California Announces New Billing Model Option for Schools Participating in the LEA Billing Option Program

The California Department of Health Care Services (DHCS) has announced the addition of Model 4 as service delivery option for schools that bill Medi-Cal for eligible direct medical services under the LEA Billing Option program. The new policy is effective July 1, 2013 and was officially issued in Policy and Procedure Letter (PPL) 13-006.

According to PPL 13-006, Model 4 will allow local educational agencies (LEAs) to use a mix of employed and contracted practitioners to “provide some services directly and contract out entire service types without directly employing a single practitioner in a service category.” Under this new billing model, the contracted practitioner or agency must first reassign their rights to bill Medi-Cal to the LEA. When submitting claims, LEAs must enter the National Provider Identification (NPI) number of the contracted practitioner or agency that provided the service.

The addition of Model 4 as a service delivery option means that California LEAs will now be able to bill for services under all four federally approved models. Prior to PPL 13-006, California LEAs were able to bill for services provided under Models 1, 2, and 3:

  • Model 2 – Contracting of Health Care Practitioners or Clinics. The LEA contracts with health care practitioners or clinics to provide health services to LEA students that the LEA does not employ practitioners to provide. For the LEA provider to bill and receive Medi-Cal reimbursement for the covered services, the provider of services must voluntarily reassign their right to payment to the LEA. [Read more about this service delivery model in the DHCS LEA Provider Manual…]
  • Model 3 – Direct Employment and Contracting with Health Care Practitioners to Supplement Services. The LEA uses a combination of employed and contracted health care practitioners to render health services to LEA students. In addition, to supplement health services that are already being rendered by their own employees, LEAs contract with additional health professionals. The services rendered by the additional health professionals must be the same as those offered by LEA practitioners. [Read more about this service delivery model in the DHCS LEA Provider Manual…]

DHCS is currently working to update the LEA Provider Manual to reflect the addition of Model 4 as a service delivery option, effective July 1, 2013, for the LEA Billing Option program.

 

Read More

PPL 13-006, issued by DHCS on July 1, 2013…

Complete DHCS LEA Provider Manual (“Models of Service Delivery” is located in section ‘loc ed a prov’, page 5)…