Processing Cases When the SOC is Retroactively Reduced

Retroactive adjustments are needed when the EW determines that the client should have had a lower MC SOC than was originally computed. EWs are responsible for discussing the following options available to the clients who have their SOC retroactively reduced:

  • Apply the SOC adjustment to the future SOC month(s), or
  • Seek reimbursement from the provider.

If the client chooses to seek reimbursement from the provider, the EW must instruct the client to give the provider a copy of “Share of Cost Medi-Cal Provider Letter” (MC 1054), so that the provider can bill MC and reimburse the client the appropriate SOC amount.

Note: Clients whose future SOC is zero before an adjustment is applied, must be advised that the only recourse is to seek reimbursement from the provider.

Reimbursement From The Provider

When a client decides to seek reimbursement from a provider, it must first be determined whether the provider has billed or submitted a SOC clearance transaction for the month which reimbursement is requested. This can be determined by viewing the MEDS “SOC Case Make-Up Inquiry Request” [SOCR] screen for the appropriate month.

If the SOC balance on the SOCR for the appropriate month is...     Then the provider...
The same as the county’s original SOC,  Has NOT submitted a SOC clearance transaction for the month in which reimbursement is being requested. No reimbursement from the provider is necessary.
Less than the original SOC or zero,

Has submitted one or more SOC clearance transactions.

If the recomputed SOC is:

  • Lower than the original SOC but higher than the SOC clearance transaction, then no SOC adjustment is necessary. The client cannot seek reimbursement from the provider or request a future SOC months adjustment. Example Example The original SOC is $100 and the provider has submitted a $25 SOC clearance transaction for medical services rendered. The recomputed SOC is $40. This recomputed SOC amount would be input to MEDS. NO SOC adjustment reimbursement from the provider or for future SOC month(s) is necessary because the $25 SOC clearance submitted by the provider is below the recomputed SOC which is $40. That means, the client has not yet met his/her correct SOC amount for the month. 
  • Lower than the SOC clearance, the client can seek reimbursement from the provider or request a future SOC months adjustment because the SOC for past months cannot be reduced on MEDS to an amount lower than the amount of clearance transactions posted. Example Example The original SOC is $100 and the provider has submitted a $25 SOC clearance transaction for medical services rendered. The recomputed SOC is $10. The SOC on MEDS may NOT be reduced to $10. MEDS does not accept an amount lower than what the client has already been certified for. The EW must complete the MC 1054. Advise the client to give the form to the provider so that the provider may bill Medi-Cal for the difference $15 ($25-$10) and reimburse the client. 

Adjustment of Future SOC Case Scenarios

Case Scenario 1

Client was eligible for July with a SOC and met the entire SOC (determined by viewing SOCR screen). It is later determined that the SOC should have been lower. The client requests an adjustment of future SOC amounts.

Case Scenario 2

Client was determined eligible for October with a SOC and met part of the SOC for that month. It is later determined that the SOC should have been lower. Client requests adjustment for the future SOC.

View the SOCR screen for the month of October to determine amount of SOC that was met.

If...  Then...
The amount cleared for the month of October is more than the recomputed SOC, 

A SOC adjustment is needed. The difference between the amount cleared and the recomputed SOC will be the amount to be adjusted.

Process adjustment according to Steps 1-3 in Case Situation 1. Example Example Client’s original SOC is $100, client paid $75; the recomputed SOC is $50, the amount to be adjusted for future month is $25. 
The amount cleared for the month of October is less than the recomputed SOC, No adjustment is necessary. Ensure the change in the SOC is posted to MEDS.

Provider Reimbursement of SOC Case Scenarios

Case Scenario 3

Client was determined eligible for November with a SOC and met the SOC. A recomputation indicates the SOC should have been zero. Client wants a reimbursement of the SOC amount that was paid to the provider(s).

Case Scenario 4

Client had a SOC for the previous month of April, for $100, and according to the MEDS SOCR screen, met $50 of this SOC. It was later determined that the SOC should have been $75. Client wants reimbursement from the provider.

  • In this situation, the client is not entitled to a provider reimbursement nor a future month SOC adjustment. Follow Step 1 in Case Situation 1 to lower the client’s SOC.
  • Ensure the SOC for April is changed to $75 on MEDS.

Case Scenario 5

Client had a SOC for the previous month of May in the amount of $200. The SOCR screen indicates that $150 of the SOC was met. It has been determined that the SOC should be $100. Client wants reimbursement from the provider.

  1. EW    
    1. Follows Steps 1-3 in Case Situation 3.
    2. Requests an on-line MEDS entry to change the SOC on MEDS to $150 (MEDS will not accept a change below the amount of services that have already been certified towards the SOC).
    3. Completes an MC 1054 showing the original SOC as $150 and the revised amount as $100, and sends it to the client.
  2. Client
    1. Submits the MC 1054 to the provider(s).
  3. Provider(s)
    1. Bills MC and reimburses the client after payment from MC is received. The provider needs to submit a copy of the MC 1054 with their MC billing.

Share of Cost Adjustment Over a Year Ago

A “Letter of Authorization” (LOA) (SCD 2595) authorizes payment for medical services received 12 months or more prior to the current month. The “LOA Request” form (SCD 1594) must be sent to the MC Program Coordinator to request an LOA.

A “Share of Cost Medi-Cal Provider Letter” (MC 1054) is completed by the EW for SOC changes for history months.

Case Situation 6

In July 2006, the EW determined that the client’s correct SOC for June 2005 should have been $100. Client’s original SOC previously recorded for June 2005 was in the amount of $200.

  1. EW    
    1. Views the SOCR screen on MEDS for the month of June 2005 to determine amount of SOC that was met. If:        
      1. None of the SOC was met, no further action is needed.
      2. The client met any or all of the SOC, retroactive adjustment is needed.
    2. Explains to the client the option of whether to apply the SOC adjustment to the future month’s SOC or seek reimbursement from the provider. If the client chooses to:
      1. Apply the SOC adjustment for future SOC months, follow the examples in Section 33.5.2.
      2. Seek reimbursement from the provider. If the previous SOC clearance is:
        1. equal to the revised SOC, complete an SC 1594. MC was not previously billed because the client did not meet the $200 original SOC.
        2. lower than the revised SOC, complete an SC 1594 and an MC 1054. The client has to show the proof of the paid amount. Example  Example  Client previously paid $75 (which is lower than the revised SOC of $100).
        3. higher than the revised SOC, complete an SC 1594 and an MC 1054 which shows the original SOC and the revised SOC. ExampleExampleClient previously paid $150.      
  2. EW Supervisor
    1. Reviews and forwards the SC 1594 and MC 1054, to the MC Program Coordinator.
  3. Program Coordinator
    1. Completes the SCD 2595 and sends it back to the EW Supervisor.
  4. EW    
    1. Gives or sends the original and copy of the SCD 2595 and the MC 1054 to the client.
  5. Client    
    1. Submits the SCD 2595 and the MC 1054 to the provider(s).
  6. Provider(s)    
    1. Bills MC and reimburses the client after the payment from MC is received. The provider needs to submit the SCD 2595 and the MC 1054 with their MC billing. 

Related Topics

Share of Cost