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 ratesto remain within its budget. Should payment rates be changes, 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.
- Claims Payment On or Before September 30, 2005
For medical and vision services provided to CMSP members on or before September 30, 2005, claims for payment will be administered by Electronic Data Systems (EDS) in the same manner as claims are processed for the Medi-Cal fee-for-service program.
For dental services provided to CMSP members on or before September 30, 2005, claims for payment shall be billed directly to Delta Dental, unless services are provided by a Rural Health Clinic. In this instance, claims shall be billed to EDS.
There is no change to payment processing for prescription drug services provided to CMSP members on or before September 30. Benefits will continue to be processed by MedImpact Health Systems, Inc. (MedImpact).
- Claims Payment On or After October 1, 2005
For medical services provided on or after October 1, 2005, provider claims payment will be administered by Anthem Blue Cross. For dentists and vision care providers who are not affiliated with a clinic (FQHC, RHC, or Tribal Health Providers), payment shall be administered by Doral Dental and Vision Service Plan (VSP) according to the terms of those provider contracts. MedImpact shall continue to administer the CMSP prescription drug benefits without change.