MedicaidAdministrativeMedium impact
20-021 Change to Capiatated Claims Encounter Duplicate Logic
Health Net·CA·Reimbursement
Effective date
Nov 25, 2019
We identified it
Jun 20, 2026
Summary
Effective November 25, 2019, CalViva Health's duplicate claims detection system now includes NDC codes as part of the validation criteria for capitated encounter claims. If the same procedure code and NDC code combination is submitted more than once for the same member, the encounter will be rejected.
Action Required
Immediately: Billing team must ensure that procedure code and NDC code combinations are unique for each capitated encounter submission to CalViva Health. Update billing system validation to prevent duplicate procedure/NDC combinations for the same member on the same date of service. Verify that billing software checks for NDC codes in addition to existing duplicate criteria before submitting encounters to avoid rejections.