We are currently looking for a Biller and Claims Specialist to join our staff at Macman Management Healthcare Services.

We are looking for an applicant to work closely with our Revenue Cycle (RC) team which is focused on leading successful client results. You will have the challenging and rewarding experience of serving as the strategic revenue improvement leader, who will be capable of providing direct leadership with our clientele. Our goal is to support maximization of systems, workflow, and processes for our clients.  You will diagnose and resolve underlying issues related to outstanding revenue collections problems including capturing lost opportunity.  Your effectiveness as a Revenue Improvement leader will be measured by your ability to work effectively both internally and externally with our team and clients. As member of our RC team your job will develop and monitor written action plans and progress reports as a result of performance deviations from revenue goals and trends.

To learn more about this position go to our Career Opportunities page under the About Us.

The Department of Health Care Services (DHCS) has identified and corrected an issue causing claims billed with CPT-4 code 76805 (ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester [> or = 14 weeks, 0 days], transabdominal approach; single or first gestation) and ICD-10-CM code Z36 (encounter for antenatal screening of mother) to erroneously deny.

This issue affected claims for dates of service on or after October 1, 2015. Providers should continue to submit claims in a timely manner. Affected claims will be reprocessed via an Erroneous Payment Correction (EPC).

Sourced from Medi-Cal.

The Department of Health Care Services (DHCS) identified a claims processing issue causing some radiology claims to erroneously deny.

Claims are being erroneously denied for CPT-4 code 76514 (ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter; corneal pachymetry, unilateral or bilateral [determination of corneal thickness]) when billed with ICD-10-CM diagnosis code Q15.0 (congenital glaucoma).

Claims are also being erroneously denied for CPT-4 code 76800 (ultrasound, spinal canal and contents) when billed with ICD-10-CM diagnosis code Q76.49 (other congenital malformations of spine, not associated with scoliosis).

DHCS has corrected this issue. Providers should continue to submit claims in a timely manner. Affected claims will be reprocessed via an Erroneous Payment Correction (EPC). Providers are encouraged to check the Medi-Cal website regularly for updates.

Medi-Cal, Every Woman Counts (EWC) and Planning, Access, Care and Treatment (Family PACT) Program have not yet adopted the 2016 updates to the Current Procedural Terminology – 4th Edition (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) Level II codes, although they will become effective for Medicare on January 1, 2016.

Providers should not use the 2016 codes to bill for Medi-Cal, EWC and Family PACT services until notified to do so in a future Medi-Cal Update.

Sourced from MediCal.

In July 2015, a Title XIX State Plan Amendment (SPA) took effect stipulating that individuals 19 years of age or younger may only receive up to two Presumptive Eligibility (PE) enrollment periods in a 12-month period from any of the PE programs or combination of programs, such as the Breast and Cervical Cancer Treatment Program (BCCTP), Child Health and Disability Prevention (CHDP) program, Hospital PE program or PE for Pregnant Women program.

The following CHDP Gateway Internet and Point of Service (POS) device response message was implemented to reflect the SPA requirements:

You are not eligible for PE because you have already received two PE enrollments within the past 12 months. Children under 19 years old are limited to two PE enrollments within the past 12 months.If a family applies for PE for a child who has received two PE enrollment periods within the past 12 months, the child will be denied a third PE enrollment. Since the child is not eligible for PE, the family must be referred to apply for Medi-Cal for the child. The application will be reviewed for Medi-Cal eligibility and the family will be notified of the determination. Families may apply for Medi-Cal in the following ways:

  • Online using the Single Streamlined Application at www.coveredca.com;
  • Call the toll-free number to apply by telephone at 1-800-300-1506; or
  • Contacting their local social services agency.

The CHDP Gateway continues granting CHDP eligibility to children who already have emergency Medi-Cal coverage. Individuals who meet the following criteria are eligible for emergency Medi-Cal coverage:

  • 19 years of age or younger
  • At or below 200 percent of the federal poverty level
  • Not enrolled in, but meet the eligibility requirements for emergency Medi-Cal

After establishing emergency Medi-Cal coverage for the child, families may reapply for and enroll the child in the state-only CHDP program through the CHDP Gateway. CHDP program services are limited to well-child health assessments and immunizations in accordance with the most current CHDP periodicity schedule.

Providers should continue to encourage parents and guardians of children receiving presumptive eligibility benefits through the CHDP Gateway to apply for Medi-Cal for their children using the application options listed above.

Effective October 1, 2015, all claims submitted with dates of service/dates of discharge on or after October 1, 2015, with ICD-10-CM/PCS codes are required to include an ICD-10 indicator. Providers should ensure that the value placed in the appropriate claim field for the ICD indicator is a single digit of “0” (zero) for ICD-10-CM/PCS codes.

Since the mid-October announcement of the delay of CA-MMIS Health Enterprise (HE) Release 2.0 provider registration and applicant enrollment for Presumptive Eligibility (PE) programs, the Department of Health Care Services (DHCS) has been diligently conducting a full system analysis to determine a new release date. DHCS is in the process of evaluating the progress of testing deliverables necessary to support system use and readiness for implementation.

Once the full system analysis is complete, and next steps are determined, DHCS will provide further information on timing to impacted providers in the Breast and Cervical Cancer Treatment Program (BCCTP), Child Health and Disability Prevention (CHDP) program and Hospital PE program.

Providers with questions or concerns may call the Telephone Service Center (TSC) Helpdesk at 1-800-541-5555 from 6 a.m. to midnight, Monday through Friday, except holidays. More information on HE updates can be found in the NewsFlash area and the Medi-Cal System Replacement Web page on the Medi-Cal website. To receive timely notifications related to HE, providers may subscribe to the Medi-Cal Subscription Service (MCSS) by completing the MCSS Subscriber Form.

DHCS looks forward to continued collaboration with the provider community.

Sourced from Medi-Cal.

MMHCS is excited to share our Peer review service offerings by our well qualified and trained physicians. We provide these unique services to Federally Qualified Health Centers (FQHC) which is led by our Chief Clinical Consultant Dr. Anil Chawla. Dr. Chawla joins us with 25 plus years of experience working in a FQHC with 20 years of experience as the Chief Medical Officer. She has extensive knowledge and implementation experience with JCAHO / NCQA as well as required expertise in HRSA and OIG regulations.

MMHCS recognizes that Peer Review is a requirement for FQHC as a part of Quality Assurance/performance improvement plan which should be completed once a year. It is a measure of quality of care rendered by providers. Several aspects of Peer review covered in our model of service include medical records review, patient complaints and grievances, adverse clinical outcomes and potential adverse events at inpatient or outpatient level. Peer review data is highly recommended as part of a provider’s performance evaluation and credentialing.

Contact us today to learn more about our new service!

The Department of Health Care Services (DHCS) will soon be implementing the next phase of the CA-MMIS Health Enterprise (HE) system. The current Confidential Screening/Billing Report (PM 160) claim submission process for Child Health and Disability Prevention (CHDP) fee-for-service providers will change.

This upcoming change will impact only CHDP fee-for-service providers who bill using the Confidential Screening/Billing Report (PM 160). Medi-Cal Managed Care Plans, Rural Health Clinics, Federally Qualifies Health Centers and Indian Health Services Memorandum of Agreement 638 Clinics will continue to use the current CHDP process for PM 160 Information only reporting until further notice.

Sourced from Medi-Cal.
On July 31, 2015, Xerox State Healthcare, LLC (Xerox) resolved the system issue that caused some providers to receive an erroneous Resubmission Turnaround Document (RTD) (Form 65-1) with Remittance Advice Detail (RAD) code 0196: This procedure requires a modifier; modifier is not present.  This error occurred for claims submitted with the following CPT-4 codes on or after June 22, 2015, until a solution was implemented on August 1, 2015:

Claims submitted on or after August 1, 2015, with the CPT-4 codes listed above did not receive the error and were processed correctly.

On August 19, 2015, Xerox began reprocessing the impacted claims that generated an erroneous RTD. Providers can expect to see these claims reflected on their warrants beginning August 24, 2015. Additionally, claims for which providers responded to the RTDs and received a denial will be reprocessed in an upcoming Erroneous Payment Correction (EPC).

Sourced from Medi-Cal.