Medicaid can be challenging to properly bill and collect for vision care services. Optometrists and ophthalmologists with Medicaid patients need to be aware of specific payor nuances and correct methods to avoiding denials and get reimbursed for their services. I recently attended a seminar for California’s Medicaid program (Medi-Cal), and learned some interesting tidbits. Medi-Cal recently compiled data from their denial records to track the 10 most common denials for vision care claims. Here they are by top denial (#1-#10), RAD Code, and corresponding denial message.

(#1) – 0139 – Procedure/service is invalid for claim type on date of service (#2) – 0314 – Recipient is not eligible for month of service billed (#3) – 0036 – RTD (Resubmission Turnaround Document) was either not returned or was returned uncorrected; therefore, your claim is formally denied (#4) – 0002 – The recipient is not eligible for benefits under the Medi-Cal program or other special programs. (#5) – 0033 – The recipient is not eligible for the special program billed and/or restricted services billed. (#6) – 0392 – Rendering provider number/license number is not on the Provider Master File. Contact rendering provider to verify number. (#7) – 0042 – Date of service is missing or invalid. (#8) – 0062 – The facility type/Place of Service is not acceptable for this procedure. (#9) – 0351 – Additional benefits are not warranted per Medi-Cal regulations. (#10) – 0010 – This service is a duplicate of a previously paid claim.

The proper follow-up procedures for these vision care claim denials depend on the type of denial message and the underlying problem with the claim. The source of the problem may be easily found through simply review and follow-up. Here are some follow-up procedures suggested and billing tips for each RAD Code:

0139 – Rebill the claim
*Check if procedure code is valid; Check date of service; Read provider manual for billing changes*
0314 – Submit appeal within 90 days
*Verify date of service on the claim; Verify recipient’s eligibility; If recipient has a Share of Cost, then collect and spend it down; Refer to Share of Cost section in Part 2 of provider manual*
0036 – Rebill the claim
*Return the RTD by the date indicated at top of RTD; If claim was resubmitted, disregard the denial.*
0002 – Submit appeal within 90 days
*Verify recipient’s eligibility; Check recipient’s date of birth and date of issue on the BIC card; Verify that recipient’s 14-character BIC number matches the number billed on the claim and/or the RAD*
0033 – Submit appeal within 90 days
*Verify recipient’s eligibility; Check recipient’s eligibility; Verify recipient is enrolled in the appropriate programs; Refer to provider manual under Services Restrictions section of Part 1 of manual for restricted codes and messages.*
0392 – Submit appeal within 90 days
*Check NPI; Verify if provider is in Provider Master File for the particular services billed; Check if provider is still active; Contact DHCS provider enrollment division*
0042 – Rebill the claim
*Verify the date of service; Check for previous payment; Check if procedure code is still valid;*
0062 – Rebill the claim
*Check the facility type/Place of Service code; Verify procedure code; Check from-through dates of service; Check Part 2 of provider manual for list of valid facilities codes*
0351 – Rebill the claim or Submit an appeal with 90 days
*Verify that the number of days or units for the services billed on the claim do not exceed acceptable maximum; For interim eye examinations within the 24-month coverage period, refer to the Professional Services: Diagnosis Codes section in the Vision Care provider manual for a list of valid diagnosis codes that must be billed with CPT-4 codes 92004 and 92014 for payment.*
0010 – Submit appeal within 90 days
*Check the NPI; Verify recipient’s 14-character BIC number; Check from-through dates, Chedk records for previous payment. If no previous payment, then verify all relevant information such as procedure code, modifier, and rendering provider number/NPI.*
I also took some additional notes pertaining to billing and Medi-Cal in general:

  • In May 2010, Medi-Cal will start offering online webinars and virtual classes.
  • Medi-Cal Regional Representatives can be scheduled come to your medical office for in-person seminars and to help with particular billing questions.
  • All lab work must be sent to PIA optical laboratories….the California Prison Industry Authority (PIA) which fabricates all eyewear for Medi-Cal recipients.
  • In general, if a denial is eligibility related, it is generally suggested to go to an appeal (if you have proof of eligibility).
  • When sending an appeal for eligibility, also send the Proof of Eligibility (either the internet print-out or physical copy).
  • If the recipient has no BIC and no SSN, contact the regional Social Services Office and they will be able to look-up the BIC number for you.
  • If you miss the 90 day appeal, submit a CIF (claims inquiry form) and get a fresh denial in order to re-appeal.
  • If it passes 6 months, send a CIF.
  • The full provider manual is online as well as the vision care section.

There is a lot of information to cover with Medi-Cal, but if you’re an optometrist or ophthalmologist with Medi-Cal patients you’ll certainly want to stay informed.

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