§ 55150. Indian Health Service Facility Out-of-Plan Reimbursement.

When the Indian Health Service Facility provides services covered by a Medi-Cal managed care plan to members of that plan and the Indian Health Service Facility does not have a subcontract with the Medi-Cal managed care plan or has a subcontract but is providing services to members not covered by the subcontract, the following reimbursement requirements shall apply:

(a) For Medi-Cal beneficiaries who are Indians, the Medi-Cal managed care plan shall reimburse the Indian Health Service Facility for services provided to the beneficiary at the applicable reimbursement rate that would have been received by the Indian Health Service Facility if the service has been rendered to a Medi-Cal beneficiary through the Medi-Cal fee-for-service program.

(b) For Medi-Cal beneficiaries who are not Indians, the Medi-Cal managed care plan shall reimburse the Indian Health Service Facility only if the Medi-Cal managed care plan has authorized the service or if the Medi-Cal managed care plan is obligated by its contract with the department to pay out-of-plan providers for the service without prior authorization (e.g., emergency services or family planning services). If reimbursement is required, reimbursement shall be at the applicable reimbursement rate that would have been received by the Indian Health Service Facility if the service had been rendered to a Medi-Cal beneficiary through the Medi-Cal fee-for-service program.

(c) The Indian Health Service Facility may be required, as a condition of payment, by the Medi-Cal managed care plan to submit supporting documentation or specific claim information in a format acceptable to the Medi-Cal managed care plan, pursuant to the Medi-Cal managed care plan's out-of-plan claims procedures which are required by the Medi-Cal managed care plan of any other provider of out-of-plan services. In addition, a Medi-Cal managed care plan may request from the Indian Health Service Facility, as a condition of payment, verification of a person's eligibility as an Indian, as defined in section 55100.

(d) Referrals made by the Indian Health Service Facility to other providers shall be coordinated with the Medi-Cal managed care plan. Providers which accept the referrals shall be responsible for obtaining authorization and payment from the Medi-Cal managed care plan.

HISTORY

1. New section filed 4-3-98; operative 4-3-98. Submitted to OAL for printing only pursuant to section 147, Senate Bill 485 (Ch. 722/92) (Register 98, No. 15).

2. Change without regulatory effect amending Note filed 4-9-98 pursuant to section 100, title 1, California Code of Regulations (Register 98, No. 15).

Note

Note: Authority cited: Stats. 1992, Ch. 722; Sections 10725, 14089.7, 14105, 14124.5, 14203 and 14312, Welfare and Institutions Code. Reference: Sections 14000, 14087.3, 14087.5, 14088, 14089, 14089.05, 14200 and 14499.5, Welfare and Institutions Code; Title 25, United States Code, Sections 13 and 1601; and Title 42, United States Code, Sections 1396(b)(m)(2)(A)(ix) and 1396(d)( l)(2).