COUNTY OF LOS ANGELES

DEPARTMENT OF MENTAL HEALTH

NUMBER:

180

DATE:

2/3/2004

PAGE

1 of 2

                         MIS

                INFO-LINE

SUBJECT:             INTEGRATED SYSTEM MEDI-CAL ELIGIBILITY VERIFICATION PROCESS                    

                                        REVISED COPY

DIRECTED TO:     All Providers           

The implementation of the Integrated System will impact many of the Department’s business practices.  We continue to receive questions from staff related to these kinds of issues.  The purpose of this InfoLine is to address Medi-Cal business rules since there have been some questions as to whether or not the Integrated System would force users to check eligibility on a monthly basis.

It is important to remember that although some changes will result from the Integrated System, most changes come from HIPAA, the State and other rules and requirements.  In the case of eligibility determination, the Integrated System is merely the vehicle that will bring providers into line with business rules that already exist but may not have been stringently enforced until now.

The Integrated System provides the HIPAA standard eligibility transaction for clients enrolled in DMH programs to receive DMH services.  DMH will not require providers to use the Integrated System to check Medi-Cal eligibility.  Providers may optionally use the Medi-Cal phone number (AVES), the POS device, the State’s Website, or the MEDS terminal instead, in which case you must include the EVC as part of the claim.  (If you use the IS for eligibility, then the IS transaction puts the EVC in the claim.)  The requirement, to check eligibility at least once a month, is standard business practice and a Medi-Cal requirement.  Originally, the IS required eligibility for each billable service.  This changed, however, since the State only requires monthly verification.

We have also sent out several notices regarding PINs (Provider Identification Number).  This number is assigned to a provider and is required to check Medi-Cal eligibility.  In current practice, units of service entered in the MHMIS will generate a Medi-Cal claim without verifying Medi-Cal eligibility.  After implementation of the Integrated System to submit a Medi-Cal claim you must either verify eligibility through the eligibility transaction in the IS, or you must include the EVC (derived from AVES, POS, the State’s Website, or the MEDS terminal) as part of the claim.  In both cases, you need a PIN.  (Except with the MEDS terminal - each user has a user logon and password).  If you do not have a PIN for your provider, you should go to the DMH Website http://www.dmh.co.la.ca.us, click the link HIPAA and the Integrated System, then Forms and download a copy of ‘Request for Lost PIN’.

We have also received a question as to whether providers need to enter the issue date on the Medi-Cal card each time they check eligibility.  The State eligibility transaction requires the ‘issue date’ of the beneficiary Medi-Cal membership card.  In current practice and in most cases, the State accepts the current date if the client cannot present the actual card.  All existing methods of checking eligibility require the date, including the AVES, the POS device and the State’s web site.  The MEDS terminal does not require the issue date. 

Medi-Cal has recently announced that it will enforce the requirement for the card issue date.  When they do this, providers will be required to determine the card issue date by asking their clients to present the Medi-Cal card or the issue date.  Otherwise the eligibility transaction will fail and the Medi-Cal claim will not be generated by the IS.  Since the negative finding on Medi-Cal eligibility would result in the County not recovering FFP, the IS will generate a message to the user that DMH will not process the claim until valid eligibility credentials are presented. 

Continued on next page.

Contact Person:

CIOB Customer Services Help Desk

Telephone:   (213)

351-2937