County of Ventura - Health Care Agency
EMSF/CHIP/TSF UNCOMPENSATED CARE PROGRAM

GENERAL RULES & CLAIMING GUIDELINES

[Note: This document is a general summary ONLY. The complete "EMSF/CHIP/TSF Policies and Procedures" and applicable law govern this program and must be referred to for full details. In the event of any inconsistency, the complete "Policies and Procedures" document will apply.]

I. GENERAL RULES

A. Allowable Gross Charges: Calculated by using CPT Codes, RBRVS unit values and Medicare Conversion Factors up to a maximum of 200% (effective July 1, 2000) of Medicare allowable for Ventura County; not to exceed billed charges.

B. Reimbursement: Maximum of 50% of Allowable Gross Charges, not to exceed billed amount; percentage may vary to be pro-rated according to the quarterly funding levels.

C. Payment Cycles: Checks will be issued quarterly; percentage of payment to be determined at the end of each fiscal quarter, based on funding levels and eligible claims received during that quarter.

D. Location: Services must be rendered in Ventura County.

II. CLAIM ELIGIBILITY

A. Submission Date: Claims must be submitted no earlier than 3 months, nor later than 120 days from the date of services following reasonable billing efforts to collect from patient and/or other payment sources (insurance, Medi-Cal, Medicare, etc.).

B. Forms: Claim must be submitted on a HCFA 1500 claim form, accompanied by a completed Uncompensated Care Program Data Claim Form and Physician Services Acknowledgment Form signed by the physician.

TO AVOID REJECTION OF CLAIMS, PLEASE NOTE THE FOLLOWING WHEN SUBMITTING CLAIMS:

• Data Claim Form: Items 19. - 24. must be completed in entirety, or claim will be rejected.
  "Pediatrics" or "Obstetrics" - is non-emergent, in-office services.
  In addition to above, select "Non-Contract Emergency" for emergent Pediatric, OB and all other emergency care.
  Items 1. - 8. are to be as complete as possible. If unable to complete any part of patient info being requested, mark question "unknown"
• Do Not Submit Duplicate Claims: A processing fee of $5.50 will be deducted from final claim payment, if duplicate claim is submitted.

C. Eligible Services:

• Emergency Medical Services Fund (EMSF - Maddy) - Service provided by a physician for care rendered in an Emergency Room of a hospital located in Ventura County; and/or within 48 hours of admission to a hospital through the Emergency Room.
• California Healthcare for Indigents Program (CHIP) - for all nonemergent Obstetric services from the time of conception until ninety (90) days after the pregnancy ends; and Pediatric care provided to a patient under 21 years of age regardless of location (in office, hospital in-patient or out-patient); or meets EMSF eligibility criteria.
• Tobacco Settlement Fund (TSF): Supplement to EMSF & CHIP - Supplement to the EMSF/CHIP for services provided by a physician for care rendered in an Emergency Room of a Hospital in Ventura County; and/or within 48 hours of admission to a hospital through the Emergency Room.
• Tobacco Settlement Fund (TSF): Beyond 48 Hours of Admission - Separate claim must be submitted for services rendered by a physician or surgeon beyond 48 hours of admission to a hospital and within 60 days of the initial services rendered in an Emergency Room within Ventura County, regardless of location (in office, hospital in-patient or out-patient). Claim must reference Date and Provider of initial Emergency Room visit.
  

D. Exclusions: Claims determined to be Medi-Cal eligible will be denied. Medi-Cal eligibility screening will be conducted by Fund Administrator (AIA) monthly on all claims received. Denied claims will be immediately returned to physician with information for Medi-Cal submission.

E. Claim Rejection and Appeals:

• Rejected claims: Revised claims previously rejected for incomplete information must be received by the contracted Fund Administrator (AIA) within 20 calendar days from the date of the rejection letter.
• Appeals: Physician must submit an appeal of any denied claim within thirty (30) calendar days from the date of the denied Remittance Advice. Request from appeal may be submitted to the Physician Reimbursement Advisory Committee, a committee of physicians selected by the Ventura County Medical Association. Appeals shall include the CHIP Data Collection Form, HCFA 1500 Claim Form, and if applicable operative reports and other supporting documents as needed. Appeals shall be mailed to:

  American Insurance Administrators (AIA)
  Ventura EMSF/CHIP/TSF
  Attn: Appeals Unit
  P.O. Box 641635
  Los Angeles, CA 90064-6135
  Jan 2002