Medi-Cal Targeted Provider Rate Increases

These increases aim to improve patient care by providing enhanced financial support that allows providers to allocate more resources toward delivering quality services.

• Payment implementation will begin in October 2024 and will be completed by December 31, 2024.
• Providers who have submitted approved claims with dates of service (DOS) beginning
  January 1, 2024, will begin receiving payment adjustments in November 2024.

No further action is required from providers to facilitate this retroactive payment process.

Corrections, Disputes & Appeals: Should you have a correction to claim (i.e coding or modifiers) please submit a new clean claim utilizing one of the standard claim forms.  For disputes regarding payment amount, please follow the dispute guidelines outlined in the following link on our  CenCal Health website. https://www.cencalhealth.org/providers/claims/corrections-disputes-appeals/

Providers can reference the following explain codes for their convenience. The descriptions highlighted in bold black represent the “Internal CenCal Health” explain codes created by CenCal Health. These codes will be displayed in our Provider Portal when a Claims Status Report is ran and on paper EOPs sent to providers; however, they will not be visible on electronic EOPs.

The blue CARCs and RARCs listed under each internal explain code are what providers will see on their electronic EOPs.

Pay code = TRI Eligible: Claim line paid at TRI rate – “KP”

• CARC – 45 = Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability)
• RARC – N442 = Payment based on alternative fee schedule.

Pay code = TRI Eligible: Contract rate is greater than TRI rate – “KQ”

• • CARC – 45 = Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability)
  • RARC – N524 = Based on policy this payment constitutes payment in full

Adjustment Code = TRI Eligible: Adjustment for TRI rate – “KR”

• • CARC – 144 = Incentive adjustment, e.g. preferred product/service
  • RARC – N442 = Payment based on alternative fee schedule.

To facilitate your understanding and implementation of these changes, please reference the following resources:

• DHCS Medi-Cal Targeted Rate Increase Fee Schedule Procedure Code List 
• DHCS TRI Provider Overview 
• DHCS Medi-Cal’s targeted provider rate increases (TRI) APL 24-007
• CenCal Health Provider TRI Overview Training Video

For a comprehensive list of impacted CPT codes, including their reimbursement, please refer to the DHCS TRI Fee Schedule available at dhcs.ca.gov/Documents/Medi-Cal-TRI-Fee-Schedule-CY-1062024.xlsx

If you have additional questions, please contact a Claims Service Representative (CSR) in the Claims Department at 805-562-1083.

What is the Targeted Rate Increase, or TRI? 

The Department of Health Care Services (DHCS) has implemented a Targeted Rate Increase, or TRI, to advance access, quality, and equity for Medi-Cal members and to promote provider participation in the Medi-Cal program. Beginning in 2024, TRI increases apply to particular services provided by the following practitioner types: 

Primary care (inclusive of nurse practitioners and physician assistants) 

Maternal care (inclusive of OB/GYN and doulas) 

Non-specialty mental health services 

Who can I call If I have questions about what TRI means for me? 

If you have specific questions regarding your claims and TRI, please contact our Claims Department at 805-562-1083, Option 1.  

Who is eligible to receive TRI? 

The TRI Fee Schedule rate applies to procedure codes identified as Primary/General Care services billed using Health Insurance Claim Form (CMS-1500) and rendered by an otherwise eligible Provider in the following Provider type categories, without regard to the rendering Provider’s specialty: 

Physicians, Physician Assistants, Nurse Practitioners, Podiatrists, Certified Nurse Midwives, Licensed Midwives, Doula Providers, Psychologists, Licensed Professional Clinical Counselors, Licensed Clinical Social Workers, and Licensed Marriage & Family Therapists. 

The TRI Fee Schedule rate applies to procedure codes identified as:  

Obstetric or Non-Specialty Mental Health Services when billed or rendered by an otherwise eligible Provider without regard to claim type or the Provider’s specialty. 

What are the new reimbursement rates under TRI? 

TRI Fee Schedule rates for contracted and qualified Medi-Cal providers are based on no less than 87.5% of the lowest California-specific Medicare Fee Schedule for eligible procedure codes. CenCal Health reimburses claims based off of the amount billed and the applicable contract rate.  

Specific rate information can be found at https://www.dhcs.ca.gov/Documents/Medi-Cal-TRI-Fee-Schedule-CY-1062024.xlsx. 

How does TRI affect Proposition 56 payments?  

Proposition 56 (Prop 56) Physician Services add-on payments are incorporated into the TRI fee schedule where applicable. This means that for applicable services, the Prop 56 add-on payment will be retired at the end of 2024, as the enhanced rates under TRI are implemented. 

Prop 56 programs for 1166 Developmental Services, 1148 Family Planning, 1154 (A) Adverse Childhood Experiences Screening, or 1176 (A-B) Hyde (Womans Health Services) (CPT codes 59840 and 59841), will not be impacted. 

When will CenCal Health fully implement TRI?  

TRI payments will begin on the Explanation of Payment (EOP) dated October 25, 2024.  

Retroactive payment adjustments for eligible services for dates of service beginning January 1, 2024 will begin in November and will be completed by December 31, 2024. Rates will be maintained prospectively, in accordance with all applicable regulatory and state guidelines.  

What do I need to do to ensure that I am receiving the correct reimbursement rates? 

The TRI rate updates will be made automatically. Providers should ensure that any claims submissions are updated per the provider’s contract and the TRI rates.