Letter of Authorization (LOA)/MC 180

MEDI-CAL

Letter of Authorization (LOA)/MC 180

Release Date

09/24/2018

Section Heading

Purpose

To convert existing policy to the new webpage - No content changes.

Policy

A Letter of Authorization (LOA)/MC 180 Over-One-Year Form (MC 180) is issued when proof of eligibility is needed for medical services that occurred more than one year after service is provided. A MC 180 may only be issued under the following conditions:

Supplemental Security Income/State Supplementary Payment (SSI/SSP) eligibility was approved but the Department of Health Care Services (DHCS) did not or could not update the Medi-Cal Eligibility Data System (MEDS).
A Court Order requiring that Medi-Cal (MC) be issued.
A State Hearing or other administrative hearing decision requiring that MC be issued.
DHCS requests that MC be issued.
An administrative error has occurred.

The County can be held liable for costs incurred when an MC 180 is issued fraudulently or incorrectly. Therefore, it is important to properly document that the MC180 was certified, approved, and issued in accordance with regulations.

Background

In accordance with the California Code of Regulations (CCR), Title 22, Section 50746, the issuance of an MC 180 is an exception in federal law. This exception allows a provider to submit a claim more than one year after the date of service.

Definitions

Terms and Descriptions

Department of Health Care Services (DHCS)

The Department that administers the MC Program in California.

MC Eligibility Data System (MEDS)

The State system that contains data and eligibility information for various health and public assistance programs, including MC.

Benefits Identification Card (BIC)

Identification card issued by DHCS to all MC beneficiaries and used by medical providers to verify MC eligibility.

Extenuating Circumstance

Circumstances beyond the control of the County or the MC beneficiary, which prevented the beneficiary from giving his/her BIC to the provider.

Medical Provider

Medical institutions/facilities/individuals that provide medical services, including pharmacies.

Negotiable Document

A document guaranteeing the payment of a specific amount of money, either on demand, or at a set time, with the payer named on the document.

Share of Cost (SOC)

The amount of money that a MC beneficiary is responsible for paying, before MC covers any medical expenses in any given month.

Supplemental Security Income/State Supplementary Payment (SSI/SSP)

A federally funded program which provides income support to eligible individuals who are aged 65 or older, blind, or disabled. Program administered by the Social Security Administration (SSA).

State Data Exchange (SDX)

The data system by which the Federal Government provides information to the State regarding the eligibility of SSI/SSP applicants and recipients.

Requirements

Reasons to issue an MC 180

A County shall provide an MC 180 to MC beneficiaries more than one year after the month of eligibility, if one of the following five conditions is met:

Conditions and Requirements

SSI/SSP eligibility was approved but DHCS did not or could not update MEDS.

County staff must ensure that the claimant was eligible for SSI/SSP in the month for which an MC 180 is being requested. The claimant must provide valid proof of his/her SSI/SSP eligibility from SSA (i.e. Award letter or letter from SSA containing the information from the award letter).

A Court Order requiring that MC be issued.

A copy of the court order that states that MC benefits must be issued to the beneficiary for the period that covers the month/year of the MC 180 request.

Instructions to issue a MC 180 under this condition is provided by a court of law (Superior Court, Municipal Court, etc.) and may cover class action lawsuit situations.

A State Hearing or other administrative hearing decision requiring that MC be issued.

This condition must be supported by a copy of the hearing decision that instructs the County to provide MC benefits to the beneficiary for the month/year that covers the period of the MC 180 request.

Hearing decisions normally come from a State Department such as DHCS or the California Department of Social Services (CDSS). The State Hearing decision is part of the fair hearing process; other administrative hearings cover decisions on rehearing requests.

A DHCS request that MC be issued.

It must be supported by a copy of the written request from DHCS and the MC 180 must have the original signature of an authorized DHCS staff person.

An administrative error has occurred.

For this condition, the error must be documented in detail on the MC 180 form. Such description should be a narrative which fully explains the County’s error rather than two or three phrases (i.e., “MEDS error” is not sufficient).

Note: The customer’s failure to provide his/her BIC to the provider or the provider’s failure to bill timely are not considered administrative errors.

Note: If an administrative error does not exist, but there are extenuating circumstances beyond the beneficiary’s or the County’s control, refer to the Procedures section for Issuing an MC 180 Due to Extenuating Circumstances. Billing problems are not by themselves considered an extenuating circumstance.

Timely request of an MC 180

Processing of the MC 180 request requires that it be submitted timely.

Conditions and Requirements

SSI/SSP Approval

Requests must be submitted:

Within four months from the State Data Exchange (SDX) update;
Within six months of the decision.

Note:

This requirement is explained on the form, “Important Medi-Cal Program Information for New Supplemental Security Income/State Supplementary Payment (SSI/SSP) Recipients” (MC 19) mailed to all new SSI/SSP Recipients.
Exceptions due to unusual circumstances should be referred to the MC Program Section.

Court Order, State Hearing, and Administrative Hearing

Requests must be submitted within six months from the date of the Notice of Action (NOA) sent to the beneficiary in compliance with a court order or hearing decision requiring that MC benefits be provided.

Administrative Error

If upon reviewing the case it is determined that an administrative error has occurred, staff will issue the MC 180 as part of the corrective action.

MC 180 Issuance

Requirements and Description

Number of MC 180 required per provider

Only one MC 180 is issued for each provider for up to 12 months of service. A provider needs only one MC 180 for all months for which the client received medical services.

County of Responsibility

The County that initially processed the case and determined eligibility for the period being requested is the County that would determine if an issuance of the MC180 is appropriate.

MC 180 Log

The state requires that counties maintain a central log that identifies all issued MC 180s.

Security Measures

The MC 180 document stock must be stored in a secured, locked cabinet in the Chief Clerk’s/DHS Designee’s office with access restricted to authorized personnel only.

Verification Docs

Acceptable Documents and Descriptions

SSI/SSP Award Letter/SSA Letter

SSI/SSP Award letter/SSA letter, verifying SSI/SSP eligibility for the period that covers the month/year of the MC 180 request.

Court Order

An order from a court of law (i.e., Superior Court, Municipal Court, etc.) which states that MC benefits must be issued for the period that covers the month/year of the MC 180 request.

State Hearing Decision Document

A hearing decision issued by the State that instructs the County to provide MC benefits to the Beneficiary for the month/year that covers the period of the MC 180 request.

DHCS Written Request

A written request from DHCS to issue MC.

Attachments

N/A

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