Provider Payment Reductions and Billing Guidelines

Immediately: Billing team must verify all PAD billing codes against the current Medi-Cal Rx Pharmacy Reimbursable Physician Administered Drugs list and the Contract Drugs List. For PADs not appearing on these lists, update billing software to route claims as medical claims instead of pharmacy claims. Implement verification process to determine appropriate billing entity before submission. Prior coverage under L.A. Care pharmacy network before January 1, 2022 does not guarantee current coverage, so verify all PAD coverage status. Identify all services currently being billed that may qualify for TRI Fee Schedule exemptions and configure billing system to bypass the 1% reduction for those services. Update claim submission protocols to ensure the automatic 1% payment reduction is not applied to exempt services (free-standing sub-acute facilities, family planning, free-standing pediatric sub-acute facilities, and TRI-listed services). For questions on TRI eligibility, contact LACareTRI@lacare.org. Failure to properly classify PADs and apply exemptions will result in incorrect reimbursement and potential claim denials.