This section provides general guidelines for HRIF Program billing. HRIF services are reimbursable to the HRIF Program when provided by CCS Program-approved HRIF providers. Providers listed in the HRIF directory have been approved to provide services to the HRIF-eligible child.
- HRIF SCG 06 SAR only covers reimbursement of diagnostic services (codes) included in the SCG 06.
- Ophthalmology diagnostic services, as listed in the SCG, may be billed by the ophthalmologist using the SAR number.
- Audiology diagnostic services, as listed in the SCG, may be billed by the approved Type C CDC performing the services using the SAR number.
- Psychologists are only authorized to bill for limited diagnostic developmental assessment procedure codes included in SCG 06. Procedure codes that represent intervention (treatment) services are not payable with the SAR.
- Developmental testing procedures rendered by either a Nurse Specialist or a Physical or Occupational Therapist must be billed by the facility with the facility’s outpatient Medi-Cal provider number.
- Providers must be enrolled in the Medi-Cal Program and use their active Medi-Cal provider number on all authorized claims for all CCS Program HRIF clients.
- Allied healthcare providers (e.g. physical/occupational, therapists, audiologists, and social workers) who are employees of a hospital or facility are exempt from the Medi-Cal provider number requirement since the facility bills for their services using the facility’s Medi-Cal provider number.
- If applicable, providers must request authorization from a client’s other commercial third party health insurance carrier or HMO prior to providing services, and bill the client’s other commercial health insurance carrier or HMO plan prior to billing the CCS Program. A denial of benefits or an EOB must be attached to each claim. CCS Program/Medi-Cal is the payor of last resort.
NOTE: See Authorization of HRIF Service, regarding other health coverage and provision of HRIF diagnostic services.
- Providers billing for HRIF patients with a SAR issued to the SCC must adhere to the specific instructions described in the Medi-Cal Provider Manual when completing the claim form. For claim completion instructions, refer to the Medi-Cal Provider Manual.
- For claim submission information, refer to the Computer Media Claims (CMC) section of the Medi-Cal Program and Eligibility manual located at: http://www.medi-cal.ca.gov/cmc_instructions.asp or call the Telephone Services Center at 1-800-541-5555.
- Claims authorized for CCS Program/Medi-Cal children residing in Marin, Napa, San Mateo, Santa Barbara, Solano, and Yolo counties must be sent to the issuing county for approval and processing. Refer to the Medi-Cal Provider Manual, CCS Program Billing Guidelines.
NOTE: If you have any questions regarding HRIF services, please submit your inquiry to the State SCD office via e-mail at: HRIF@dhcs.ca.gov.