Common use of Services with Unestablished Fees Clause in Contracts

Services with Unestablished Fees. If a fee has not been established by Medi-Cal for a particular procedure, and CalOptima has provided authorization for County to provide such service, CalOptima shall reimburse County under the following guidelines: a. “By Report & Unlisted” codes that CalOptima has provided authorization for County to provide such service will be paid at forty percent (40%) of billed charges and must follow Medi-Cal billing rules, policies and guidelines. When billing CalOptima for these codes, County shall include documentation of Covered Services provided. b. County shall utilize current billing codes and modifiers for Medi-Cal. c. CPT or HCPC codes not contained in the Medi-Cal fee schedule at the time of service are not reimbursable. d. If the billed charges are determined to be unallowable, in excess of usual and customary charges, or inappropriate pursuant to a medical review by CalOptima, CalOptima will contact provider for additional justification and these will be handled on a case-by-case basis.

Services with Unestablished Fees. If a fee has not been established by Medi-Cal for a particular procedure, and CalOptima has provided authorization for County to provide such service, CalOptima shall reimburse County under the following guidelines: a. “By Report & Unlisted” " codes that CalOptima has provided authorization for County to provide such service will be paid at forty percent (40%) of billed charges and must follow Medi-Cal billing rules, policies and guidelines. When billing CalOptima for these codes, County shall include documentation of Covered Services provided. b. County shall utilize current billing payment codes and modifiers for MediMed-Cal. c. CPT or HCPC codes not contained in the Medi-Cal fee schedule at the time of service are not reimbursable. d. If the billed charges are determined to be unallowable, in excess of usual and customary charges, or inappropriate pursuant to a medical review by CalOptima, CalOptima will contact provider for additional justification and these will be handled on a case-by-case basis.

Services with Unestablished Fees. If a fee has not been established by Medi-Cal for a particular procedure, and CalOptima has provided authorization for County to provide such service, CalOptima shall reimburse County under the following guidelines: a. “By Report Repo1t & Unlisted” " codes that CalOptima has provided authorization for County to provide such service will be paid at forty percent (40%) of billed ofbilled charges and must follow Medi-Cal billing rules, policies and guidelines. When billing CalOptima for these codes, County shall include documentation of Covered Services provided. b. County shall utilize current billing codes and modifiers for Medi-Cal. c. CPT or HCPC codes not contained in the Medi-Cal fee schedule at the time of service are not reimbursable. d. If the billed charges are determined detennined to be unallowable, in excess of usual ofusual and customary charges, or inappropriate pursuant to a medical review by CalOptima, CalOptima will contact provider for additional justification and these will be handled on a case-by-case basis.

Services with Unestablished Fees. If a fee has not been established by Medi-Cal Medicare for a particular procedure, and CalOptima has provided authorization for County Professional to provide such service, CalOptima shall reimburse County under the following guidelines: a. “By Report & Unlisted” codes that CalOptima has provided authorization for County to provide such service will be paid at forty percent (40%) of billed charges and must follow Medi-Cal Medicare billing rules, policies rules and guidelines. When billing CalOptima for these codes, County shall include documentation of Covered Services provided. b. County shall utilize current billing payment codes and modifiers for Medi-CalMedicare. c. CPT or HCPC codes not contained in the Medi-Cal Medicare fee schedule at the time of service are not reimbursable. d. If the billed charges are determined to be unallowable, in excess of usual and customary charges, or inappropriate pursuant to a medical review by CalOptima, CalOptima will contact provider County for additional justification and these will be handled on a case-by-case basis.