Skip to Main Content

California Health & Wellness uses cookies. By continuing to use our site, you agree to our Privacy Policy and Terms of Use.

California Health & Wellness is no longer a Medi-Cal plan starting January 1, 2024. Regardless of the county you live in, your Medi-Cal service and benefits will not be impacted by the health plan changes since you will be assigned to a new health plan. The county you live in determines your new health plan. Learn more
California Health & Wellness is no longer a Medi-Cal plan starting January 1, 2024. Regardless of the county you live in, your Medi-Cal service and benefits will not be impacted by the health plan changes since you will be assigned to a new health plan. The county you live in determines your new health plan. Learn more

20-741 Avoid Post-Payment Collection by Ensuring Medi-Cal is the Payer of Last Resort

Date: 12/18/20

Requirements for Medi-Cal cost avoidance and post-payment recovery for other health coverage

Medi-Cal managed care plans (MCPs) are required to be the payer of last resort for services when a member has other healthcare coverage (OHC). On April 20, 2020, the California Department of Healthcare Services (DHCS) issued All Plan Letter (APL) 20-010 to ensure both providers and MCPs, like California Health and Wellness Plan (CHWP) and CHWP’s delegated providers, are doing their part to correctly identify OHC and avoid unnecessary costs. APL 20-010 provides clarification and guidance regarding requirements for cost avoidance and post-payment recovery when a member has OHC.

To view APL 20-010 in its entirety, visit the DHCS website (PDF).

New guidelines for cost avoidance and post-payment recovery

DHCS new requirements includes the following:

  • Use the Medi-Cal Eligibility Record for processing OHC claims.
  • Beginning January 1, 2021, CHWP and its independent practice associations (IPAs) must include OHC information in their notification to the provider when a claim is denied due to the presence of OHC. OHC information includes, but is not limited to:
    • The name of the OHC provider
    • The policy number
    • Contact or billing information
  • PPG’s may continue to direct providers to access the necessary member OHC information using the Automated Eligibility Verification System at 1-800-427-1295, or the Medi-Cal Online Eligibility Portal. Information pertaining to OHC carriers can be found in the Health and Human Services Open Data Portal at data.chhs.ca.gov/dataset/aevs-carrier-codes-for-other-health-coverage. Additional information on changes to the Medi-Cal Eligibility Reports will be coming from CHWP at a later date.
  • CHWP and its delegated IPAs must not process claims for payment for a member whose Medi-Cal eligibility record indicates OHC, other than a code of A or N, unless the provider presents proof that all sources of payment have been exhausted, or the provided service meets requirements for billing Medi-Cal directly.
  • CHWP must report new OHC information not found on the Medi-Cal eligibility record or OHC information that is different from what is found on the Medi-Cal Eligibility Record to DHCS within 10 calendar days of discovery.
  • CHWP is required to submit detailed information regarding their recoveries to DHCS on a monthly report no later than the 15th of each month.
  • On a monthly basis, CHWP must report and return all recovered monies that are 13 months or older from the date of payment of a service to DHCS using the monthly report.

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.