Medi-Cal/Medicaid

Medicaid Program

Social Security Title 19 is a program for medical Assistance for low in come individual  and families. The Centers for Medicare and Medicaid Ssevices of the Bureau of Program Operations of the US Department of Health and Human Services (DHHS) is responsible for the federal aspects of Medicaid. But each state design its own Medicaid program within federal guidelines. Coverage and benefits varies from state to state because the federal government set a minimum requirements. 

The program is known as Medicaid in 49 states and Medi-Cal in California. 
Medicaid Eligibility
Medicaid is available to certain needy and low-income people, such as elderly (65 and above), blind, disabled, and families members who are dependent children to a single parent and financially eligible base on income and resources.

Eligible Group for Medicaid Benefits:
     Pregnant women and children
     Temporary Assistance for Needy Families (TANF)
     Infants born from Medicaid eligible pregnant women
     Children younger than 6 y/o
     Family whose income is below 135% of Federal Poverty Level (FPL)
     Aged and Disabled
     Supplemental Security Income (SSI-related group)
     Medicaid Qualified Medicare Beneficiaries (QMB or kwim-bees)
     Specified Low-Income Medicare Beneficiaries (SLMB or slim-bee)

Medicaid Basic Benefits:
    Family Planning (Family PACT - Planning Access Treatment and Care in Medi-Cal)
    Home Health Care
    Immunizations
    Inpatient Hospital Care
    Laboratory and X-ray
    Outpatient Hospital Care
    Physician's care
    Screening, Diagnosis and Treatment of children younger than 21 y/o
    Skilled Nursing care
    Some states, might include the following services:

       a. Allergy care                                                                       b. Ambulance services     
       c. Some medically necessary cosmetic procedure                d. Chiropractic care
       e. Clinic care                                                                         f. Dental care
       g. Dermatological care                                                          h. Emergency department care
       i. Eye glasses                                                                         j. Hospice care
       k. Intermediate care                                                              l. Occupational Therapy services
       m. Podiatric Care                                                                  n. Private Duty Nursing
       o. Prosthetic devices                                                             p. Psychiatric care
       q. Respiratory care                                                                r. Speech Therapy

Eligibility Verification

A plastic Medi-Cal identification must be abstracted from the card for claim submission are patient's name, Medi-Cal ID number, gender and date of birth.







Point-of-Service (POS) Machine

Medicaid terminal equipment, such as
Point-of-Service (POS) machine. When professional services are rendered, eligibility must be verified which must be done in a number of ways. POS is a machine that allows the user to verify the coverage in seconds. Some provider offices have their own electronic system verification  via touch-tone telephone or modem.

Certain procedures and services are subject to authorization by Medi-Cal before reimbursement can be approved.  Authorization requests are made with a Treatment Authorization Request (TAR).  Authorization requirements are based on Federal and State law.

There are two ways to submit a TAR for review, electronically or by paper.

The TAR processing system will accept TARS via the electronic TAR (eTAR) system.  Electronic TAR (eTAR) is a web-based direct data entry system used by Medi-Cal providers.  Medi-Cal providers have the ability to use eTAR for the purpose of submitting most TARs and inquiring about TAR decisions.  eTARs submitted by providers are entered via a secured location on the Department of Health Care Services (DHCS) Medi-Cal website and reviewed and adjudicated by DHCS consultants.  For additional information, refer to the eTAR Submission Guidelines in this section.

Medical Necessity

The Medi-Cal program defines medical necessity as the provision of health care services that are reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.

Authorization may be granted when the services requested are reasonably expected to:

• Restore lost functions

• Minimize deterioration of existing functions

• Provide necessary training in the use of orthotic or prosthetic devices

• Provide the capability for self care, including feeding, toilet activities and ambulation

Electronic Treatment Authorization Request (eTAR) Submission Guidelines

The TAR processing system will accept electronic treatment authorization transactions via the current electronic TAR (eTAR) system.  Using the eTAR submission process, providers can create, update, inquire and view responses for TARs online. Using eTAR eliminates mail and paper processing time.

To use the eTAR application, providers must have a Medi-Cal Point of Service (POS) Network/Internet Agreement form on file.  This form is available in the Part 1 manual and on the Medi-Cal website (www.medi-cal.ca.gov) by clicking the “Forms” link. 

            Note: Attachments for eTARs submitted via the attachment fax line

                        (1-877-270-8779) must have a completed TAR 3 Attachment 

                        form as the cover sheet or first page for attachments.  

The Web-based treatment authorization transaction is available on the Medi-Cal website (www.medi-cal.ca.gov) by logging on to “Transaction Services” and clicking the “Online TAR Applications” link.

Providers submitting eTARs for a procedure code that does not normally require a TAR must select the special handling description “Cannot bill direct, TAR is required,” which is found in the Patient Information section of the eTAR application.