Department of Health Care Services guidance concerning non-covered benefits

This communication serves to inform and remind our care provider partners of long standing Department of Health Care Services (DHCS) guidance concerning non-covered benefits:

• The DHCS fee for service provider manual publishes a list of codes flagged as non-benefits.
• Please be aware the introductory language that prefaces the non-benefit list indicates Medi-Cal Managed Care may provide reimbursement for a non-benefit with an approved treatment authorization request.
• Please find below a link to the DHCS fee for service provider manual TAR and Non-Benefit – Introduction to the List:
  • [tarandnon.pdf (ca.gov)]
• In the event the service requested is found on the DHCS non-benefit list, providers cannot deny services as a non-benefit, a medical necessity review will need to be completed. If the service is found to be medical necessary, the services must be authorized.
• DHCS has indicated Medi-Cal plans and their delegates are required to review non-covered benefits for medical necessity.