Frequently Asked Questions (FAQ)

The Billing Team does not provide guidance on Third Party billing.  It is the provider’s responsibility to bill all third-party insurance outside of IRIS.

It is up to the contract providers to enroll with Medicare and bill Medicare within their own system when Medi-Cal requires it for coordination of benefits (see Service Tables -MedCCC—Library). If Medicare does not get billed, then Medi-Cal will not be billed. The services should not be entered in IRIS without a Medicare denial or payment.

No, a new FIN does not need to be created. A new claim can be generated from the same FIN. Email the Billing Team with the new claim number so that they can ensure HCA/IT/EDI submits the claim with an original claim indicator.

The client should contact Social Services Agency to have the OHC status updated.

Providers should inform the client that they may choose to apply the charges to the family SOC.  Do not charge the client if they choose not to apply the charges to the family SOC.

An original claim is the initial submission.  Origin claims must be submitted within 12 months of the month of service.

Replacement claims are claims that correct previously submitted claims.  A claim may be submitted to replace an approved claim or a denied claim no later than 15 months after the month of service.

a.    Reference Specialty Mental Health Billing Manual Specialty Mental Health Services Billing Manual SFY 2025-26 ; (Section 5.5.0 Duplicate Services) A claim for an outpatient service is considered a duplicate if all of the following data elements are the same as another service line within a claim that was approved in history:
     i.    The member’s CIN
     ii.    Rendering provider NPI
     iii.    Procedure code(s)
     iv.    Date of service

b.    With the exception of Sign Language or Oral Interpretive Services (T1013), Peer Support Services, Group Services (H0025) or mobile services (H2011 – POS 15).
c.    If the provider renders two of the same services to the same member on the same day in two or more separate encounters, all encounters must be claimed as one service to ensure the additional encounters are not denied as duplicate services.

a.    Contract providers have been instructed not to use Special Guarantors. If exceptions are made, they will be rare. The direction will come from the contract monitor or program manager.  
b.    To replace the Special Guarantor, you may use a parent/guardian or self in registration.  
c.    There are no additional funds by using the Special Guarantor.

Contract providers should work on both at the same time. They should work on the prior fiscal year so that there is no timely filing limitation and no risk of not being reimbursed.

The Billing Team does not provide guidance on third party billing.  It is the responsibility to bill all third-party insurance outside of IRIS.

Providers must make every attempt to bill a client’s other health coverage (OHC) plan, including Medicare before billing Medi-Cal, as Medi-Cal is the payer of last resort.

For Mental Health programs: If the member’s OHC does not respond within 90 days, the provider may submit a claim to Medi-Cal on the 91st day. The claim submitted to Medi-Cal must contain information about the claim submitted to the member’s OHC.

Reference: Short Doyle Specialty Mental Health Billing Manual FY 2025-26, section 5.28.0 and 5.29.0 SMHS FY2025-26 Billing Manual

For SUD-DMC/ODS: If Medicare does not respond within 90 days, the provider may submit a claim to Medi-Cal on the 91st day. The claim submitted to Medi-Cal must contain OHC information about Medicare claim even if the OHC is $0.
HCA has asked for clarification on this rule with Medi-Cal on Other Health Coverage Non-Medicare as it isn’t clearly stated in the Drug Medi-Cal ODS Billing Manual, further information coming soon.

Reference: Short Doyle DMC-ODS Billing Manual FY 2025-26, section 5.2.29 DMC-ODS Billing Manual SFY 2025-26

If an AOB cannot be obtained to bill other health coverage (OHC), do not enter charges in IRIS, Medi-Cal can ONLY be billed after the primary is billed. In such cases, it may be appropriate to escalate the matter by contacting the SSA (Supervising Social Worker or Social Services Agency), depending on the case structure. This may help prevent delays in care and billing.

Mental Health Plan (MHP) programs – AOB is not required for Medi-Cal Short Doyle. However, a signed AOB is required for other health coverage (third party, commercial, Medicare HMO, Medicare Advantage, One Care Advantage) plans. A separate
AOB is required for each health plan.

Substance Use Disorder (SUD/DMC) programs – AOB is required for Medi-Cal ADP Drug and any other health coverage, including, commercial, Medicare HMO, Medicare Advantage, One Care Advantage plans. A separate AOB is required for each health plan.

Contract providers can choose to enter residential bed days on a daily, weekly, or monthly basis.

SUD – DMC/ODS claims are submitted Tuesdays, to ensure claims are included in the weekly submission, entries must be completed by 5pm on each Monday.

MHP claims are submitted on Wednesdays, to ensure claims are included in the weekly submission, entries must be completed by 5pm on each Tuesday.

All residential and withdrawal management bed day services can be batched on a single encounter for the same month of service.

While this is not a formal mandate, verifying eligibility for each client and date of service is strongly recommended to avoid claim denials and delays. This is ultimately a business decision for each provider organization.

Group services are excluded from the duplicate service guideline. The group services would be billed separately and NOT be combined.

References: The following is taken from the SMHS Billing Manual section 5.5.0 Duplicate Services SMHS FY2025-26 Billing Manual:

Outpatient services are listed in the Service Table. Duplicate services are not allowed with the exception of Sign Language or Oral Interpretive Services (T1013) Interactive Complexity (90785), Peer Support Services, group services (H0025), mobile crisis (H2011, Place of service 15), T2021 (therapy substitute code), T2024 (assessment substitute code), T1017 and T1017:HK combination, any code that has the HQ modifier indicating that the service was delivered as a group service, and a BH-CONNECT monthly code.

The group CDMs in IRIS are hardcoded at the group rate and with the group modifier HQ, providers don’t have to worry about calculating out the rate for the purpose of entering and billing in IRIS.

Reference: SMHS Billing Manual section 5.24.0 How to Select Codes Based on Time, Group Services, SMHS FY2025-26 Billing Manual :

Group Services:
Group services are indicated by appending modifier HQ or by the definition of the service. SD/MC will adjust the rate for group services by 4.5. Counties should submit claims for each member receiving group services and SD/MCwill adjust the rate for each by 4.5. For example, if the county’s rate for therapy rendered by a specific provider type for 84 minutes is $99 and that county claims 90849 (Multiple family group psychotherapy, 84 minutes) rendered by that same provider type, the rate for each member in that group will be $22 (or $99/4.5) for unit of service. Please refer to the Service Table to see which codes are defined as group services and which codes take the HQ modifier.

Yes. Many services do not require a Coordination of Benefits (COB). These services will automatically roll to the next benefit order (Medi-Cal) in IRIS when "Contract Provider Medicare" is entered as the primary and Medi-Cal as the secondary.

See service table to determine which services do not require COB (Medicare COB Required?)

Reference: DMC-ODS-Service-Table-25-26.xlsx Specialty-Mental-Health-Service-Table-25-26.xlsx

Yes. Some provider types are eligible to render Medi-Cal services (DMC/SMHS), but not Medicare. If the provider is not eligible to bill Medicare, Medi-Cal can be billed directly. The IRIS system recognizes the providers that aren’t required to bill Medicare, those services are rolled automatically to bill Medi-Cal.

Medicare must be billed first if services are rendered by any of the following licensed provider types:

1. Physician
2. Physician Assistant
3. Nurse Practitioner
4. Licensed Clinical Social Worker
5. Clinical Psychologist
6. Licensed Marriage and Family Therapist
7. Licensed Professional Clinical Counselor

Reference: SMHS FY2025-26 Billing Manual section 5.28.0 or DMC-ODS Billing Manual SFY 2025-26 section 5.2.29

Orgs identified as SUD Residentials; the POS is hardcoded in IRIS with “55”. The Encounter Type should be “Residential”. For services other than bed days, it is acceptable to use Encounter Type “Home”, the POS is hardcoded in IRIS with “55”.

POS 55 – Residential Substance Abuse Treatment Facility – A facility which provides treatment for substance (alcohol and drug) abuse to live in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.

• Providers may collect SOC payments from a subscriber on the date that services are rendered, or providers may allow a subscriber to “obligate” payment for rendered services.
• Obligating payment means the provider allows the subscriber to pay for the services at a later date or through an installment plan.
• Obligated payments must be used by the provider to clear Share of Cost.
• SOC obligation agreements are between the subscriber and the provider and should be in writing, signed by both parties for protection.
• Medi-Cal will not reimburse the provider for SOC payments obligated but not paid by the subscriber.

References: Share of Cost (SOC) (share)

S9484 does not requirement coordination of benefits (COB), which means Medi-Cal can be billed directly without billing Medicare. Medicare COB rules apply to Medicare part B, Medicare Advantage (CMAP) and OneCare CMAP. . The system (IRIS) will automatically roll the service to bypass Medicare and bill Medi-Cal directly.

Primary health plans, Third Party HMO, PPOs, and Medicare HMO plans must be billed first. The charges are to be entered once a payment or a denial is received by the primary OR at day 91 with no response.

Only the client or their authorized representative can request eligibility changes through the Social Services Agency (SSA). They should contact SSA as soon as possible to update their eligibility status.

If the client’s Medi-Cal coverage indicates incarcerated, the health plan to enter for the client is Unfunded/Uninsured.
Continue to track client eligibility and if there is a change in Medi-Cal coverage, update the health plan and post charges to the retroactive date, if applicable.

Mental Health Plan – Medi-Cal continues to cover out of county clients. No change, continue to post charges.

SUD/DMC – County code other than 30 who are in the process of updating Medi-Cal benefits or transferring their Medi-Cal to Orange County, enter Medi-Cal health plan (Medical ADP Drug…) and post charges.

If the client does not have Medi-Cal coverage, register the client with health plan Unfunded/Uninsured.

Contract providers may choose to enter (post) services into IRIS for “Uninsured/Unfunded” clients who are:

• In the process of applying for Medi-Cal and have no other form of insurance
• Not enrolled in any health insurance plan

Continue to post charges in IRIS with Medi-Cal health plan. The Revenue Cycle system will apply an Edit Failure to the claim. The charges will remain in the contract providers billing queues.

Continue to track eligibility and if there is a change in the aid code, update in registration. The claims in the Edit Failure queue will need to be cancelled in order for the new claim to pick up the change in aid code.