Things we had to learn the hard way

The admission day counts as Day 1. The initial assessments start on Day 1, and the care plan conference and IPC review are due by Day 30, which is the enrollment date plus 29 days.

After that, a comprehensive reassessment is due every six months (180 days). A significant change in condition calls for a reassessment of its own.

S5102 is the day-care day: one line per attended day, and it needs an approved day-care TAR covering that date.

H2000 is the multidisciplinary assessment day, billed one line per assessment day under its own authorization.

T1023 is the face-to-face eligibility screening. It is billed once per admission, on the screening date, whether or not the person attended that day.

An H2000 or T1023 authorization does not make an ordinary attendance day billable. Only S5102 coverage does.

When a participant receives emergency remote services instead of attending in person, the S5102 line for each remote day carries a modifier.

CR is for a public emergency. SC is for a personal emergency. Record the window and the reason once, so every remote day in it is billed the same way.

CBAS centers report unusual occurrences to DHCS, usually by phone within 24 hours, with a written report after.

Start the clock at the time of the incident, not the time someone filed the report. Record when you reported and the reference you were given.

The Medi-Cal Provider Portal’s Multiple Subscriber Eligibility tool checks up to 200 people per upload. The portal offers an .xls template, but the upload itself must be a CSV.

The response names two organizations per member: the managed-care plan and, often, a delegated provider. A member whose plan on file matches either one hasn’t switched plans.

L.A. Care splits CBAS paperwork in two. The face-to-face screening (T1023) goes on an inquiry asking the plan to run its CBAS eligibility tool, form LA2903.

Day-care (S5102) and assessment (H2000) days go on the PL1798 prior authorization form. One TAR covers one service code.

For a dual-eligible (D-SNP) member billed to Anthem Blue Cross, the claim must carry the plan-issued HMO member ID. A bare Medi-Cal CIN is rejected.

Other Anthem members, and D-SNP members at other plans, bill fine with the CIN.

The claim number on an 837 (CLM01) can be at most 20 characters. If yours are longer, the payer echoes back a truncated version in the 835, and EDI is upper-cased in transit.

Match first on the payer’s own claim number (CLP07) once a claim has been adjudicated, then on the exact claim number, and only then on a 20-character prefix when the returned number is exactly 20 characters long.