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DHCS All Plan Letter 21-002 — post-payment recovery and Other Health Coverage (OHC) reporting
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Guidance and FAQs from DHCS on MCP requirements for post-payment recovery reporting, OHC discovery/reporting, file submission processes, claim statuses, and treatment of recoveries — applicable to Medi‑Cal managed care plans (MCPs).
Policy Summary
Payersanfranciscohealthplan
PolicyPost-payment recovery and OHC reporting (APL 21-002 FAQs)
Policy CodePolicy N/A
Change TypeGuidance/Operational
Effective DateJan 1, 2021
Next Review DateN/A
Key ActionInclude known OHC details (carrier, policy number, contact) in provider denial notifications or on the Remittance Advice when denying claims for OHC.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
Apr 1, 2021initial report deadline
3 yearsinitial look-back
12 monthsmonthly look-back
10 daysreport newly discovered OHC
15thmonthly report due by
Post-payment Recovery & OHC Reporting Criteria
Post-payment recovery and OHC reporting criteria
Key coverage and reporting criteria extracted from the APL FAQs.
Initial post-payment recovery report must include three years of historical recovery activity (look-back period ends the day before submission).
Subsequent monthly reports must contain 12 months of historical recovery activity (rolling 12-month look-back).
Use claim statuses: Paid, Denied, Open (replaces 'pending'), and Recouping (new). Change Recouping to Paid when the full claim amount has been recouped.
Reports include recoveries even if money was recovered within 12 months from the date of payment; include unsolicited provider refunds due to OHC. If a refund due to OHC is received after 12 months, MCPs must remit to DHCS unless an active repayment plan was initiated within the past 12 months.
MCPs must report newly discovered OHC that is not found or is different from MEDS to DHCS within 10 calendar days of discovery; submit complete verified data (do not submit partial records).
If the 834 OHC indicator is 'N' and discovered OHC is not yet in HISDB, report the OHC to DHCS and wait 72 business hours; if the indicator remains 'N', do not use the OHC. If the indicator changes, MCPs may process the claim using the newly discovered OHC.
Beginning Jan 1, 2021, MCPs must include known OHC information (carrier name, policy number, and contact/billing information) in provider denial notifications or on the Remittance Advice when denying claims for OHC. Providers may access OHC via AEVS/HISDB.
MCPs must submit a test file (ten line items, Appendix B layout) to DHCS SFTP by March 10, 2021 and upload monthly production reports to the designated SFTP folder; DHCS will only notify MCPs on errors.
Third party tort liability and California Children's Services are outside the scope of this APL; fraud collection is outside COB scope and handled per contract fraud provisions.
DHCS requires MCPs to follow State Plan Attachment 4.22-B cost-effectiveness standards when pursuing recoveries; the report should show the full recovered amount (remit net after contractor/collection fees as applicable).
Claims to be reported must fall within the report's defined paid date range; the same recovery may appear on multiple reports while the paid date remains in range and will drop off once the paid date is outside the report range. Include previously reported claims if status changed.
Paid Date is not required on the post-payment recovery report (Paid Date exists on paid claims/encounter files).
MCPs must not process claims using OHC when the 834 indicator is 'N' unless the HISDB/AEVS shows the OHC or the 72-business-hour reporting/wait process results in the indicator changing.
MCPs should attempt to verify unknown OHC prior to submission using carriers, automated systems, or provider portals; do not submit partial OHC records.
MCPs may request HISDB access or batch update instructions via their MCOD contract manager; DHCS does not return a direct response file for batch processing and retains batch files in a subfolder until the Thursday after processing.
Test file must conform to Appendix B (10 lines) and include required fields such as EOB information and HI-36 instructions.
If an MCP initiated recoupment within 12 months and receives funds after month 12, the MCP may retain monies when an active repayment plan existed; otherwise recoveries beyond 12 months must be redirected to DHCS.
APL applies to any OHC claims paid by Medi-Cal (includes Medicare as OHC) but excludes California Children's Services and third party tort liability cases.
Post-payment recovery and OHC reporting requirements
Post-payment recovery reporting and remit rules summarized from DHCS FAQs.
MCPs must report recoveries for claims paid after April 1, 2018.
MCPs should include previously reported recoveries if the claim status has changed (for example, open to recouping or paid).
MCPs should not attempt recovery for claims with a paid date more than 12 months prior to recovery initiation (unless an active repayment agreement exists within the past 12 months).
If 'Bill Date' is after 12 months from 'Claim Paid Date' and a refund was received, MCPs must remit the recovered amount to DHCS unless an active repayment agreement was in place within the past 12 months.
DHCS will pursue recovery on claims with 'open' claim status that have dropped off monthly reports; MCPs should stop active pursuit when claims drop off the monthly report.
MCPs may either bill primary carriers or recoup from providers for recoveries; both approaches are acceptable.
MCPs should submit monthly post-payment recovery reports as close to the 1st of each month as possible; reports will be accepted if submitted by the 15th of the month.
DHCS will record the full recovered amount in the 'Remit Amount' field; DHCS does not plan to provide a separate 'Net Remit Amount' field. MCPs should report full recovered amount and remit net after allowable fees.
MCPs may submit more than one monthly post-payment recovery report file if unable to combine reports into one file.
HISDB monthly file is generally sufficient for OHC needs; daily files provide more current changes. MCPs can request HISDB access via their MCOD contract manager.
Codes, Identifiers, and Recovery Thresholds
OHC and claim status codes referencedmixed
| A | Pay & Chase — providers may bill OHC or Medi‑Cal; MCPs should recover from carrier if service covered |
| N | No coverage indicated |
| C | VA/Tricare (OHC code for those coverages) |
| Recouping | Claim status added to indicate claims in repayment agreements where full amount not recouped within 12 months |
| Paid | Claim fully recouped / paid |
| Denied | Third party payer processed the claim but denied payment |
| Open | Includes claims billed to OHC but not yet paid (replaces 'pending') |
Identifier mappingmixed
| CIN | Client Index Number referenced as 'Medicaid Number' field |
Recovery timeline threshold
Retention ruleMCPs may retain recoveries when an active repayment plan (recoupment/repayment agreement) was initiated within 12 months of the claim paid date; recoveries billed or paid within 12 months may still be retained by the MCP.
Reporting requirementPost-payment recovery reports must include recoveries regardless of dollar amount; MCPs must follow DHCS cost‑effectiveness standards per State Plan Attachment 4.22‑B when pursuing recoveries.
Contractor fees handlingReport the full amount recovered to DHCS and remit the recovered amount minus any contractor/collection fees charged to the MCP.
Unsolicited refundsInclude unsolicited provider refunds due to OHC in reports; if refund received after 12 months, remit to DHCS unless an active repayment plan existed within 12 months.
Look‑back interactionInitial report covers three‑year look‑back; monthly reports use a 12‑month rolling look‑back—retention rules reference the 12‑month initiation window for recoupment.
Recovery retention window
Retention windowMCPs may retain recoveries only if recoupment was initiated within 12 months from the claim paid date.
Report inclusionMonthly reports should include recoveries for claims with paid dates in the report's defined paid‑date range; a recovery drops off when the paid date falls outside that range.
Implementation scopeReports include recoveries for claims paid after April 1, 2018; MCPs should not attempt recovery for claims with paid dates more than 12 months prior to recovery initiation.
Provider Notices, File Submissions, and Reporting Actions
Documentation Required
Include OHC details in provider denial notifications (effective Jan 1, 2021)
Beginning January 1, 2021, when an MCP denies a claim because Other Health Coverage (OHC) exists, the MCP must include known OHC details in the provider notification (for example, on the Remittance Advice or a standalone denial notice). Required information includes the OHC carrier name, policy number, and contact/billing information.
- Include carrier name, policy number, and contact/billing information in denial notification or RA.
- Apply this requirement for denials due to presence of OHC beginning Jan 1, 2021.
Billing Rule
SFTP test upload by March 10, 2021 and monthly SFTP production uploads
MCPs must submit a test file with ten line items to their designated DHCS SFTP post-payment recovery test folder by March 10, 2021, using the layout defined in Appendix B. Monthly production reports must be uploaded to the MCP's designated SFTP folder; DHCS will notify MCPs only if there is an error or the file is not received.
- Test file must be ten line items and follow Appendix B layout.
- Upload monthly production files to the designated SFTP folder; no confirmation is sent unless there is an error.
- Usernames/passwords for SFTP access were distributed; contact MCOD contract manager if not received.
Note
Provide provider access to OHC via RA, standalone notice, or DHCS systems
MCPs should include OHC information on the Remittance Advice (RA); if the RA cannot contain the OHC details, MCPs must send the OHC information on a standalone denial notice. Medi‑Cal providers may also access member OHC information from DHCS eligibility systems or AEVS.
- Incorporate OHC info on the RA when possible; otherwise accompany denial with a standalone notice.
- Providers may access OHC via DHCS eligibility system or Automated Eligibility Verification System (AEVS).
Billing Rule
Multiple monthly post-payment recovery report files permitted
If an MCP cannot combine all recovery data into a single monthly file, DHCS will accept more than one monthly post-payment recovery report file from that MCP; multiple files are allowed rather than forcing a single combined submission.
- Acceptable to submit multiple monthly report files if unable to combine into one file.
- MCPs should still aim to submit reports close to the 1st of each month (acceptable by the 15th).
Key Terms and Identifiers
Recouping
DefinitionRecouping: claim status indicating an established repayment agreement between the MCP and provider where the full amount has not been recouped within 12 months from the original date of payment.
Status transitionChange claim status from 'Recouping' to 'Paid' once the full claim amount has been recouped.
Reporting behaviorClaims in 'Recouping' status are included in the post‑payment recovery reports and may appear on multiple monthly reports while their paid date remains in range.
OHC indicator codes (Appendix B)
Code A'A' — Pay & Chase: providers may bill other health coverage (OHC) or Medi‑Cal; MCPs should pursue recovery from the carrier if the service is covered.
Code N'N' — No coverage indicated (no OHC present in 834 indicator).
Code C'C' — VA/Tricare: OHC code used for VA or TRICARE coverage.
Usage noteThe 834 file contains only the OHC indicator; detailed OHC information is available on AEVS/HISDB.
SFTP (DHCS E‑Transfer) requirements
SFTP designationSecure File Transfer Protocol (SFTP) is the DHCS E‑Transfer site and MCPs must use their designated MCP folder for test and production uploads.
Test file deadlineMCPs must submit a test file containing ten line items in the Appendix B layout to DHCS' SFTP by March 10, 2021.
Error notificationsDHCS will not send confirmations for successful uploads; MCPs will only receive notifications if there is an error or the file is not received.
Multiple/multi‑file uploadsMCPs may automate SFTP uploads (scripts) and may submit more than one monthly recovery report file if unable to combine them.
Medicaid Number (CIN)
Medicaid identifierCIN — Client Index Number is the 'Medicaid Number' referenced in report fields.
Field formattingMedicaid Number (CIN), TIN, and TCN fields are text‑formatted but will accept traditional numeric characters.
HISDB mapping noteHISDB contains member OHC information; MEDS/834 contain only OHC indicator while detailed identifiers live in HISDB files.
Third Party Liability (TPL) — APL definition
TPL definitionThird Party Liability (TPL) for post‑payment recoveries is defined as other insurance coverage (not subrogation or tort liability).
Scope exclusionTPL as defined in the APL excludes third‑party tort liability and California Children's Services cases from recovery requirements.
Recovery approachesMCPs may bill primary carriers or recoup from providers for recoveries; both approaches are acceptable for TPL recoveries.
MEDS_ID and CIN mapping
MEDS_ID locationMEDS_ID occupies positions 3–11 in the 834 file and corresponds to a member's SSN or pseudo‑SSN.
CIN locationCIN occupies positions 27–35 in the 834 file.
Pseudo‑SSN noteIf a member lacks an SSN, MEDS_ID will be a pseudo‑SSN (starts with 9 and ends with P or Q), which maps to MEDS/CIN records.
Policy Summary
Payersanfranciscohealthplan
PolicyPost-payment recovery and OHC reporting (APL 21-002 FAQs)
Policy CodePolicy N/A
Change TypeGuidance/Operational
Effective DateJan 1, 2021
Next Review DateN/A
Key ActionInclude known OHC details (carrier, policy number, contact) in provider denial notifications or on the Remittance Advice when denying claims for OHC.
SourceLink
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