Under California law, the CMSP Governing Board is authorized to set payment rates for health care services covered under CMSP. The Governing Board sets these rates within the context of annual program revenues and expenditures. CMSP payment rates have been and continue to be based on specified percentages of the amounts paid under the Medi-Cal fee-for-service program.
Providers must accept CMSP payment as payment in full for services provided. When a CMSP recipient has other health coverage, providers are required to bill the insurance carrier first prior to billing CMSP or submit a denial letter from the carrier with the CMSP claim.
CMSP may change its payment rates to remain within its budget. Should payment rates be changed, participating medical, dental and vision services providers shall be notified in advance by Anthem Blue Cross of such rate changes. Pharmacies shall be notified by MedImpact Health Systems Inc of any pharmacy payment rate changes.
For medical services, provider claims payment is administered by Anthem Blue Cross. For dentists and vision care providers that are not affiliated with a clinic (FQHC, RHC, or Tribal Health Providers), payment is administered by DentaQuest (previously Doral Dental) and Vision Service Plan (VSP) according to the terms of those provider contracts. Payment rates for services provided to CMSP members are set by the Governing Board in accordance with the rates of payment policy.
- Rates of Payment Policy Effective December 19, 2008
- Rates of Payment Policy Effective January 1, 2012
WebEx Medi-Cal Retro-Claim Training Program - Training Materials
In June 2008, a WebEx training was conducted for payment/billing staff with hospitals and clinics (FQHC, RHC and Tribal Health Program clinics) on Medi-Cal Retro Claim submission. The training assisted providers in understanding the process for re-billing Medi-Cal for CMSP members who are retroactively eligible for Medi-Cal. The training covered the following topics:
- Retroactive TAR Process and Requirements
- SOC Clearance
- Medi-Cal Claim Submission: Beyond the Six-Month Billing Limit
- Medi-Cal Claim Submission: Over-One-Year Claims