White Papers

Adjustment of Laboratory Services Claims Due to Annual Rate Update

In a recent memorandum from Xerox State Healthcare, LLC (Xerox), which processes all of the Medi-Cal claims for the California Department of Healthcare Services (DHCS), in compliance with Welfare and Institutions Code (W&I Code), Section 14105.22, Medi-Cal maximum reimbursement rates for clinical laboratory or laboratory services may not exceed 80 percent of the lowest maximum allowance established by the Federal Medicare program for the same or similar services.

Therefore, Xerox State Healthcare, LLC has revised the 2011 and 2012 rates to adjust the reimbursements of “paid claims” for laboratory services under the following procedure codes. This means Xerox State Healthcare, LLC will begin taking back money paid on these previously paid claims. (70 CPT CODES)

80047  
80400  
80402  
80406  
80408  
80410  
80412
80414  
80415  
80416  
80417  
80418  
80420  
80422 
80424  
80426  
80428  
80430  
80432  
80434  
80435
80436  
80438  
80439  
80440  
81020  
82075  
83020
83037  
83719  
83861  
83937  
83950  
83951  
83987 
84061  
84449  
84586  
85397  
85598  
86005  
86305
86336  
86355  
86780  
86825  
86826  
86901  
87150
87153  
87493  
87905  
87906  
88720  
88738  
88740
88741  
89310  
89325  
G0123  
G0143  
G0144  
G0145
G0147  
G0148  
G0432  
G0433  
G0435  
G9143  
P9612

According to Xerox State Healthcare, LLC there is no action required on the provider side as they will adjust the affected claims processed from January 1, 2011 through August 6, 2013. These adjustments will appear on Remittance Advice Details (RAD) beginning July 31, 2014 with RAD code “0883: Retroactive Price Correction.”

It further explains that the recoveries are authorized under the provisions of W&I Code, Sections 14176 and 14177, and California Code Regulations (CCR), Title 22, Section 51458.1(a)(1). In addition, the W&I Code authorizes the Department of Health Care Services to enter into repayment agreements with providers, or offset overpayments against amounts due. If the total warrant amount is not sufficient to offset the recovery, the negative balance will be converted to an accounts receivable transaction and subtracted from future Medi-Cal reimbursements.

If you disagree with these adjustments, you may submit a Claims Inquiry Form (CIF) within six months of the new RAD date, or you may submit an Appeal Form within 90 days of the new RAD date.

APS Medical Billing is closely monitoring and will provide an update as it becomes available. Should you have questions, please contact your Practice Manager.

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