CMS NET USER GROUP

MEETING

TOPICS

PEND/DENY INDICATOR

PANELING

CMS NET USER GROUP MEETING

PEND/DENY INDICATOR

PEND/DENY INDICATOR

What is a Pend/Deny Indicator? Procedure codes that should

suspend at EDS for manual review or deny as Medi-Cal non-covered benefits are flagged with a pend/deny indicator.

PEND/DENY INDICATOR

The indicator is date of service specific.

The information in the CMS Net system comes from the procedure master file.

Payment Systems Division has primary responsibility for decisions related to the procedure master file.

PEND/DENY INDICATOR

The CMS Net system will not allow you to authorize a procedure code with a “D” or “T” indicator unless you have override authority.

PEND/DENY INDICATOR

Users who do not have override authority receive an error message when attempting to authorize a procedure code with a “D” or “T” indicator.

PEND/DENY INDICATOR

EDS Definition of IndicatorCode Description

D Deny claim – Not a covered benefit for Medi-Cal (can be overridden with a TAR/SAR).

T Deny – obsolete code (not covered even with a TAR/SAR)

PEND/DENY INDICATOR

“D” Indicator

A CCS SAR will override the “D” indicator in the EDS system.

Reimbursement of the procedure code is the last price on file.

PEND/DENY INDICATOR

“D” Indicator

If there is no price on file, an exception pricing processing form or documentation for manual pricing (e.g. report) is required.

PEND/DENY INDICATOR

“D” Indicator

Identify if there is another procedure code that can be used.

Determine if there is a better alternative. (e.g., using a miscellaneous code and attaching the required information.)

PEND/DENY INDICATOR

“D” Indicator

Use discretion to determine if it is a procedure code that should be authorized.

Verify if there is a price on file and the amount.

PEND/DENY INDICATOR

“T” Indicator

Procedure code is obsolete. An authorization should NOT be issued for a code with a “T” indicator. The provider will not be reimbursed, as the code is not payable and cannot be overridden with a CCS SAR.

PEND/DENY INDICATOR

“T” Indicator

Inform the provider that they have requested authorization for a code that is obsolete and they need to provide a valid code or their request cannot be authorized.

PEND/DENY INDICATOR

Summary

A procedure code with a “D” indicator should be overridden and authorized only on rare circumstances when there is not another option or alternative code.

PEND/DENY INDICATOR

Summary

A procedure code with a “T” indicator should never be overridden.

QUESTIONS?

PANELING

PANELING

What has changed with the implementation of E-47? For most provider types, it is

required the provider have an active Medi-Cal provider number prior to becoming paneled.

PANELING

If you know that a provider was paneled but can not locate them in the new system, it may be because they do not have an active Medi-Cal provider number.

OR

PANELING

The provider did not respond to the CMS letter requesting they complete the form to update their information.

If a provider is paneled in the old system and has a Medi-Cal provider number, contact the Provider Services Unit at (916) 322-8702, to have the provider added in the new system.

PANELING

Emergency Services If a provider has rendered emergency

services and does not meet the paneling requirements, the service code grouping 01 can be issued to the facility now that the facility charges have been included in the service code groupings.

PANELING

The emergency physician should bill using the facilities SAR number.

The physician should indicate the facility as the referring provider and themselves as the rendering provider.

PANELING

The Provider Services Unit is now processing panel applications received the first week of December.

QUESTIONS?