Updated process for submitting service and utilization information and copies of paid invoices related to third party liability

On May 10, 2021, the California Department of Health Care Services (DHCS) released APL 21-007, the Third-Party Tort Liability Reporting Requirement All Plan Letter (APL). This APL mandates processes for submitting service and utilization information and copies of paid invoices/claims for covered services related to third-party liability (TPL) torts to DHCS These requirements replace submission procedure previously required by APL 17-021, 11-012, and 01-002.

Providers must submit the requested service and utilization information using only the standardized DHCS Excel template and must compile all service and utilization information for covered services associated with a given Medi-Cal Managed Care member within one Excel file. 

Effective August 2, 2021, all delegated provider medical groups (PMGs) and independent physician associations (IPAs) must submit service and utilization information and, when requested, copies of paid invoices/claims for covered services to Anthem Blue Cross (Anthem) within the time frame outlined in Anthem’s request. This information must contain the following data elements:

• Name of the managed care plan or IPA
• Member name
• Date of birth (provided by DHCS)
• Client index number (CIN)
• Date of injury
• Claim control number
• Claim line number
• Claim type
• Service from date
• Service to date
• Provider legal name
• National provider identifier
• Diagnosis code 1 (primary diagnosis)
• Diagnosis code 2 (secondary diagnosis)
• Drug label name
• Amount billed
• Amount paid: the actual amount the PMG or IPA paid to the provider for services
• Reasonable value: absent the amount paid due to capitated or other service type, the reasonable value of the service must be provided, pursuant to Title 28, California Code of Regulations (CCR), section 1300.71(a)(3)3)
• CPT^® code and type
• Primary/secondary claim denial reason code and description(s)

Effective August 2, 2021, Anthem began to require all PMGs and IPAs to enter the required data into the template and email to SSB_TPL@anthem.com. 

Failure to provide the required information timely may result in issuance of a corrective action plan.