Medi-Cal fee-for-service
California law (Welfare and Institutions Code section 14115) sets a six-month billing limit for Medi-Cal claims, counted from the month of service. Claims received later are paid at a reduced rate or denied unless one of the exceptions in the law applies, and the provider must be able to document the reason.
Plans and brokers
Managed care plans publish their own limits in their provider policies, and brokers set theirs in their contracts, often shorter than Medi-Cal’s. Each payer can also have a separate, shorter deadline for corrected claims and appeals.
How legs run out of time
Legs rarely miss the deadline because nobody billed them. They miss it because they were held for a missing signature or authorization and forgotten, or because a denial on an 835 wasn’t worked until it was too late to correct. Seeing every unbilled leg with the reason it is waiting, and its age, is the fix.
Going deeper: Billing Medi-Cal NEMT trips: the codes and what a clean claim needs
Related terms
- 835 remittance (ERA)An 835, or electronic remittance advice (ERA), is the file a payer sends back after processing claims.
- 837P claim (CMS-1500)An 837P is the standard electronic file for a professional health care claim, and the CMS-1500 is the paper form with the same content.
- Payer (funding source)The payer, also called the funding source, is whoever pays for a trip leg: a broker, a health plan directly, Medi-Cal fee-for-service, a facility, a workers’ compensation administrator or the rider.
- Prior authorizationPrior authorization is the payer’s approval of a ride before it happens.
Sources
Checked on . Rules change: check the current version with the payer before you bill.