Medi-Cal Resubmission of Erroneously Denied Laboratory Services Claims

The Department of Health Care Services (DHCS) identified a claims processing issue affecting non-split billable pathology claims billed with NCCI-associated modifier in the first modifier position. This issue caused some claims to erroneously deny with Remittance Advice Details (RAD) code 0196: This procedure requires a modifier; modifier is not present. The issue affected claims for dates of service from January 1, 2011, through October 25, 2021.

No action is required on your part. The California Medicaid Management Information System (MMIS) Fiscal Intermediary will resubmit the affected claims. These resubmissions will appear on RAD forms beginning January 13, 2022, with Claim Control Number (CCN) prefix 200455.

Source: https://files.medi-cal.ca.gov/pubsdoco/epc/2022/31585_p43332.pdf