Claims Submissions and Status

 

Claims Submission and Payment Inquiries Paper claims should be submitted to the Claims Department.  For claim payment inquiries and information regarding electronic claim submission, please contact the Claims Department.  For verification of claims receipt by PHP, please contact the Claims Department.

 

Physician Fee Schedule

PHC California is a Medi-Cal managed care plan and follows Medi-Cal fee schedules unless a differing reimbursement rate is contracted.  (By clicking on the link above, you will go to the Medi-Cal website which is operated by the California Department of Health Care Services and not PHC California.)

Initial Claim Submission

Claims for services provided to members assigned to PHC California with the exception of inpatient services (see below) must be submitted on the appropriate billing form (CMS1500, UB04, etc.) within ninety (90) calendar days, or as stated in the written service agreement with PHC California.  The provider is responsible to submit all claims to PHC California within the specified timely filing limit.  PHC California may deny any claim billed by the provider that is not received within the specified timely filing limit.

The following information must be included on every claim:

1. Provider name
2. Provider address
3. Patient name
4. Patient date of birth
5. Patient ID
6. Date(s) of service
7. All ICD10 diagnosis code(s) present upon visit
8. Revenue, CPT, HCPCS code for service or item provided
9. NDC(s) for any drugs provided
10. Billed charges
11. Place of service or UB04 bill type code
12. Tax ID number
13. NPI number
14. Name and state license number of rendering provider

Claims that do not meet the criteria described above will be returned to the provider indicating the necessary information that is missing.  PHC California will process only legible claims received on the proper claim form that contains the essential data elements described above.

Only current standard procedural terminology is acceptable for reimbursement per the following coding manuals:

• Current Procedural Terminology (CPT) for physician procedural terminology
• International Classification of Diseases (ICD10-CM) for diagnostic coding
• Health Care Procedure Coding System (HCPC)

CMS-1500 paper claim submissions must be submitted on form OMB-0938-0999(08-05) as noted on the document’s footer.  We accept the revised CMS-1500 and UB-04 forms printed in Flint OCR Red, J6983, (or exact match) ink.

To ensure timely claim processing, PHC California requires that adequate and appropriate documentation be submitted with each claim filed.

Documentation required with a CMS1500 or UB04 claim form:

Documentation	Applies to
Other coverage explanation of benefits	All Providers
Dialysis log	Dialysis Service
Doctor’s orders, nursing or therapy notes	Home Health
Full medical record with discharge summary	Hospital
Consult, procedures report	Physician
Emergency room report	Emergency Medicine Physician
Operative report	Surgeon
Minimum Data Set (MDS) Assessment	Skilled Nursing Facility

Standard Code Sets

Standard Code Sets as required by HIPAA are the codes used to identify specific diagnosis and clinical procedures on claims and encounter forms.  All providers are required to submit claims and encounters using current HIPAA compliant codes, which include the standard CMS codes for ICD10, CPT, HCPCS, NDC and CDT, as appropriate.

Information for Obtaining an NPI

To obtain a national provider identifier (NPI) you may:

• Telephone: (800) 465-3203 or TTY: (800) 692-2326
• E-mail [email protected]
• Mail to NPI Enumerator P.O. Box 6059 Fargo, ND 58108-6059
• Refer to CMS’s NPI information (By clicking this link, you will be taken to the Centers for Medicare and Medicaid Services’ website.)

Claim Definitions

Clean Claim — A “clean claim” is defined as a claim for services submitted by a practitioner that is complete and includes all information reasonably required by PHC California, and as to which request for payment there is no material issue regarding PHC California’s obligation to pay under the terms of a managed care plan.

Timely Filing Limit — The claim’s “Timely Filing Limit” is defined as the calendar day period between the claim’s last date of service, or payment/denial by the primary payer, and the date by which PHC California must first receive the claim.

Received Date — The “Received Date” is the oldest PHC California date stamp on the claim.  Acceptable date stamps include any of the following:

• PHC California’s Claims department date stamp,
• Primary payer claim payment/denial date

Claims Processing

Claims will be paid to contracted providers in accordance with the timeliness provisions set forth in the provider’s contract and/or by applicable California Law.  Unless the subcontracting provider and contractor have agreed in writing to an alternate payment schedule, claims will be adjudicated as follows:

• For clean claims, expect reimbursement within 45 days of PHC California’s receipt of the claim if submitted on paper
• You will receive an Explanation of Benefits (EOB) that details how each service is paid
• You will receive an Explanation of Payment and Recovery Detail (EOPRD) when PHP identifies a previous claim overpayment

Submission of Inpatient Claims

Inpatient services are carved out of PHC California’s contract with the California Department of Health Care Services (DHCS).  Inpatient services must be authorized on a paper Treatment Authorization Request (TAR) form and submitted to PHC California’s Utilization Management Department.  Approved TARs must accompany claims submission to DHCS following DHCS’s guidance.  See the Medi-Cal website for the Inpatient Services provider manual.  (By clicking on the link above, you will go to the Medi-Cal website which is operated by the California Department of Health Care Services and not PHC California.)

DHCS 030716 PHC Form 1.0