Introduction:

The following describes CalOptima’s reimbursement rates for covered Medi-Cal services rendered by a non-contracted provider to a member who is enrolled in CalOptima Direct or in a shared-risk group.

Please refer to CalOptima Authorization Required List for prior authorization requirements. CalOptima shall not reimburse providers services that are subject to prior authorization for which such authorization has not been secured.

For Medi-Cal fee-for-service rates, please see
http://files.medi-cal.ca.gov/pubsdoco/Rates/RatesHome.asp.

For assistance on claims billing instructions, please call CalOptima’s Claims Inquiry line at (714) 246-8885, between 8:00 a.m. and 4:00 p.m., Monday through Friday.

Professional Services:

• For dates of service on and after January 1, 2008, CalOptima shall reimburse non-emergency professional services at 123% of the Medi-Cal fee-for-service rate effective on the date of service.
• For dates of service on and after January 1, 2008, CalOptima shall reimburse emergency professional services at 100% of the Medi-Cal fee-for-service rate effective on the date of service.
• For dates of service on and after January 1, 2008, CalOptima shall reimburse a CCS paneled specialist at 140% of the Medi-Cal fee-for-service rate effective on the date of service for members 21 years of age and under.
• CalOptima shall update the CalOptima fee schedule on a quarterly basis, in accordance with CalOptima Policy FF.1002: CalOptima Fee Schedule.

Ancillary Services:

• For dates of service on and after January 1, 2008, CalOptima shall reimburse ancillary services at 100% of the Medi-Cal fee-for-service rate effective on the date of service.
• CalOptima shall update the CalOptima fee schedule on a quarterly basis, in accordance with CalOptima Policy FF.1002: CalOptima Fee Schedule.

Federally Qualified Health Center (FQHC) Services:

• CalOptima shall reimburse an FQHC at the same amount paid by Medi-Cal fee-for-service for the same service provided by a provider that is not an FQHC.
• CalOptima shall reimburse an FQHC for each procedure performed, and not at an all-inclusive rate.
• CalOptima shall reimburse an FQHC for CHDP services billed on the PM 160 Form and in accordance to CHDP billing procedures at the same amount paid by Medi-Cal fee-for-service for the same service provided by a provider that is not an FQHC.

Outpatient Hospital Services:

• For dates of service on and after January 1, 2007, CalOptima shall reimburse emergency outpatient services at 100% of Medi-Cal fee-for-service payments effective on the date of service.
• For dates of service on and after January 1, 2008, CalOptima shall reimburse authorized non-emergency outpatient services at 100% of the Medi-Cal fee-for-service rate effective on the date of service.

Emergency Inpatient Hospital Services:

• For dates of service on and after January 1, 2007, CalOptima shall reimburse emergency inpatient services at the regional rates established by the Department of Health Care Services (DHCS) as follows:
  
  Dates of Services January 1, 2007, through June 30, 2008
  
  

  Region	Regional Rates
  	Non-tertiary Hospital	Tertiary Hospital
  Southern California	$1,158	$1,804
  San Francisco / Bay Area	$1,594	$2,468
  Other	$1,291	$1,779

  
  Dates of Services July 1, 2008, through June 30, 2009
  
  

  Region	Regional Rates
  	Non-tertiary Hospital	Tertiary Hospital
  Southern California	$1,283	$1,998
  San Francisco / Bay Area	$1,771	$2,742
  Other	$1,411	$1,944

  Region Designation	Counties
  Southern California	Los Angeles, Orange, Riverside, San Bernardino and Ventura
  San Francisco / Bay Area	Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Santa Cruz, Solano and Sonoma
  Other	All other counties*

* Please refer to the California Medical Assistance Commission (CMAC) at http://www.cmac.ca.gov/files/cmacannualreport2008.pdf for details regarding region designation.


• For purposes of these payments, a tertiary hospital is a hospital that is either:
  • A Children's Hospital specified in Welfare and Institutions Code, Section 10727; or
  • A Level I or Level II trauma center as designated by the Emergency Medical Services Authority pursuant to Health and Safety Code, Section 1797.1.

Non-Emergency Inpatient Hospital Services:

• For dates of service on and after November 1, 2008, CalOptima shall reimburse post-stabilization services following an emergency admission at the lesser of either:
  • The non-contracted hospital’s Interim Rate, as defined by the DHCS, on the date of service, less 10%, or
  • The applicable regional rate, as provided above, less 5%.
  
  The following table shows the regional rates less 5%:
  
  

  Region	Regional Rates -5%
  	Non-tertiary Hospital	Tertiary Hospital
  Southern California	$1,219	$1,898
  San Francisco / Bay Area	$1,682	$2,605
  Other	$1,340	$1,847