Cost Avoidance and Post-Payment Recovery for Other Health Coverage
DHCS released APL 21-002, Cost Avoidance and Post-Payment Recovery for Other Health Coverage (OHC). Medi-Cal members must utilize their OHC for covered services prior to utilizing their Medi-Cal benefits. Managed Care Plans (MCPs) must include OHC information in their notification to the provider when a claim is denied due to the presence of OHC. SFHP is required to make sure providers are identifying and billing the OHC carrier as primary prior to seeking payment from Medi-Cal. MCPs must seek reimbursement for covered services for which the third party is liable.
Link to DHCS APL 21-002:
APL 21-002 (ca.gov)
Please review these documents for additional information on the APL policy, DMG requirements, OHC reporting guidelines, and FAQs. Please note, SFHP will continue to update this page with new documents as we receive guidance from DHCS.
OHC information is now available on paper remittance advice and SFHP’s Provider Portal.
The following information is displayed on paper remits when a claim is denied due to the presence of OHC:
- Carrier Name
- Member Policy Number
- Carrier Phone Number
- Carrier Address
For providers receiving electronic remittance advice (835s), SFHP’s Provider Portal has been enhanced to display the information.
APL 21-002 Appendix A – OHC Code Descriptions (3/17/2021)
SFHP – OHC Reporting Memo (4/8/2021)
DMG Requirements Memo (6/2/2021)
APL 21-002 Appendix B – Reporting Requirements (6/2/2021)
OHC Information Report Template (6/2/2021)
For further questions regarding APL 21-002, please contact SFHP’s Provider Relations Department at 1(415) 547-7818 ext. 7084 or email provider.relations@sfhp.org