20-594 'By Report' Billing Guidelines

Date: 07/24/20

Learn more about the zero basic rates for fee schedules and exceptions for billing

California Health & Wellness Plan (CHWP) wants to make sure providers are reimbursed accurately for ‘By Report’ pricing. These guidelines identify ‘By Report’ procedures and appropriate reimbursement rates for providers.

HCPCS/CPT codes that have a basic rate of $0.00 (zero) are considered ‘By Report’ procedures. These codes have specialized pricing rates, as defined by CHWP guidelines.  

CHWP providers who bill with ‘By Report’ HCPCS/CPT codes are reimbursed at the default rate of 20% of billed charges with some exceptions.  

Exceptions include but are not limited to HCPCS

HCPCS code Z7610, as billable in an outpatient hospital, emergency room (ER), ancillary service center (ASC) or clinic setting and does not have a rate on the Medi-Cal Fee Schedule, is an exception. The system is configured to price as follows:

• When applicable to drugs Z7610 is billed with a National Drug Code number which dictates the Medi-Cal rate.
• When billed without a National Drug Code, Z7610 is payable as follows based on a custom configuration as determined by CHWP.

-    Participating providers are reimbursed at 100% of Medi-Cal rates.

-    Participating providers are paid at $10.00 plus applicable multipliers.

• Participating providers whose contracts are not reimbursed based on Medi-Cal allowable rates are paid based on their contract rates.

Medi-Cal fee schedules on the DHCS website

Please see the Department of Health Care Services Medi-Cal website to view the Medi-Cal rates.

Additional information

Providers are encouraged to access CHWP’s provider portal online for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact CHWP at 1-877-658-0305.