Medi-Cal Top 10 Most common Denials and what to do Follow-up

Medi-Cal Top 10 Most common Denials and what to do
There are many reasons why a provider might receive a Medi-Cal Denial when billing with a UB04 claim form. These denied claims represent claims that are incomplete, services billed are not
payable or information given by the provider is inappropriate. Many Remittance Advice Details
(RAD) codes and messages include billing advice to help providers correct denied claims. It’s
important to verify information on the original claim against the RAD as we will be showing later
in this article.
Medi-Cal has released in its most recent Webinar the top 10 most common denial messages as
listed in the table below. We will quickly cover what went wrong and what you should be doing
to correct it/get paid.
Follow-up Options
First thing billers and providers should understand is the various follow-up (F/U) options to get
paid on a denied claim.
 Rebill the claim – This is done when a claim has a simple corrections.
 Submit a Claims Inquiry Form (CIF) –These are for tracking, underpayments, and
overpayments.
 Submit and Appeal form –This is used to dispute or resolve problems related to
denied claims and often requires supporting documentation.
 Contact Correspondence Specialist Unit (CSU) – This is mainly for Long Term Care
(LTC) as an addition to the options above.
The timelines to file any of these is as follows:
Information supplied by MMHCS.com
sourced from Medi-Cal.ca.gov
Denied Claim Follow-Up Procedures for Top 10 Denials
Denial Code #1 – RAD code 0010 –“This service is a duplicate of a previously paid claim.”
What to review:
 Check the provider number/National Provider Identifier (NPI).
 Verify the recipient’s 14-character ID number.
 Check “from-through” dates of service.
 Check records for previous payments. If no payment is found, verify all relevant
information.
Example: Procedure code, modifier and rendering provider number/NPI
Type of F/U action: Appeal unless the claim dates of service are overlapping with those of a
Long Term Care (LTC) facility claim where an appeal and CSU may be needed.
Denial Code # 2 –RAD code 0314 –“Recipient is not eligible for the month of service billed.”
What to review:
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Verify the recipient’s ID number with a valid Medi-Cal Benefits Identification Card
(BIC) prior to rendering service, except in an emergency.
Verify if the recipient has a Share of Cost (SOC) and is eligible for the month of
service.
Confirm the recipient’s eligibility.
Collect and spend down the SOC.
Type of F/U action: Appeal
Denial Code #3 –RAD code 0037 –“Health Care Plan enrollee, capitated service not billable to
Medi-Cal.”
What to Review:
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Verify the recipient’s eligibility.
Verify the recipient’s 14-character ID number on the RAD.
Check the county code.
o Verify county code in the MCP: Code Directory section of the Part 1
provider manual.
Type of F/U action: Bill the Managed Care Plan (MCP) and take their denial and EOB
and then re-bill the claim to Medi-Cal if allowable.
Information supplied by MMHCS.com
sourced from Medi-Cal.ca.gov
Denial Code #4 –RAD code 0145 –“This procedure is not a Medi-Cal benefit on this date of
service.”
What to review:
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Verify procedure code
Verify “From-through” dates of service
Verify Authorization information
Type of F/U action: Correct and rebill the claim. Note: Always remember to code
according to the specifications in the TAR where applicable.
Denial Code #5 –RAD code 0031 –“The provider was not eligible for the services billed on the
date of service.”
What to review:
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Verify date of service on the claim is correct.
Verify billing provider number on the claim is correct.
Verify rendering provider number on the claim is correct.
Type of F/U action: Correct and rebill and if denied again, Appeal.
Denial Code #6 –RAD code 9897 –“HCPCS Qualifier and NDC (National Drug Code)/UPN
(Universal Product Number) is missing.”
What to review:
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Check the HCPCS Qualifier and NDC/UPN.
Type of F/U action: Correct and rebill.
Denial Code #7 –RAD code 0250 –“Quantity exceeds allowed for per-visit codes, or a claim
with the same date of service and the same per-visit code was found in history. Medical
justification required.”
What to review:
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Verify the recipient’s 14-character ID number on the RAD.
Verify the per-visit code billed.
Check records for previous payments. If no payment is found, verify all relevant
information.
o Example: Procedure code, modifier and rendering provider number/NPI
Type of F/U action: Rebill the corrected claim or submit a CIF and Submit documentation for
the services billed.
Denial Code #8 –RAD code 0079 –“Service billed exceeds remaining occurrences approved
on the TAR (Treatment Authorization Request).”
What to review:
Information supplied by MMHCS.com
sourced from Medi-Cal.ca.gov
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Check records for previous payments.
Verify date(s) of service on the claim.
Verify the approved date(s) of service on the Adjudication Response (AR). If
incorrect, request correction of TAR in writing from your local Medi-Cal field office.
Type of F/U action: Rebill the corrected claim. Medi-Cal recommends using e-TARs to help
avoid these errors.
Denial Code #9 –RAD code 9952 –“Type of Bill Code for APR-DRG Claim Invalid or Missing.”
What to review:
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Verify the correct Type of Bill Code billed.
For DRG claim completion standards refer to the UB-04 completion: Inpatient
Services section in the Part 2 provider manual.
Type of F/U action: Submit an Appeal or rebill the corrected claim.
Denial Code #10 –RAD code 0105 –“This service requires a valid sterilization Consent Form.”
What to review:
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Refer to the Sterilization section in the appropriate Part 2 provider manual for
information about this form.
Type of F/U action: Either send a CIF with supporting documentation or rebill the corrected
claim.
Thank you for reading. If you have any questions about denial management contact us at
[email protected].
Information supplied by MMHCS.com
sourced from Medi-Cal.ca.gov

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