Common Elements of Insured Services

Elements that are common to all insured services, and therefore not billable as an additional item to either MCP or the patient, are:

(a) being available to provide follow-up insured services to the patient and making arrangements for coverage when not available, 

(b) making any arrangements for appointment(s) for the insured service, 

(c) making arrangements for any related assessments, procedures or therapy and/or interpreting results, 

(d) obtaining and reviewing information (including history taking) from any appropriate source(s) so as to arrive at any decision(s) made in order to perform the elements of the service, unless stated otherwise, 

(e) obtaining consents or delivering written consents, 

(f) keeping and maintaining appropriate physician’s records, 

(g) preparing or submitting documents or records or providing information for use in programs administered by the DHCS, 

(h) conferring with and/or providing advice, direction or information to physicians and other professionals associated with the health and development of the patient, 

(i) providing premises, equipment, supplies and personnel for the common elements of the service, and 

(j) direct physical encounter with the patient including any appropriate physical examination and ongoing monitoring of the patient’s condition where indicated, unless specifically listed as a “monitoring only” fee. 

CLAIM SUBMISSION AND DOCUMENTATION REQUIREMENTS 

4.1.1 All service items billed to MCP are the sole responsibility of the physician rendering the service with respect to appropriate documentation and billing. 

4.1.2 If a specific fee code for the service rendered is listed in the Payment Schedule, that fee code must be used in claiming for the service, without substitution. 

4.1.3 Claims for services rendered in hospitals and long term care facilities must include the hospital/facility number of the institution where the service was rendered. 

4.1.4 For all services in the In-Hospital Diagnostic, Radiology and Nuclear Medicine Sections, the date of service is the date the service is reported rather than the date the patient is subject to the procedure. For all other services, date of service is the date of patient contact. 

4.1.5 Documentation of services which are to be billed to MCP must be completed before claims for these services are submitted to MCP. 

4.1.6 All claims submitted must be verifiable from the physician’s records with regard to the examination and/or procedure claimed. Where specific elements of record requirement are listed in this Preamble, but do not appear in the patient record of that service, that element of the service is deemed not to have been rendered and the fee component represented by that element is not payable.

 4.1.7 A physician shall, upon request by MCP, make available to MCP copies of patient records as may be required to clarify or verify services for which fees have been claimed. 

4.1.8 For MCP Audit purposes, it is required that physicians maintain records supporting services billed to MCP for a period of six years. MCP Audit is routinely two years.