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©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care.. Provided.

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Presentation on theme: "©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care.. Provided."— Presentation transcript:

1 ©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care.. Provided by Coventry Health Care® California Medical Bill Reviewer Re-Certification Unit 2: Official Medical Fee Schedule Module 1: California Fee Schedule

2 CA Regulations Training – CA Fee ScheduleMarch Overview Understand the Different Sections of the California Fee Schedule Understand How to Review Out of State Services Understand the Importance of Timeliness of Payment The California Fee Schedule is complex and provides a great deal of information on how to accurately price medical bills. Understand the Different Sections of the California Fee Schedule Understand How to Review Out of State Services Understand the Importance of Timeliness of Payment In this module, you will learn about the different sections of the Fee Schedule, how to review out of state services, and the importance of timeliness of payment. Lets start by looking at the different sections of the California Fee Schedule...

3 CA Regulations Training – CA Fee ScheduleMarch California Fee Schedule The California Fee Schedule is comprised of several different fee schedules. Fee Schedules - Pursuant to LC and Physician ServicesTitle 8 CCR Inpatient Title 8 CCR & OutpatientTitle 8 CCR , & PharmacyTitle 8 CCR Pathology & LaboratoryTitle 8 CCR DME, P & O, SuppliesTitle 8 CCR AmbulanceTitle 8 CCR

4 CA Regulations Training – CA Fee ScheduleMarch Out of State Services California claims fall under California jurisdiction, however, the claims administrator may opt to reimburse according to where services are rendered. Refer to your client rules when processing bills that include out of state services.

5 CA Regulations Training – CA Fee ScheduleMarch Out of State Services Occasionally a California worker may be injured out of state or move out of state after their injury. In this case, California would still be obligated to pay for medical services, only to an out-of-state provider. Portland, OR Alturas, CA Claims administrators have specific guidelines on how to handle these scenarios.

6 CA Regulations Training – CA Fee ScheduleMarch Out of State Services Consult with the insurer to see what their out of state policy is. The claims administrator will have guidelines on: How to pay these providers. Whether reimbursements should be made per the: California Fee Schedule The Fee Schedule in the Providers state U&C guidelines Contracted rate

7 CA Regulations Training – CA Fee ScheduleMarch Timeliness of Payment The State of California mandates that reimbursement for medical services must be paid within a specific timeframe. Per LC (b): Payment for medical treatment shall be made within 45 working days (60 days if government entity is the employer) after receipt of each separate, itemized billing, together with any required reports. In the absence of proper objection, automatic penalty and interest is required. You should be aware that the client for which you process may have their own timelines for issuing payment that are different from those of the State.

8 CA Regulations Training – CA Fee ScheduleMarch Timeliness of Payment If a provider submits a bill to the claims administrator without proper documentation for his services, the claims administrator must notify the provider in writing of the necessary documentation before payment is made. This must take place within 30 business days. Once the information is received from the provider, the 45-day time period for payment begins again.

9 CA Regulations Training – CA Fee ScheduleMarch Timeliness of Payment If however, all required documentation has been submitted and payment is not made within the required timeframe, the provider is entitled to penalties and interest based on the reimbursement amount. This is a self-imposed fee issued by the administrator to the provider. This is why turnaround time in bill review is so important and something you should be very aware of.

10 CA Regulations Training – CA Fee ScheduleMarch Summary The different sections of the California Fee Schedule. The importance of timeliness of payment. How to review out of state services.


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