1. (a) The Department, upon review of substantiating documentation received to justify good cause for late submittal of the claim, may receive and authorize the processing of late claims if the reason for delayed submission is due to the following circumstances which are beyond the control of the provider:

   1. (1) Failure of the patient or legal representative, due to deliberate concealment or physical or mental incapacity, to present identification as a Medi-Cal beneficiary. Delayed billing shall be submitted not later than 60 days after the date certified by the provider as the date the patient was first identified as a Medi-Cal beneficiary. The date certified by the provider as the date the patient was first identified shall not be later than one year after the month in which the service was rendered. Identification of a patient as a Medi-Cal beneficiary means presentation of any of the following for the month of service:

      1. (A) Medi-Cal card.
      2. (B) MEDI label.
      3. (C) Proof of eligibility (POE) label.
      4. (D) Any of the above indicating Kaiser, Ross-Loos or CHAMPUS coverage, when accompanied by denial of coverage or an explanation of the other coverage by that carrier.
   2. (2) Billing involving other coverage, including Medicare or other health insurance coverage. Billing shall be submitted not later than one year after the month of service to permit the provider to obtain proof of payment, partial payment or nonliability of the carrier.
   3. (3) Initiation of legal proceedings to obtain payment of a liable third party, pursuant to Section 14115 of the Welfare and Institutions Code.

   4. (4) Determination by the Director that the provider was prevented from submitting bills for services, within the time limits set forth in Section 51008, due to circumstances beyond the control of the provider, as described below. The Director may extend the time period for the submission of bills for a period not to exceed one year from the date of service for any of the following:

      1. (A) Delay or error in the certification or determination of Medi-Cal eligibility by the State or county.
      2. (B) Damage to or destruction of the provider's business office or records by a natural disaster, including fire, flood or earthquake; or circumstances involving such disaster have substantially interfered with processing bills in a timely manner.

      3. (C) Delay of required authorization by:

         1. 1. Medi-Cal Field Services.
         2. 2. Professional Standards Review Organization.
         3. 3. California Children's Services.
      4. (D) Compliance with Section 51470 (b) involving undelivered custom-made items.
      5. (E) Delay by the Department in enrolling a provider or fiscal intermediary in supplying billing forms to the provider.
      6. (F) Theft, sabotage or other deliberate, willful acts by an employee.
      7. (G) Other circumstances that are clearly beyond the control of a provider that have been reported to the appropriate law enforcement or fire agency when applicable.
      8. (H) The unforeseen cessation of maternity care for a patient for whom prenatal care was provided on the assumption that global billing would be used.

   5. (5) Special circumstances that cause a billing delay beyond the time limitations specified in this Section 51008. Such bills may be submitted for processing beyond the time limits specified in Section 51008, provided such submittal is within 60 days after the date of resolution of the circumstances causing the billing delay. These circumstances include:

      1. (A) Court decisions.
      2. (B) State hearing decisions.

2. (b) Circumstances that shall not be considered beyond the control of the provider include, but are not limited to:

   1. (1) Negligence by employees.
   2. (2) Misunderstanding of or unfamiliarity with Medi-Cal regulations.
   3. (3) Illness or absence of any employee trained to prepare bills.
   4. (4) Delays caused by the United States Postal Service or any private delivery service.

Note: Authority cited: Section 20, Health and Safety Code; and Sections 10725, 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14021, 14053, 14115, 14124.1, 14124.2, 14124.24, 14131 and 14133, Welfare and Institutions Code; and Title 42, Code of Federal Regulations, Section 447.45(d)(4)(iv).

History

1. Renumbering and amendment of former section 51008(e) to section 51008.5 filed 12-6-85; effective thirtieth day thereafter (Register 85, No. 49). For prior history, see Register 81, No. 31.

2. New subsection (a)(4)(H) and amendment of Note filed 9-16-92; operative 10-16-92 (Register 92, No. 38).

3. Editorial correction of subsection (a) (Register 2011, No. 26).

4. Change without regulatory effect relocating former subsections (b)(5)-(b)(5)(B) to new subsections (a)(5)-(a)(5)(B) and amending Note filed 6-29-2011 pursuant to section 100, title 1, California Code of Regulations (Register 2011, No. 26).

5. Change without regulatory effect amending Note filed 12-16-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 51).