Financial Screen Settings for SOC Clients:

When a Medi-Cal eligibility transaction reports that a client has a Share of Cost, their claims require special handling.  The Share of Cost balance must be recorded and then, as services are provided throughout the month, spent down. Once the SOC = $0.00, the client becomes Medi-Cal eligible for that month. Until then, the client is responsible for the cost of care.

Claims for these clients are billed to LA DMH and in most cases this will be the only payer for these clients. As such the payer account recorded for a client with a share of cost will look like the one below.

Recording/Tracking Share of Cost Balances

The key to successfully billing SOC claims lies in recording an initial SOC balance for each month that a share of cost applies, then spending it down as services are provided. This requires some SOC-specific settings on the Financial screen.

1. Flag the client as one with a share of cost.  Check the Check for SOC When Claiming box then click the Save Financial Data button.
2. Click the Manage SOC Amount link. If you don’t see these fields, click the More Details link to expand the screen.

Note: If you don’t enable Check for SOC When Claiming, then claims may be sent to DMH without the required SOC information and will more than likely be denied.

 3. Set the funding to be used for claims where the SOC balance is not $0.00 and that are entirely the client's responsibility.  These claims must still be reported to LA DMH in order to qualify for reimbursement of the portion not paid by the client at fiscal year-end. Such claims must be charged to a non-Medi-CAL funding source. There are three options for doing this: 

• By default, they’ll be billed to the non-Medi-CAL version of the same funding source. E.g., if the client uses PEI-Adult you'll want to bill the claims the client is 100% responsible for to the non-Medi-CAL PEI-Adult fund. If this is your preference, then no action is required. 
• If you do not have a contract for the non-Medi-CAL version of the client's fund or have reached your MCA for that fund and want to bill these claims to a different non-Medi-CAL funding source, select it from the list provided, then click Update. 
• Alternatively, you may opt to not ask for reimbursement from the county at FY end for those claims which the client is 100% responsible. If that’s true, then check the "I want to bill the non-Medi-CAL fund for the client's configured funding source even if there is no contract" box. If you do this, the drop-down list of non-MC funds disappears and claims that are entirely the client’s responsibility will bill against the non-MC version of the fund they usually bill against, even if it is not in your contract. Click Update to set this option.

Note: Step 3 is only required when billing to DMH IS and is not required for IBHIS claiming.

 4. Enter the SOC balance. The current month is selected by default. To record a share of cost for a previous month, select it from the View share of cost details list and click Refresh, then click Enter a New Share of Cost Balance. 

On the resulting screen, enter the SOC amount reported by the State and the date that this applies, typically the first day of the month, then click Add Share of Cost Balance.

Your screen will update to display the SOC record.

What Happens When a Claim for a Client with Share of Cost is Invoiced? 

Clients with a Share of Cost are not Medi-Cal eligible until the entire SOC amount has been obligated to the client. When activities for SOC clients enter the invoicing queue and the system check indicates that SOC for that month of service has not been met, they’re diverted to Accounting – Claims with Problems Preventing Invoicing.

Such a claim will look like the one shown below and cite the problem as “This client uses SOC but this Medi-Cal claim does not have an SOC amount applied and there is a non-zero SOC balance for the month the service was performed”. 

Please do not mark these claims as resolved until they’ve been updated to apply SOC.

Processing SOC Claims – Single Payer (DMH)

Since Share of Cost applies to all services a client receives, whether provided by your agency or another service provider, the outstanding SOC balance may change frequently. It is recommended that you perform a single-subscriber eligibility check on the State Medi-Cal site at http://www.medi-cal.ca.gov/ every time you are working with claims for one of these clients.  We highly recommend that you follow the workflow outlined below, performing each step in the order listed. 

1. Perform a single-subscriber eligibility check on the State Medi-Cal site. If the SOC balance reported by the State matches the SOC balance in Exym, then you do not need to adjust the Exym balance.
2. If the SOC balance reported by the State does not match the Exym balance, then you will need to adjust it.
   • Select the client’s Financial screen.
   • Click Manage SOC balance.
   • Click Enter a New Share of Cost Balance.
   • Create a new entry to record the SOC balance reported by the State. Enter the current balance, the date that the eligibility check was performed, and a note to explain why the balance is reduced.        
   • A balance adjustment entry will look like the one below.
3. Click the Services without SOC Assignment tab. You’ll see a screen like the one below listing billable activities sorted by Service Date.
4. Click the Apply SOC button for the first claim you want to work with. Your screen will update again. The new screen reports the current SOC balance, the service charge amount (fee) and the amount of SOC to be applied. If you’ve collected all or a portion of this fee from the client, record the amount paid. Otherwise, leave the Amount of SOC Paid by Client field blank.
5. Click Apply SOC. This will do several things:
   • Update the SOC balance, reducing it by the Service Charge Amount. Note that the SOC balance previously reported as $486.52 has been reduced to $166.52.
   • Move the claim to the SOC Assignments tab. If you made this SOC assignment in error, you may cancel it by clicking Take Back SOC Balance.
   • Create a record on the SOC Balance tab to report the Activity ID used to obligate the SOC and the new balance. Note that there is still a remaining SOC balance for this client.
   • If the SOC was not completely spent down, the funding will be updated to bill the claim as stipulated on the Funding Source for 100% SOC Claims tab.
6. If you have more than one claim to assign, repeat steps 3 - 5 to complete this process. When more than one claim is assigned on the same day, all of the claims are reported as a single balance record. Each claim assigned will further reduce the SOC balance until it is completely spent down ($0.00).   The following screen reports two adjustments on the same date.          
7. Perform Share of Cost Transactions on the State Medi-Cal site at http://www.medi-cal.ca.gov/ . This must be done to reduce the amount of SOC remaining on the State site.
8. Mark the claim(s) as resolved on Accounting – Claims with Problems Preventing Invoicing. This will release them to be invoiced. If you bill DMH via EDI or IBHIS, the claims will be included in your next regularly scheduled 837 files.  If you manually enter claims into DMH IS, they’ll appear on the MIS Billing Report.

When the SOC has been completely spent down, the SOC Assignments screen will look like the one below.

If Claims with Problems Preventing Invoicing listed multiple claims citing the problem as “This client uses SOC but this Medi-Cal claim does not have an SOC amount applied and there is a non-zero SOC balance for the month the service was performed”, those claims will automatically be marked as resolved and be set for inclusion in your next regularly scheduled 837 file (EDI billing) or appear on the MIS Billing Report the next day (direct data entry billing). 

Processing Claims – Multiple Payers (OHC or Medi/Medi)

When a client has OHC and a share of cost, the claims must be billed to the OHC payer first, just as they are for clients with OHC who do not have a share of cost. When the OHC claims have been processed and paid or denied, you will record the claim adjudication details as usual. Then, if a balance remains, the claim will “roll over to bill to LA DMH as usual, except that at this point, the SOC claiming rules will apply. This means that you will need to follow the same steps to allocate SOC and bill as described above for single-payer clients with a share of cost.

Voiding SOC Claims

Voids for SOC claims are generated in the same way as other voids. Where this process differs is that for each void, you’ll need to decide whether or not to reverse the SOC spend down associated with the claim.

You should reverse the SOC amount applied to a claim whether or not it has actually been submitted to DMH, if…

• The activity was added in error and will be deleted.
• The activity was billed and will be retained but will updated to No Charge.
• The claim will be rebilled but was voided to change any of the billing information (e.g. date of service, number of minutes billed, funding source billed).

To reverse SOC when voiding a claim, please follow these steps in this order:

1. Select Accounting – Manage Claims – Individual Activities or Accounting – Manage Claims – Group Activities from the main menu.
2. Locate the desired claim on the grid.
3. Click View Claims.
4. Click the desired modification option (correct Activity, Correct Activity and Set Note to In Progress, or Delete Activity).
5. Select Clients – Edit Client Data (Tabs) – Financial from the main menu.
6. Click Manage SOC Balance.
7. Click the SOC Assignments tab.
8. Locate the claim to be voided, then click the Take Back SOC button. This will reverse the previous spend down associated with this claim and adjust the SOC balance accordingly.  For example, if the current SOC balance is $0.00 and you reverse SOC for a claim that charged $320.00, the SOC balance will now be $320.00.
9. If the claim will not be rebilled, then the SOC Transaction you performed on the State Medi-Cal Site must be cancelled. 
   • Log on to http://www.medi-cal.ca.gov/ .
   • Click the SOC (Spend down) Transactions link.
   • Bubble SOC (Spend Down) Reversal
   • Enter the information into the fields marked as required. Be sure that the service date, procedure code, charge amount and SOC Applied amount match the original transaction you recorded to bill the claim.

Correcting/Rebilling Denied SOC Claims

The procedures for correcting and re-billing denied SOC claims is pending final development. This is because the procedures will vary, depending on why the claims were denied and whether they were submitted prior to the recent changes in SOC processing in Exym. If you have denied SOC claims, please open a ticket with the Exym Help Desk to ask for assistance and be sure to include the Activity IDs for the denied claims.