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Cost Avoidance
This type of OHC code requires the provider to bill the other health coverage carrier prior to billing MC. An Explanation of Benefits (EOB) from the private coverage carrier, indicating either a denial of payment or partial payment, must be attached to the provider's claim to MC.
Exception: The provider is not required to bill the private carrier first when a person is in Long Term Care or is receiving prenatal or preventative pediatric services when the individual has a cost avoidance type of coverage.
Other Health Coverage (OHC) provided by absent parents through the Department of Child Support Services (DCSS) should not be subject to cost avoidance. This OHC information can be viewed on the View HIS Information screen in MEDS, under ABS-PARENT-INS data field (known as ABS Flag):
- ABS Flag “Y” = OHC provided by the absent parent
- ABS Flag “G” = Good cause is granted
- ABS Flag “C” = OHC provided by the custodial parent
Cost Avoidance Coverage Identification
Private health insurance coverage which must be coded with the cost avoidance OHC code may be identified by either DHCS or by the EW. DHCS will place the cost avoidance code directly on MEDS when an individual is identified as having OHC. The EW must update the OHC information in CalSAWS.
OHC information. An ABS flag value of 'Y' indicates OHC provided by the absent parent and if a good cause is granted, ABS flag value of ‘G’ displays.
Effective Date of Cost Avoidance
Applicants - The first month of eligibility.
Recipients - The first of the future month.
Related Topics
Overview of the Managed Care Two-Plan Model
Health Care Options Enrollment Contractor
Managed Care for Mental Health Services
Coordinated Care Initiative - Cal MediConnect
Health Insurance Premium Payment (HIPP) Program
Removal of OHC Codes for Victims of Domestic Violence
OHC for Foster Care/Adoption Assistance Children
Repayment for Medical Services