California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5.5 - INDIANS AND INDIAN HEALTH SERVICE FACILITIES IN MEDI-CAL MANAGED CARE PROGRAMS › Section 55150 - Indian Health Service Facility Out-of-Plan Reimbursement

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
When the Indian Health Service Facility provides services
					 covered by a Medi-Cal managed care plan to members of that plan and the Indian
					 Health Service Facility does not have a subcontract with the Medi-Cal managed
					 care plan or has a subcontract but is providing services to members not covered
					 by the subcontract, the following reimbursement requirements shall
					 apply:
(a) For Medi-Cal beneficiaries
				  who are Indians, the Medi-Cal managed care plan shall reimburse the Indian
				  Health Service Facility for services provided to the beneficiary at the
				  applicable reimbursement rate that would have been received by the Indian
				  Health Service Facility if the service has been rendered to a Medi-Cal
				  beneficiary through the Medi-Cal fee-for-service program.
(b) For Medi-Cal beneficiaries who are not
				  Indians, the Medi-Cal managed care plan shall reimburse the Indian Health
				  Service Facility only if the Medi-Cal managed care plan has authorized the
				  service or if the Medi-Cal managed care plan is obligated by its contract with
				  the department to pay out-of-plan providers for the service without prior
				  authorization (e.g., emergency services or family planning services). If
				  reimbursement is required, reimbursement shall be at the applicable
				  reimbursement rate that would have been received by the Indian Health Service
				  Facility if the service had been rendered to a Medi-Cal beneficiary through the
				  Medi-Cal fee-for-service program.
(c) The Indian Health Service Facility may be
				  required, as a condition of payment, by the Medi-Cal managed care plan to
				  submit supporting documentation or specific claim information in a format
				  acceptable to the Medi-Cal managed care plan, pursuant to the Medi-Cal managed
				  care plan's out-of-plan claims procedures which are required by the Medi-Cal
				  managed care plan of any other provider of out-of-plan services. In addition, a
				  Medi-Cal managed care plan may request from the Indian Health Service Facility,
				  as a condition of payment, verification of a person's eligibility as an Indian,
				  as defined in section
				  55100.
(d) Referrals made by the Indian Health
				  Service Facility to other providers shall be coordinated with the Medi-Cal
				  managed care plan. Providers which accept the referrals shall be responsible
				  for obtaining authorization and payment from the Medi-Cal managed care
				  plan.
1. New
					 section filed 4-3-98; operative 4-3-98. Submitted to OAL for printing only
					 pursuant to section
					 147, Senate Bill 485 (Ch. 722/92)
					 (Register 98, No. 15).
2. Change without regulatory effect amending
					 NOTE filed 4-9-98 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 98, No. 15).
Note: Authority cited: Stats. 1992, Ch. 722; Sections
						10725,
						14089.7,
						14105,
						14124.5,
						14203
						and
						14312,
						Welfare and Institutions Code. Reference: Sections
						14000,
						14087.3,
						14087.5,
						14088,
						14089,
						14089.05,
						14200
						and
						14499.5,
						Welfare and Institutions Code; Title 25, United States Code, Sections
						13 and
						1601; and Title 42, United States
						Code, Sections
						1396(b)(m)(2)(A)(ix)
						and 1396(d)(l)(2).