Cal. Code Regs. Tit. 22, § 51005 - Other Health Care Coverage
(a) Wherever beneficiaries eligible for
benefits under this program are also eligible for the same benefits, either
full or partial, under any other State or Federal medical care program or under
other contractual or legal entitlement, including but not limited to a private
group or indemnification insurance program or the Federal Medicare program, the
Department shall require the full utilization of benefits available through the
other programs, before utilizing Medi-Cal covered benefits. This requirement
shall not apply to beneficiaries covered under Medi-Cal capitated contracting
arrangements except to the extent permitted under the capitated contract.
(1) The maximum reimbursement by Medi-Cal for
services rendered to beneficiaries with other State, Federal, or private health
care coverage shall be the reimbursement calculated on a claim for similar
services established under chapter 7 (sections
14000 through
14199) of the Welfare and
Institutions Code, less the amount of the payment made by the other State,
Federal, or private health care program.
(2) Where a claim for medical services
involves coverage under both the Medicare and Medi-Cal programs, the maximum
reimbursement by Medi-Cal shall be the amount established for similar services
under chapter 7 (sections
14000 through
14199) of the Welfare and
Institutions Code, less the amount paid by Medicare. In the event the
Department cannot for any reason establish the amount it would have paid for
similar services, the maximum reimbursement shall be the amount of the Medicare
deductible and coinsurance claimed.
(b) If the billing information is different
from what appears on the Medi-Cal card, or is not on the Medi-Cal card a
provider of services shall notify the Department of any other health care
coverage of a Medi-Cal beneficiary within 60 days of learning such entitlement
exists. The information shall include the name and Medi-Cal identification
number of the beneficiary, the insured and the name of the health insurance
carrier providing the beneficiary's other health care coverage; the policy and
group number, and termination date, if available. This information shall be
provided to the Department's Health Insurance Unit referral desk via the toll
free telephone number 1-800-952-5294 as published in the Medi-Cal Provider
Manuals and Provider Bulletins.
(c)
If the Department has established probable existence of third party liability
before a claim is filed, the Department's fiscal intermediary shall, as
directed by the Department, deny provider claims submitted for a beneficiary
who has other health care coverage in effect unless the claim is accompanied by
a notice of denial of liability, proof of termination of coverage, or partial
payment notice. The provider shall first seek payment from the beneficiary's
other health care coverage prior to submitting a claim to the
Department.
(d) When the Department
has paid for services and other health care coverage benefits are available as
enumerated in subsection (a), the Department may recover payment for those
services from the liable party.
(e)
Whenever the Department receives payment for a health care service provided to
a beneficiary which is in excess of both the amount which the Department has
expended on behalf of the beneficiary for said service, and the administrative
costs incurred in the collection of such payment, the excess shall be returned
to the payor who made the payment.
Notes
2. New subsections (b), (c) and (d) filed 7-13-73; effective thirtieth day thereafter (Register 73, No. 28).
3. New NOTE filed 8-30-84 (Register 84, No. 35).
4. Amendment filed 6-28-89; operative 7-28-89 (Register 89, No. 26).
5. Amendment of subsection (a) filed 1-29-90 as an emergency; operative 1-29-90 (Register 90, No. 5). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed by operation of law on 5-29-90.
6. Change without regulatory effect pursuant to section 100(b)(3), Title 1, California Code of Regulations amending subsections (a)(1) and (2), filed 6-5-90 (Register 90, No. 30).
7. Amendment of subsections (a)(1) and (2) refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A Certificate of Compliance must be transmitted to OAL by 11-6-90 or emergency language will be repealed by operation of law on the following day.
8. Certificate of Compliance as to 1-29-90 order transmitted to OAL 10-24-90 and filed 11-26-90 (Register 91, No. 2).
Note: Authority cited: Sections 10725, 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14000, 14005, 14023, 14023.7, 14024, 14109.5, 14124.90 and 14490, Welfare and Institutions Code; and Chapter 93, Statutes of 1989.
2. New subsections (b), (c) and (d) filed 7-13-73; effective thirtieth day thereafter (Register 73, No. 28).
3. New NOTE filed 8-30-84 (Register 84, No. 35).
4. Amendment filed 6-28-89; operative 7-28-89 (Register 89, No. 26).
5. Amendment of subsection (a) filed 1-29-90 as an emergency; operative 1-29-90 (Register 90, No. 5). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed by operation of law on 5-29-90.
6. Change without regulatory effect pursuant to section 100(b)(3), Title 1, California Code of Regulations amending subsections (a)(1) and (2), filed 6-5-90 (Register 90, No. 30).
7. Amendment of subsections (a)(1) and (2) refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A Certificate of Compliance must be transmitted to OAL by 11-6-90 or emergency language will be repealed by operation of law on the following day.
8. Certificate of Compliance as to 1-29-90 order transmitted to OAL 10-24-90 and filed 11-26-90 (Register 91, No. 2).
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