Cal. Code Regs. Tit. 22, § 51502.1 - Requirements for Electronic Claims Submission
(a) As used in this section, the following
definitions shall apply:
(1) "Biller"
includes any employee, officer, agent or director of the entity which will bill
on behalf of a provider pursuant to a contractual relationship with the
provider which does not include payment to billers on the basis of a percentage
of amount billed or collected from Medi-Cal.
(2) "Source Documents" include every document
or record on which the provider or the biller relies to submit a claim, as
described in Title 22, Section
51476. Source documents shall also
include all printed representations of information transmitted as a claim to
the biller or the fiscal intermediary, whether transmitted by the provider or
biller.
(3) "Provider" shall have
the same meaning as in Section
51051 of these
regulations.
(4) "Electronic claims
submission" means that submission of Medi-Cal claims for service on magnetic
tape, computer-to-computer via telephone or other electronic means which are
approved by the Director as being compatible with and acceptable for processing
by the State claims processing system.
(b) Any enrolled provider may request of the
Department authorization to transmit claims to the fiscal intermediary
electronically. The Director shall provide written acknowledgement of
provider's request for electronic claims submission participation within 30
days of receipt of the request. This acknowledgement shall identify additional
information, if any, needed. The Director shall notify the provider in writing
of approval or denial within six months of receipt of the request. In the event
that the request is denied, the written notice shall specifically set forth the
reasons for the denial.
(c) The
Director shall authorize such billing unless the Director determines that the
requesting provider is ineligible for electronic claims submission. In
determining eligibility, the Director shall consider the provider's history of
Medi-Cal provider participation, for the three years preceding provider request
for participation. A provider shall be determined ineligible for electronic
claims submission if during the three years one of the following criteria is
met. The provider has:
(1) Been convicted of
any felony, crime or misdemeanor involving fraud or abuse of the Medi-Cal,
Medicaid or Medicare programs.
(2)
Been convicted of any crime involving dishonesty, corruption, theft, fraud,
kickbacks, rebates or bribes.
(3)
Been found liable or convicted in any civil or criminal legal action involving
misuse of electronic communication mechanisms.
(4) Been the subject of any civil or criminal
proceedings by any private or public entity administering Medi-Cal, Medicaid or
private insurance, which result in one of the following: suspension from the
Medi-Cal program in accordance with Title 22, CAC, Section
51458, placement on special claims
review in accordance with Section
51460, placement on prior
Authorization in accordance with Title 22, CAC, Section
51455, recovery of overpayments in
excess of 10 percent of total provider annual Medi-Cal payments for the most
recent full fiscal year in accordance with Title 22, CAC, Section
51458.1 or the filing of criminal
charges for fraudulent billing of the Medi-Cal program in accordance with
Sections
14107
of the Welfare and Institutions Code and 72 of the Penal Code.
(5) Failed or refused to provide the
Department, its duly authorized agents or agents of other state or federal
agencies charged with the review of state or federal expenditures with patient
records, source documents or other documentation required by statute or
regulation.
(6) Made any false or
misleading statement in patient records, substantiation of claims, requests for
prior authorization, Departmental application or other documentation in
violation of statute or regulation.
(d) Any provider determined by the Director
to be eligible for electronic claims submission may employ a biller certified
by the Director as eligible to perform such billing. The Director shall provide
written acknowledgement of biller request to perform such billing for an
eligible provider within 30 days of application date. This acknowledgement
shall identify additional information, if any, needed. The Director shall
notify biller in writing of approval or denial within six months of request
receipt. In the event such a request is denied the written notice shall specify
reasons for denial. In determining the eligibility of a biller, the Director
shall consider the biller's history of Medi-Cal participation or overall
business activities for the three years preceding participation request
receipt. A biller shall be determined to be ineligible for electronic claim
submission if one of the following criteria is met during the three years
preceding receipt of request for participation. The biller has:
(1) Been convicted of any crime involving
dishonesty, corruption, fraud, computer fraud, embezzlement, larceny, forgery,
falsification of documents, kickbacks, rebates or bribes.
(2) Been found liable or convicted in any
civil, criminal or administrative actions involving illegal use of electronic
communication mechanisms.
(3)
Submitted claims for services not claimed by a provider or for a greater dollar
amount than claimed by a provider under the Medi-Cal, Medicaid, Medicare
programs or any other health insurance carrier.
(4) Entered an agreement for compensation
with any provider based upon percentage or other variable related to the amount
billed or collected from the Medi-Cal, Medicaid, or Medicare programs in
violation of state or federal law.
(5) Failed or refused to produce source
documents for the Department, its duly authorized agents or agents of other
state or federal agencies charged with review of state or federal expenditures
as provided in statute or regulation.
(6) Failed to demonstrate it employs adequate
precautions to protect the confidentiality of Medi-Cal beneficiary records and
claims submission methods in accordance with statute or
regulation.
(e) The
agreement between a provider and a biller shall be in writing and shall be
readily retrievable and available on request to the Department or any duly
authorized agency for Departmental review to ensure compliance with state and
federal standards. Said agreement must in no case contain an agreement for
compensation of the biller based on a formula which has as a factor the
percentage of the amount billed or collected from the Medi-Cal, Medicaid or
Medicare programs in violation of state or federal law.
(f) Any provider or biller eligible for
electronic claims submission shall, prior to engaging in any such billing,
enter into an agreement with the Department specifying the conditions of
participation in such billing methods. This agreement shall be drafted by the
Department. The provider and biller shall agree to conditions which shall
include, but not be limited to, the following:
(1) Any and all source documents used in
documenting, preparing or submitting claims shall be retained in a manner
readily retrievable and shall be made available to agents of the Department or
any other duly authorized agency on request during normal business hours.
Out-of-state providers may be required to produce source documents at a
location designated by the Department within the State of California.
(2) All source documents shall be maintained
for a period of at least three years from the date received by the FI for
payment, as specified by Title 22, CAC, Section
51476.
(3) Source documents, originals or on
microfilm/microfiche, shall show the identification of the person or persons
who actually rendered the service claimed. All providers shall have on file a
printed representation of all information transmitted electronically as a claim
by the provider to the biller or the fiscal intermediary. All billers shall
produce a printed representation of all information transmitted electronically
as a claim by the provider to the biller on demand of the Department or any
other authorized agency.
(4) Any
instructions between a provider and a biller related to the submission of
Medi-Cal claims shall be in writing and available for inspection.
(5) Claims shall not be processed until such
time as the Department's fiscal intermediary receives, verifies and posts a
Claims Certification Statement and Control Sheet, which shall include all of
the following:
(A) A certification of the
truth and accuracy of each claim.
(B) The number and total dollar amount of
claims submitted.
(C) Such
beneficiary identification as the Department may require.
(D) The signature of the provider or the
provider's agent.
(6) The
Department shall be promptly notified by the provider of any changes in a
provider's or biller's status which might affect such person's ability to
participate in electronic billing methods.
(7) The provider shall be responsible for
ensuring that all remittances and paid claims information are reviewed and that
corrections for any overpayments are promptly pursued through the Department's
Fiscal Intermediary within the applicable limits of Section
51008(d) of Title
22, CAC.
(8) The provider shall
bill those services requiring submission of a MEDI label or other attachment
with the claim in accordance with Department billing instructions including
instructions regarding structuring the remarks section in a format compatible
with electronic data submission.
(g) No provider or potential biller shall
submit claims electronically without first securing the approval of the
Department for the system to be used for claims submission. In reviewing a
proposed billing system, the Department may request submission of a test
billing and consider the:
(1) Compatibility
with and acceptability for processing by the State claims processing
system.
(2) Provider's or potential
biller's system for maintaining adequate documentation to support the services,
claims and medical necessity thereof.
(h) The test billing and signed
provider/biller agreements shall constitute formal request for participation in
the electronic claims submission program.
(i) Ongoing approval of the billing system is
contingent upon maintenance of the system as approved by the Department under
subsection (g). Failure to do so shall be considered grounds for the Department
to disapprove the provider or biller for the submission of claims
electronically.
(j) Failure or
refusal of a provider or a biller to continue to comply with the standards of
participation set forth in subsections (c) through (g) shall subject a provider
or biller to immediate suspension from participation in the electronic claims
submission program. For purposes of applying the standards set forth in those
subsections (c) and (d), suspension will occur if one of the events set forth
in those subsections has occurred during the three year period prior to the
proposed suspension. Notification of the suspension shall be in writing. The
provider or biller has the right to appeal the suspension in writing within 30
days of the date of notification. The Department shall review the appeal and
any supporting documents in accordance with the time frames and procedures
specified in Section
51015(d) of these
regulations.
Notes
2. Order of Repeal of 6-29-84 emergency language filed 11-28-84 by OAL pursuant to Government Code Section 11349.6(b) (Register 84, No. 48).
3. New section filed 3-18-85 as an emergency; effective upon filing (Register 85, No. 14). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 7-16-85.
4. Certificate of Compliance including amendment of subsection (c)(4) filed 7-15-85 (Register 85, No. 29).
5. Amendment of subsection (f)(2) and new subsection (j) filed 4-24-87; operative 5-24-87 (Register 87, No. 17).
6. Amendment of subsection (a)(3) and NOTE filed 9-28-99 as an emergency; operative 9-28-99 (Register 99, No. 40). A Certificate of Compliance must be transmitted to OAL by 3-27-2000 or emergency language will be repealed by operation of law on the following day. Submitted to OAL for printing only pursuant to section 78, AB 1107 (Chapter 146, Statutes of 1999).
7. Amendment of subsection (a)(3) and NOTE refiled 11-24-99 as an emergency; operative 11-24-99 (Register 99, No. 48). A Certificate of Compliance must be transmitted to OAL by 5-22-2000 or emergency language will be repealed by operation of law on the following day. Submitted to OAL for printing only pursuant to section 78, AB 1107 (Chapter 146, Statutes of 1999).
8. Amendment of subsection (a)(3) and NOTE refiled 5-5-2000 as an emergency; operative 5-22-2000 (Register 2000, No. 18). A Certificate of Compliance must be transmitted to OAL by 9-19-2000 or emergency language will be repealed by operation of law on the following day.
9. Amendment of subsection (a)(3) and NOTE refiled 8-28-2000 as an emergency; operative 9-6-2000 (Register 2000, No. 35). A Certificate of Compliance must be transmitted to OAL by 1-4-2001 or emergency language will be repealed by operation of law on the following day.
10. Certificate of Compliance as to 8-28-2000 order transmitted to OAL 12-26-2000 and filed 2-8-2001 (Register 2001, No. 6).
Note: Authority cited: Sections 10725, 14040, 14105 and 14124.5, Welfare and Institutions Code; and Section 78, Chapter 146, Statutes of 1999. Reference: Sections 14040, 14100.2, 14107, 14115, 14124.1, 14124.2 and 14170, Welfare and Institutions Code.
2. Order of Repeal of 6-29-84 emergency language filed 11-28-84 by OAL pursuant to Government Code Section 11349.6(b) (Register 84, No. 48).
3. New section filed 3-18-85 as an emergency; effective upon filing (Register 85, No. 14). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 7-16-85.
4. Certificate of Compliance including amendment of subsection (c)(4) filed 7-15-85 (Register 85, No. 29).
5. Amendment of subsection (f)(2) and new subsection (j) filed 4-24-87; operative 5-24-87 (Register 87, No. 17).
6. Amendment of subsection (a)(3) and Note filed 9-28-99 as an emergency; operative 9-28-99 (Register 99, No. 40). A Certificate of Compliance must be transmitted to OAL by 3-27-2000 or emergency language will be repealed by operation of law on the following day. Submitted to OAL for printing only pursuant to section 78, AB 1107 (Chapter 146, Statutes of 1999).
7. Amendment of subsection (a)(3) and Note refiled 11-24-99 as an emergency; operative 11-24-99 (Register 99, No. 48). A Certificate of Compliance must be transmitted to OAL by 5-22-2000 or emergency language will be repealed by operation of law on the following day. Submitted to OAL for printing only pursuant to section 78, AB 1107 (Chapter 146, Statutes of 1999).
8. Amendment of subsection (a)(3) and Note refiled 5-5-2000 as an emergency; operative 5-22-2000 (Register 2000, No. 18). A Certificate of Compliance must be transmitted to OAL by 9-19-2000 or emergency language will be repealed by operation of law on the following day.
9. Amendment of subsection (a)(3) and Note refiled 8-28-2000 as an emergency; operative 9-6-2000 (Register 2000, No. 35). A Certificate of Compliance must be transmitted to OAL by 1-4-2001 or emergency language will be repealed by operation of law on the following day.
10. Certificate of Compliance as to 8-28-2000 order transmitted to OAL 12-26-2000 and filed 2-8-2001 (Register 2001, No. 6).
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