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California HME Update
Update on Medi-Cal Claw Back for Pharmacies/DME/Medical Supplies  
 
We wanted to share the latest information on the status of the Medi-Cal claw back of the 10% provider rate reduction retroactive to June 1, 2011. For pharmacy claims, which include some drugs, enteral formula and diabetic test strips, the period is June 1,2011 to February 7, 2014. For DME/Medical supplies the recoupment period is June 1, 2011 to October 24, 2013. Here is the latest;
  • The pharmacy claw back which began for the large chains in September has now been extended to smaller pharmacies. If you provide enteral formula or diabetic test strips you should have already seen on your RADs or electronically in your 835 reports the total amount of your individual recoupment and the actual specific effected claim lines. They will show as a reprocessed claim with amount previously and the adjusted claim to show the claw back. The total amount to be recouped will be listed on the last page of the RAD or in the 835 file as a "balance forward Transaction". For the non-large chain pharmacies all of the impacted claims should have been reprocessed in the same week meaning the total shown is all that is going to be recouped.
  • If a pharmacy provider has multiple locations with a unique NPI then you will need to look at each NPI RAD or 835 report to get the aggregate total being recouped.
  • The actual take back of payments has not yet begun and it will likely start in December. We will hopefully be able to provide you with a specific date. The recoupment will be 5% of the weekly check write to the provider until the total amount is recouped. If a provider wants to claim a hardship and seek an alternative payment plan they need to contact Xerox.
  • The claw back for DME/Medical Supplies has not yet begun, meaning no initial notice to providers as outlined in #1 and no firm date or window of time when the actual recoupment will begin. We believe that it is likely that process will not begin any earlier than end of the year and perhaps later. Typically DHCS uses a two week delay between notice to provider of the specific impacted claims and actual recoupment no earlier than two weeks after that. It will likely be longer.
If you have any questions please call the CAMPS office. We will try to keep you updated as more information becomes available. 
 
   




One Capitol Mall, Suite 800
Sacramento, CA 95814 
t: (916) 443-2115 
f: (916) 444-7462