Below are some of the common denials we have seen over the years reviewing Medi-Cal receivables for hospitals. 

  • Past Filing Statute: We often receive accounts that are too old to work. Medi-Cal has a one year filing statute, while many health plans have statutes that are as short as 180 or even 90 days (depending on the contract with the hospital). We still spend time reviewing these “past statute” accounts in order to identify any trends, or check hospital notes for any recent activity which could justify a CIF or an Appeal. Sometimes the accounts are simply forgotten about once the initial claim is submitted.
  • Hospital not qualified/approved to provide certain procedures: We have found many instances where the hospital administered services without proper qualification or certification. For example, not all hospitals are approved to bill the Family PACT program, or the “facility type” (Place of Service) is not acceptable for a particular procedure.
  • Patient not qualified/approved to receive certain procedures: On the other hand, we have found that some patients have a limited scope of coverage under the Medi-Cal program. In some cases the patient’s eligibility is restricted to Emergency and/or Pregnancy related diagnoses. In other cases the patient only has Presumptive Eligibility, which qualifies them for a very limited range of services during a specified “presumptive” period of time.
  • Procedure not a benefit of the Medi-Cal Program: We have found that some patients receive services that are completely outside the scope of Medi-Cal coverage altogether. DHS is constantly updating their TAR/Non-Benefit list, and they notify all providers via a monthly bulletin. Some previously-valid codes become expired/deleted on certain dates, while other codes become active/added on specified dates. If the providers do not immediately update their Charge Master with these frequent changes, they risk either administering non-benefit services to Medi-Cal patients or billing perfectly-valid services with codes that have been replaced with new ones.
  • Some procedures not valid with certain diagnoses: Some procedure codes are not valid when billed in conjunction with certain diagnosis codes. Probably the most common combination of this type of problem is when either a urinalysis, fetal monitoring or ultrasound charge is billed in conjunction with a pregnancy related diagnosis code. These are not payable in the Medi-Cal Program. Another common issue we find is with Echocardiography services. These charges are not valid with certain diagnosis codes.
  • Services included in another procedure which paid: We have found that many accounts have balances that are caused by denials for charges that were already included in another procedure that previously paid. A majority of these “previously included” charges comprise certain drugs, supplies, IV’s and injections that are not separately payable.