When the Indian Health Service Facility provides services
covered by a Medi-Cal managed care plan to members of that plan and the Indian
Health Service Facility does not have a subcontract with the Medi-Cal managed
care plan or has a subcontract but is providing services to members not covered
by the subcontract, the following reimbursement requirements shall
apply:
(a) For Medi-Cal beneficiaries
who are Indians, the Medi-Cal managed care plan shall reimburse the Indian
Health Service Facility for services provided to the beneficiary at the
applicable reimbursement rate that would have been received by the Indian
Health Service Facility if the service has been rendered to a Medi-Cal
beneficiary through the Medi-Cal fee-for-service program.
(b) For Medi-Cal beneficiaries who are not
Indians, the Medi-Cal managed care plan shall reimburse the Indian Health
Service Facility only if the Medi-Cal managed care plan has authorized the
service or if the Medi-Cal managed care plan is obligated by its contract with
the department to pay out-of-plan providers for the service without prior
authorization (e.g., emergency services or family planning services). If
reimbursement is required, reimbursement shall be at the applicable
reimbursement rate that would have been received by the Indian Health Service
Facility if the service had been rendered to a Medi-Cal beneficiary through the
Medi-Cal fee-for-service program.
(c) The Indian Health Service Facility may be
required, as a condition of payment, by the Medi-Cal managed care plan to
submit supporting documentation or specific claim information in a format
acceptable to the Medi-Cal managed care plan, pursuant to the Medi-Cal managed
care plan's out-of-plan claims procedures which are required by the Medi-Cal
managed care plan of any other provider of out-of-plan services. In addition, a
Medi-Cal managed care plan may request from the Indian Health Service Facility,
as a condition of payment, verification of a person's eligibility as an Indian,
as defined in section
55100.
(d) Referrals made by the Indian Health
Service Facility to other providers shall be coordinated with the Medi-Cal
managed care plan. Providers which accept the referrals shall be responsible
for obtaining authorization and payment from the Medi-Cal managed care
plan.
Notes
Cal. Code Regs. Tit. 22, §
55150
1. New
section filed 4-3-98; operative 4-3-98. Submitted to OAL for printing only
pursuant to section
147, Senate Bill 485 (Ch. 722/92)
(Register 98, No. 15).
2. Change without regulatory effect amending
NOTE filed 4-9-98 pursuant to section
100, title 1, California Code of
Regulations (Register 98, No. 15).
Note: Authority cited: Stats. 1992, Ch. 722; Sections
10725,
14089.7,
14105,
14124.5,
14203
and
14312,
Welfare and Institutions Code. Reference: Sections
14000,
14087.3,
14087.5,
14088,
14089,
14089.05,
14200
and
14499.5,
Welfare and Institutions Code; Title 25, United States Code, Sections
13 and
1601; and Title 42, United States
Code, Sections
1396(b)(m)(2)(A)(ix)
and 1396(d)(l)(2).
1. New section filed
4-3-98; operative 4-3-98. Submitted to OAL for printing only pursuant to
section 147, Senate Bill 485 (Ch. 722/92) (Register 98, No. 15).
2.
Change without regulatory effect amending Note filed 4-9-98 pursuant to section
100, title 1, California Code of Regulations (Register 98, No.
15).
