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.
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 and dental 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 dental providers that are not affiliated with a clinic (FQHC, RHC, or Tribal Health Providers), payment is administered by DentaQuest. 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 March 28, 2013
- Payment Policy Regarding Termination of Eligiblity Effective January 1, 2014
Medi-Cal Retro-Claiming Webinar Training
Materials from a 2008 CMSP webinar training offer instructions for payment/billing staff with hospitals and clinics (FQHC, RHC and Tribal Health Program clinics) on the Medi-Cal Retro Claim submission. The materials are intended to assist providers in understanding the process for re-billing Medi-Cal for CMSP members who are retroactively eligible for Medi-Cal. Topics include:
- 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