Claims Procedures

Claims Submission

California Health and Wellness requires that Enhanced Care Management/Community Service (ECM/CS) providers submit fee-for-service professional/outpatient claims on the paper CMS-1500 claim form, EDI 837 professional, outpatient, or California Health and Wellness invoice form.

California Health and Wellness prefers that all claims be submitted electronically. Refer to electronic claims submission for more information.

For providers unable to send claims electronically, paper claims are accepted if on the proper type of form. Requirements for paper forms are described below.

Providers billing for professional services, and medical suppliers, must complete the CMS-1500 (version 02/12) form. The form must be completed in accordance with the guidelines in the National Uniform Claim Committee (NUCC) 1500 Claim Form Reference Instruction Manual Version 5.0 7/17.

If non-compliant, paper claims follow the same editing logic as electronic claims and will be rejected with a letter sent to the provider indicating the reason for rejection. When billing CMS-1500, California Health and Wellness only accepts standard claim forms printed in Flint OCR Red, J6983 (or exact match) ink.

Paper claim forms must be typed in black ink in either 10 or 12 point Times New Roman font, and on the required original red and white version of the form, to ensure clean acceptance and processing.

Claims submitted on black and white, handwritten or nonstandard forms will be rejected and a letter will be sent to the provider indicating the reason for rejection. These claims will not be returned to the provider. To reduce document handling time, providers must not use highlights, italics, bold text, or staples for multiple page submissions.

Copies of the form cannot be used for submission of claims, since a copy may not accurately replicate the scale and OCR color of the form. California Health and Wellness Plan does not supply claim forms to providers. Providers should purchase these forms from a supplier of their choice.

Providers unable to bill on CMS-1500 (02/12) must complete the California Health and Wellness Plan Invoice form. The form must be completed in accordance with the California Health and Wellness Plan invoice submission instructions.

All paper CMS-1500 (02/12) claims and supporting information must be submitted to:

All paper California Health and Wellness Invoice forms and supporting information must be submitted to:

• Email: CalAIM_CS_invoicesubmission@centene.com
• Address:
  California Health and Wellness Plan – Cal AIM Invoice
  PO Box 10439
  Van Nuys, CA 91410-0439
• Fax: (833) 386-1043
• Web Portal

Timely Filing of Claims

California Health and Wellness Plan will waive the Timely Filing of Claims for a reasonable period in the event that the provider provides notice to California Health and Wellness Plan, along with appropriate evidence, of extenuating circumstances that resulted in the delayed submission. California Health and Wellness Plan will determine extenuating circumstances and the reasonableness of the submission date. This in no way limits California Health and Wellness Plan's ability to provide incentives for prompt submission of claims.

Complete Claim Definition

CMS-1500 (02/12)

A complete claim is a claim, or portion of a claim, that is submitted on a complete format adopted by the National Uniform Billing Committee and which includes attachments and supplemental information or documentation that provide reasonably relevant information, or necessary information, to determine payer liability.

Important Note: We require that all facility claims be billed on the UB-04 form.

California Health and Wellness Plan uses the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual as the standard source for codes and code descriptions to be entered in the various form locators (FL). The National Uniform Billing Committee's UB-04 Data Specifications Manual is available here.

Coding
Correct coding is key to submitting valid claims. To ensure claims are as accurate as possible, use current valid diagnosis and procedure codes and code them to the highest level of specificity (maximum number of digits) available.

Diagnosis Coding
The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), is currently used to code diagnostic information on claims. Multiple entities publish ICD-10-CM manuals and the full ICD-10-CM is available for purchase from the American Medical Association (AMA) bookstore on the Internet.

Procedure Coding
Use Healthcare Common Procedure Coding System (HCPCS) Level I and II codes to indicate procedures on all claims, except for inpatient hospitals. ICD-10-CM codes are used for procedure coding on inpatient hospital Part A claims.

For all other uses, Level I Current Procedural Terminology (CPT-4) codes describe medical procedures and professional services. CPT is a numeric coding system maintained by the AMA. The CPT code book is available from the AMA bookstore on the Internet.

California Health and Wellness Plan invoice form – List of required fields from the state final rule billing guides for Community Services.

Claims Submission Instructions CMS-1500 (02/12)

Mandatory Items for ECM and CS Claims Submission

All professional and institutional claims require the following mandatory items:

• Appropriate type of insurance coverage (box 1 of the CMS-1500).
• Billing provider tax identification number (TIN), address and phone number.
• Billing provider National Provider Identifier (NPI).
• Place of service (professional).
  • Original submission is indicated with a 1 in claim frequency box or resubmission code (box 22).
  • Codes 7 and 8 should be used to indicate a corrected, voided or replacement claim and must include the original claim ID.
• Patient name, California Health and Wellness Plan identification (ID) number, address, sex, and date of birth (MM/DD/YYYY format) must be included. If the subscriber is also the patient, only the subscriber data needs to be submitted. If different, then submit both subscriber and patient information.
• Other health insurance information and other payer payment, if applicable.
• Patient or subscriber medical release signature/authorization.
• Accept assignment (box 13 of the CMS-1500).
• Referring provider name and NPI.
• Rendering/attending provider NPI and authorized signature.
• Primary diagnosis code and all additional diagnosis codes (up to 12 for professional; up to 24 for institutional) with the proper ICD indicator (only ICD 10 codes are applicable for claims with dates of service on and after October 1, 2015).
• Diagnosis pointers are required on professional claims and up to four can be accepted per service line.
• Diagnosis codes, revenue codes, CPT, HCPCS, modifiers, or HIPPS codes that are current and active for the date of service. Claims with incomplete coding, or having expired codes, will be contested as invalid or incomplete claims.
• Authorization, if applicable, should be sent in the 2300 Loop, REF segment with a G1 qualifier for electronic claims (box 23 for CMS-1500).
• Referral information, if applicable.
• Service line date required for professional and outpatient procedures.
• Charges for listed services and total charges for the claim.
• Days or units.
• Name and address of service location.

This is not meant to be a fully inclusive list of claim form elements. Additional fields may be required, depending on the type of claim, line of business and/or state regulatory submission guidelines.

To avoid possible denial or delay in processing, the above information must be correct and complete.

The following providers must include additional information as outlined:

• Non-primary care providers: The first and last name of the referring physician and the referral number given by the referring physician or participating physician group (PPG) (include state license number if available). The only exceptions are anesthesia and assistant surgeon claims described in Specific Billing Requirements.
• Providers not specified: A properly completed paper or electronic billing instrument submitted in accordance with California Health and Wellness Plan's specifications and any state-designated data requirements included in statutes or regulations.

Claims Submission Instructions – California Health and Wellness Plan Invoice form

A separate invoice is required for:

• Each Member.
• Different Billing or Rendering Provider.
• Service lines needed exceed six (6).

To optimize the use of the invoice form capabilities intended to ease the invoice creation process, download the form to your computer and open using a PDF reader. This will allow the use of built-in functions that are not consistently available when the PDF opens in Windows Explorer or Edge, Google Chrome, Mozilla Firefox, or Apple's Safari. A free version of Adobe's PDF Reader is available here.

The form is fillable by simply typing in the field and tabbing to the next field. When possible, values are provided to improve accuracy and minimize risk of errors on submission.

All invoices require the following mandatory items which are identified by the red asterisk *:

• Billing provider's National Provider Identifier (NPI).
• Billing provider's Tax Identification Number (TIN).
• Billing provider's last name, or Organization's name, address, phone number.
• Rendering provider's Tax Identification Number (TIN).
• Rendering provider's last name, or Organization's name, address, phone number.
• Member's Client Identification Number (CIN).
• Member's last and first name, date of birth, and residential address.
• Member's signature (Insured's or Authorized Person's Signature).
• Payor's Primary ID.
• Diagnosis code(s) (may enter up to 10).
• Service start date.
• Service end date.
• Place of service.
• Procedure.
• Modifier(s).
• Diagnosis # (Pointer reference to the specific Diagnosis code(s) from the previous section).
• Service unit count & cost.
• Administrative information:
  • Invoice date and number.
  • Provider signature & date.

To ensure timely and accurate processing, completion of the following items is strongly recommended:

• Billing provider's first name.
• Rendering provider's National Provider Identifier (NPI).
• Rendering provider's first name.
• Member's homeless indicator.
• Payor's name.
• Service name.
• Administrative information:
  • Control number.
  • Attachments (indicator yes/no).
  • Authorization number (include if an authorization was obtained).
  • Submission type.
  • Original claim ID (should include for Submission types: Resubmission and Corrected Billing).

Upon completion of the form, if the invoice will be submitted via Email or Upload, simply click on the corresponding link at the top right of the form to activate opening an email client with the email address populated or a web browser with the website/URL opened.

Invoice form downloads

California Health and Wellness Plan

• California Health and Wellness ECM and Community Supports Invoice Claim Form (PDF)
• California Health and Wellness ECM and Community Supports Invoice Claim Form (XLSX)

Paper Claims Submission Rejections and Resolutions

• Medical Paper Claims Submission Rejections and Resolutions (PDF)

Claims Coding Practice

Non-participating providers are expected to comply with standard coding practices. California Health and Wellness Plan uses code auditing software to improve accuracy and efficiency in claims processing, payment, and reporting. The software detects and documents coding errors on provider claims prior to payment by analyzing CPT/HCPCS, ICD-10, modifiers and place of service codes against correct coding guidelines. The following sources are utilized in determining correct coding guidelines:

• Centers for Medicare & Medicaid Services (including NCCI, MUE, and Claims Processing Manual guidelines)
• Public domain specialty provider associations (such as American College of Surgeons, American Academy of Orthopaedic Surgeons, etc.).
• State provider manuals and fee schedules.
• American Medical Association (CPT, HCPCS, and ICD-10 publications).
• Health plan policies and provider contract considerations.
• Clinical consultants who research, document, and provide edit recommendations based on the most common clinical scenario.
• In addition to nationally recognized coding guidelines, the software has flexibility to allow business rules that are unique to the needs of individual product lines.

California Health and Wellness Plan may request medical records or other documentation to verify that all procedures/services billed are properly supported in accordance with correct coding guidelines.

Specific ECM and CS Billing Requirements

The following are billing requirements for specific services and procedures.

• All Services: Prior authorizations are required for all contracted and non-contracting provider claims except in certain emergent situations.
• Providers submitting multiple CMS-1500 successor forms must staple the completed forms together and number the pages appropriately.
• Modifier GQ will need to be added when billing for phone/telephonic services in addition to the HCPC & modifier combination identified below.

Provider Contact Information

Acknowledgment of Claims

California Health and Wellness Plan acknowledges electronically submitted claims, whether or not the claims are complete, within two business days via a 277CA to the clearinghouse following receipt. California Health and Wellness Plan acknowledges paper claims within 15 business days following receipt for Medi-Cal claims. If a paper claim is paid or denied within 15 days, the Remittance Advice (RA) is the acknowledgment of claims receipt. A provider may obtain an acknowledgment of claim receipt in the following manner:

• Medi-Cal claims: Confirm claims receipt(s) by calling the Medi-Cal Provider Services Center at 1-800-675-6110.

Claims received from a provider's clearinghouse are acknowledged directly to the clearinghouse in the same manner and time frames noted above.

Date of receipt

Date of receipt is the business day when a claim is first delivered, EDI, electronically via email, portal upload, fax, or physically, to California Health and Wellness Plan's designated address for submission of the claim.

Reimbursement of Claims

California Health and Wellness Plan reimburses each complete claim, or portion thereof, from a provider of service no later than:

• 45 business days for Medi-Cal plans

This time frame begins after receipt of the claim unless the claim is contested or denied. California Health and Wellness Plan reserves the right to adjudicate claims using reasonable payment policies and non-standard coding methodologies. These policies and methodologies are consistent with available standards accepted by nationally recognized medical organizations, federal regulatory bodies and major credentialing organizations.

Denied or Contested Claims

California Health and Wellness Plan notifies the provider of service, in writing, of a denied or contested Medi-Cal claim no later than 45 business days after receipt of the claim.

Date of contest or date of denial is the electronic mark or postmark date indicating the date when the contest or denial was transmitted electronically or mailed by U.S. mail.

A contested claim is one that California Health and Wellness Plan cannot adjudicate or accurately determine liability because more information is needed from either the provider, the claimant or a third party.

Incomplete claims or claims that require additional information are contested in writing by California Health and Wellness Plan in the form of an Explanation of Payment/Remittance Advice (EOP/RA), which may in some circumstances be followed by additional written communication within the timeframes noted above.

If California Health and Wellness Plan needs additional information before the claim can be adjudicated, the necessary information must be submitted within 365 days of the date of the EOP/RA that reflects the contested claim, in order to have the claim considered by California Health and Wellness.

The EOP/RA for each claim, if wholly or partially denied or contested, includes an explanation of why
California Health and Wellness Plan made its determination. Supplemental notices to contest the claim, describing the missing information needed, is sent to the provider within 24 hours of a determination.

If California Health and Wellness Plan has contested a claim, each EOP/RA includes instructions on how to submit the required information in order to complete the claim. Each EOP/RA reflecting a denied, adjusted or contested claim includes instructions on the department to contact for general inquiries or how to file a provider dispute, including the procedures for obtaining provider dispute forms and the mailing address for submission of the dispute.

Interest on Late Payment of Claims

Medi-Cal Claims

Late payments on complete Medi-Cal claims that are neither contested nor denied automatically include interest at the rate of 15 percent per year for the period of time that the payment is late.

The late payment on a complete Medi-Cal claim for emergency room (ER) services that is neither contested nor denied automatically includes the greater of $15 for each 12-month period or portion thereof on a non-prorated basis, or interest at 15 percent per year for the period of time that the payment is late.

If California Health and Wellness Plan does not automatically include the interest fee with a late-paid complete Medi-Cal claim, an additional $10 is sent to the provider of service.

Overpayment of Claims

The California Health and Wellness Plan Provider Services Department is available to assist with overpayment inquiries. A provider who has identified an overpayment should send a refund with supporting documentation to:

California Recoveries Address:
California Health and Wellness Plan Overpayment Recovery Department
Claims Refunds
PO Box 886027
Los Angeles, CA 90088-6027

If California Health and Wellness Plan identifies an overpayment due to a processing error, coordination of benefits, subrogation, member eligibility, or other reasons, a notice is sent that includes the following:

• Member's name and ID number
• Provider's account number
• Date of service
• Amount of overpayment
• California Health and Wellness Plan's payment date
• Detailed reason for the refund request

Failure to comply with timely filing guidelines when overpayment situations are the result of another carrier being responsible does not release the provider from liability.

If the overpayment request is not contested by the provider, and California Health and Wellness Plan does not receive a full refund or an agreed-upon satisfactory repayment amount within 45 days from the date of the overpayment notification, a withhold in the amount of the overpayment may be placed on future claim payments.

Provider Dispute

Whenever possible, California Health and Wellness Plan strives to informally resolve issues raised by providers at the time of the initial contact. If an issue cannot be resolved informally by a customer contact associate, California Health and Wellness Plan offers its nonparticipating providers a dispute and appeal process.

Provider Dispute Resolution Process