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Non-Payment of Inappropriate Claiming for Members Not Enrolled in the ALW Program
Effective date
Not stated in the notice
Identified
Oct 10, 2026
Summary
DHCS is notifying California facilities that claims for Assisted Living Waiver (ALW) services may be denied if members are not properly enrolled in the ALW program or if claims do not comply with ALW requirements. DHCS is currently reviewing previously paid claims and may deny or reprocess erroneously paid claims. Facilities must verify ALW eligibility before delivering services, comply with all ALW standards and policies, submit claims with correct procedure codes and modifiers, and review internal processes to ensure accurate claiming and documentation.
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What to do
Action · 7 steps
01Immediately, the billing team and clinical staff must.
02Implement a verification process to confirm ALW eligibility prior to delivering services and submitting claims, using DHCS-approved processes outlined by the Care Coordination Agency (CCA).
03Review and ensure full compliance with all ALW standards, policies, and contract requirements in billing operations.
04Audit all claims submitted for correct procedure codes and modifiers consistent with ALW program integrity guidance.
05Review internal processes and documentation workflows to ensure accurate claiming and documentation for all ALW services.
06If the facility receives notification from DHCS regarding non-payable claims due to non-compliance, respond promptly with corrective action.
07Contact ALWClaimsSupport@dhcs.ca.gov with facility name and National Provider Identifier if clarification is needed.
If missed: Failure to comply may result in claim denials and potential reprocessing of previously paid claims with recoupment.
Original notice
Non-Payment of Inappropriate Claiming for Members Not Enrolled in the ALW Program
mcweb.apps.prd.cammis.medi-cal.ca.gov · Always check the source before changing claims.