12, 2021, California Health & Wellness Plan (CHWP) informed providers on update 21-273, Report Third Party Liability, of the new reporting requirements for Third-Party Liability (TPL) claims to the Department of Health Care Services (DHCS).
On May 10, 2021, the DHCS issued final All Plan Letter (APL) 21-007 to Medi-Cal managed care plans (MCPs). APL 21-007 calls for a new standard reporting requirement for submitting claims related to TPL cases.
Effective August 8, 2021, the DHCS will require all MCPs to send claims data for covered services under the new process. The new process require the use of a DHCS-approved Excel worksheet. The TPL data must be sent via the DHCS Secure File Transfer Protocol (SFTP) portal.
Responsibilities
CHWP must notify and provide the DHCS with information related to potential and confirmed TPL cases that involve CHWP members. Upon request from the DHCS, providers are required to assist CHWP with the needed information. CHWP will send providers a letter to request TPL claims information and an itemized list of services for affected members. An approved Excel worksheet will be provided by CHWP along with the request for TPL claims data. Providers must follow the instructions in this request.
Providers must supply CHWP with copies of requested documents in the time frame described in CHWP’s request letter. Your quick response is critical in order to deliver the information to DHCS no later than 30 calendar days of the DHCS request.
New DHCS standardized TPL reporting requirements
The new process will replace any existing process of submitting TPL claims data as of August 8, 2021. The new format will combine all claims information in a DHCS-approved Excel worksheet for each Medi-Cal member. All claims data submissions must include the data elements as outlined below.
Field | Description |
|---|---|
MCP/IPA | Name of the PPG or independent physician association (IPA) (the name of the business entity owned by a network of independent physicians) |
Member name | The name of the Medi-Cal member |
Date of birth | The Medi-Cal member's date of birth |
CIN | The Client Index Number (CIN) 9-digit character on the Medi-Cal Benefits Identification Card; It starts with the number “9” and ends with an alpha (A-Z) |
Date of injury | The Medi-Cal member's date of injury |
CCN | A Claim Control Number (CCN) uniquely identifies any processed claims within a specific plan code |
Claim line number | The last two characters of the CCN are the claim line number and they are unique for each service |
Claim type | Identifies the general type of service that was rendered |
Service from date | Identifies the start date of the service on a claim |
Service to date | Identifies the end date of the service on a claim |
Provider legal name | Indicates the provider's legal name |
NPI | The National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare & Medicaid Services |
Diagnosis code 1 | Identifies the diagnosis code for the principal condition requiring medical attention |
Diagnosis code 2 | Identifies the secondary diagnosis code which requires supplementary medical treatment |
Drug label name | Label name of the drug (if claim is for drug) |
Billed amount | Identifies amount billed to the plan from the provider |
Paid amount | Identifies the actual amount paid to the provider for services |
Reasonable value | Identifies the reasonable/customary value of the service provided. Absent the “Amount paid,” due to capitated or other service type, the “Reasonable value” of the service must be provided, pursuant to Title 28, California Code of Regulations (CCR), section 1300.71(a)(3) |
CPT code | Official CPT code used to report medical, surgical, and diagnostic procedures and services; CPT is a registered trademark of the American Medical Association |
CPT type | There are three types of CPT codes: Category 1 (procedures and contemporary medical practices), Category 2 (clinical laboratory services) and Category 3 (emerging technologies, services and procedures); CPT is a registered trademark of the American Medical Association |
Claim deny reason code 1 & description | Primary denial code and description (if claim denied) |
Claim deny reason code 2 & description | Secondary denial code and description (if claim denied) |
Additional information
Providers are encouraged to access CHWP’s provider portal online for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CHWP at 877-658-0305.