Letter of Authorization

A Letter of Authorization authorizes payment for medical services received over 12 months before the current month.

A Letter of Authorization is not required if the medical services were received within 12 months of the current month. Months still showing on the [INQM] screen in MEDS do not require an LOA.

An LOA, may be required if:

SSI/SSP was approved but BIC was never issued.
A court action requires that benefits be issued.
A State or other administrative hearing decision requires that benefits be issued.
The County determines that an administrative error has occurred.

Note: The client’s county of residence during the benefit month is responsible for issuing the LOA.

Benefits were approved retroactively (there is a 2 in the third digit of the eligibility code, refer to Eligibility Status Code in MEDS QRG.)

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

If an LOA is lost, every effort must be made to locate the original. A replacement LOA will not be issued for 30 days following the report of a lost LOA.

Error

Some examples of acceptable administrative errors include, but are not limited to the following:

Failure to approve a MC application due to legitimate errors made in the course of determining eligibility (i.e., the application is misplaced and eligibility was never determined, an applicant was denied but should have been approved and an appeal was not filed).
Failure to issue a BIC within a year from the date of the service because the CalSAWS, CalHEERS, or MEDS shows an incorrect client address for the month of request.
BIC issued within one year, but it is coded incorrectly and cannot be used to bill for the services provided (i.e., the BIC shows a Medically Indigent/Long Term Care 53 Aid Code and the applicant received and was eligible for acute care services in that month).

If the EW finds that an administrative error does not exist, but extenuating circumstances exist beyond the client’s or the county’s control, or if the EW is unsure whether a particular situation meets the definition of an administrative error, the MC Program Coordinator should be contacted for assistance.

An example of extenuating circumstances beyond a client’s control would be a medical condition that severely impaired his/her functioning. The client needs to describe how the impairment prevented him/her from giving the provider the necessary documentation of his/her MC eligibility.

Provider Billing Error

Billing problems, such as the provider failed to bill MC timely, are not by themselves considered an extenuating circumstance. Clients who are sent to collections after providing a MC card should be told that Welfare and Institutions Code Section 14019.4 prevents a provider from billing the clients in these situations. MC providers are obligated to accept MC payment for covered services even if eligibility is established retroactively from the month of application. The “MC Provider Billing Notice” SCD 2460 includes this information and can be mailed to the client.

Determining if an LOA is Required

IF	AND	Then
The client provides medical bills within 12 months of the current month...	The client was active and eligible during the month of service...(there is a 2 in the third digit of the eligibility code, refer to Eligibility Status Code in MEDS QRG.	No LOA is required. EW should inform the client that the Provider must contact the State for payment. (Issues form SCD 2460 if applicable).
	The client was not active in MEDS but was eligible in CalSAWS and/or CalHEERS…	No LOA is required. Submit SCD 1296 to add/activate the client on MEDS. Confirm that all three systems (CalSAWS, CalHEERS, and MEDS) match.
	The client is not eligible for MC…	Determine if a Denial NOA was sent previously, issue if needed. NOTE: The EW can reprint the Denial NOA at the client’s request.
	The client is currently active on MC but did not have MC for the month of service…	Explore Retroactive MC.
The client provides medical bills over 12 months before the current month...	The client was active and eligible during the month of Administrative service, with timely coverage…	No LOA is required. EW must issue form SCD 2460 to the client to submit to their provider.
	The client was active and eligible for the month of service, but coverage was not timely	LOA is required.
	The client was not active in MEDS but was eligible in CalSAWS and/or CalHEERS…	LOA is required.
	The client was not eligible for MC…	Determine if a Denial NOA was sent previously, issue if needed. NOTE: The EW can reprint the Denial NOA at the client’s request.
	The client is currently active on MC but did not have MC for the month of service…	Retroactive MC cannot be approved when requested after 12 months.

Letter of Authorization Examples

Example:

In June 2016, a client brings in an unpaid medical bill from July 2013, the client is potentially eligible for an LOA.

Example:

In May 2016 a client brings in unpaid medical bills from July 2015, the client is NOT eligible for
an LOA. (The provider can still bill the State without an LOA).

Example:

The client provides medical bills for 3 months at Valley Medical Center (VMC) and 15 months at
Saint Louise Regional Hospital (SLRH). The client was eligible for all months. The LOA request was submitted and complete. The Program Coordinator will complete one LOA for VMC and two separate LOAs for SLRH.

Example:

A client is approved for Medi-Cal on 3/1/2018 and eligibility is sent as to MEDS beginning
4/1/2018 due to an administrative error. The client is incarcerated on 5/3/2018 and has Medi-Cal partial month suspension for the month of May 2018 (restriction code of 820), and full month suspension from June 2018 onwards (restriction code of 800).

The client reports to the County that he was released on 8/1/2018 and has a medical bill for March 2018. After reviewing the case, the client is approved for a Letter of Authorization (LOA) for March 2018.

Action: EW32 transaction must be completed with a release date of 08/01/2018 to remove the incarceration from the incorrect months (08/2018 and forwards) prior to completing EW51 transaction to approve LOA for March 2018.

Letter of Authorization Process

Follow the procedure below when a valid reason exists to issue a non-SSI/SSP LOA for payment of medical services received more than 12 months before the current MEDS month:

EW
1. Completes the “Letter of Authorization Request” (SCD 1594), documenting all of the following information:
  1. The client’s name, CIN,14 digit County ID (at the time the services were received), address, and SOC amount,
  2. The client’s confirmed mailing address,
  3. The EW’s name, worker number and phone number,
  4. The MC date of application and the date of approval (this is the date the EW authorizes the case in CalSAWS), and other health coverage code,
  5. The EW Supervisor name/worker number, his/her phone number and signature,
  6. The provider’s name and if available, the provider number,
  7. The month(s) for which the client received services and is being billed for,
  8. The reason for the request:
    1. Court action - Attach a copy of the Court Order.
    2. Fair Hearing decision - Attach a copy of the decision.
    3. Administrative Error - Include a clear description of the error and attach supporting documents.
2. Attaches the following documents to the SCD 1594:
  1. MEDS screen for the month(s) requested (INQM, INQ6, and/or INQ7), AND
  2. If the client has no SOC: a copy of MC 176M or MC 176M-LTC budget worksheet OR a relevant CalSAWS page showing zero SOC/SOC, OR
  3. If the client has SOC: a copy of MC 180-2 “Record of Health Care Cost” completed by the provider AND a MEDS screen (INQM, INQ6, INQ7, SOCR) showing that the SOC has been certified.
3. Submits the SCD 1594 and the appropriate documents to the Supervisor for review.
EW Supervisor
1. Reviews the SCD 1594 and attachments for completeness, enter signature, and emails the request to the MC Program Coordinators.
MCProgram Coordinator
1. Reviews the request packet. If the LOA is:
  1. Approved:
    1. Completes a “Notification of Eligibility for Letter of Authorization” (SCD 2595) if all criteria are met.
    2. Sends the SCD 2595 to the requesting EW Supervisor by email, as attachment.
  2. Denied or incomplete:
    1. Completes a “LOA Reject Memo” (SCD 2458)
    2. Note: When appropriate, notates that the EW must issue form SCD 2460 to the client to submit to their provider.
2. Sends the SCD 2458 to the EW Supervisor as an email attachment.
EWS
1. Forwards the SCD 2595 or SCD 2458 to the EW and ensures appropriate action is taken.
EW
1. If the LOA is Approved:
  1. Completes a “Request for Online Transaction” (SCD 1296) form to request an EW 51 transaction and to indicate the requested month(s) and an appropriate "E-LOA Reasons,” listed on the Table under the “Other” section of the form. Attach a copy of the SCD 2595 to the SCD 1296.
  2. Prints the SCD 2595, and mails it to the client.
  3. The LOA is only valid for 60-days, it is important that the client submits the SCD 2595 to the provider immediately.
  4. Submits the SCD 1594 packet and a copy of the SCD 2595 for IDM scanning.
  5. Documents all actions taken, in the Journal section in CalSAWS; including, the results of the LOA (approved), the requested month(s), and/or LOA issuance date (from the SCD 2595).
    1. NOTE: If the client’s SOC is not yet certified on MEDS, a SOCO transaction must be requested at the same time by completing the form SCD 1296 SOCO, “MEDS SOCO” to have the amount the client has agreed to pay or has already paid toward the required SOC.
2. If the LOA is denied or incomplete:
  1. Prints and mails the SCD 2458 to the client, and attaches a SCD 2460, if applicable.
  2. Submits a copy of the SCD 2458 and SCD 2460 (if applicable) for IDM scanning.
  3. Documents all actions taken in the Journal Detail page in CalSAWS.
CST
1. Records MC eligibility for the month(s) of request via EW 51 transaction.
2. Records Share of Cost Obligation (SOCO transaction), if requested.

MEDS Transaction

An EW51 online transaction is used to add Medi-Cal eligibility for over 12 months prior to the current MEDS month and to authorize electronic Letter of Authorization (E-LOA) claiming. MEDS will automatically place Restriction Codes along with Eligibility Status Codes to indicate the eligible LOA month(s) after the EW51 transaction is successfully submitted.

For corrections and removal of erroneous E-LOA, the EW shall submit a GadWIN ticket with appropriate information to be escalated to State MEDS Helpdesk.

Note: When requesting to record Medi-Cal eligibility over one year for Minimum Essential Coverage (MEC) only, the EW50 online transaction should be used instead of EW51.

The following Restriction codes and E-LOA Reason codes can also be found on MEDS QRG.

E-LOA Restriction Codes

Restriction Code	Definition
400	LOA authorized, no restrictions, full month of eligibility
410	LOA authorized, S/URS (Substance Use Disorder Restriction subject to Surveillance Utilization Review) restriction, full month of eligibility
401	LOA authorized, Limited Access restriction, full month of eligibility
411	LOA authorized, S/URS restriction and limited access restriction, full month of eligibility
840	LOA authorized, partial month incarceration, partial month of eligibility
841	LOA authorized, partial month incarceration and limited access restriction, partial month of eligibility

E-LOA Reasons

LOA Reason	Definition
D	SSI/SSP eligibility approved for a retroactive period
E	Court order requires that Medi-Cal be issued
F	State Hearing or other administrative hearing decision requires that Medi-Cal be provided
G	The California Department of Health Care Services requests that Medi-Cal be issued
H	Administrative Error

Prior to requesting a LOA, the following considerations should be reviewed:

When there is incarceration (see INQU screen) posted in error, or when the client was incarcerated part of the month of which LOA is approved, submit an SCD 1296 to request the EW32 transaction for correcting incarceration or lifting suspension, and the EW51 transaction. MTO must complete the EW32 transaction prior to submitting the EW51 transaction.
An E-LOA Restriction Code will not replace a Hospice Restriction Code. To authorize an LOA in a month with a Hospice Restriction Code, EW submits a GadWIN ticket to escalate to State MEDS Helpdesk.
An E-LOA Authorization will not replace a Long-Term Care (LTC) Restriction Code. To authorize an LOA in a month with LTC Restriction Code, EW submits a GadWIN ticket to escalate to State MEDS Helpdesk.
The County of Responsibility for LOA requested month(s) is responsible for processing the EW51 transaction.

SSI/SSP Letter of Authorization Process

SSI clients sometimes contact Social Services Agency to request a Letter of Authorization (LOA) for payment authorization of medical services received a year or more prior to the current MEDS month. Requests made by SSI only clients are processed at Valley Medical Center; requests from SSI/QMB clients are processed at the district office where the case is located.

An SSI/SSP client must request a MC LOA within six months of the approval decision or four months from the date of SDX update known as the “LAST-SDX-CHG” date on the [INQX] screen.

Note: The “LAST-SDX-CHG” date is not a reliable date as it changes in MEDS every time an update to the record is processed.

For exceptions due to extenuating circumstances, contact the MC Program Coordinator. An example of an extenuating circumstance would be a medical condition that severely impaired the SSI/SSP client’s functioning. Additionally, the client would need to describe how this reduced function prevented him/her from giving the provider the necessary documentation of his/her MC eligibility.

Note: Billing problems are not by themselves considered an extenuating circumstance.

Follow the procedure below when a valid reason exists to issue an SSI/SSP LOA for payment of medical services received one year or more prior to the current MEDS month:

SSI/SSP LOA Process

EW
1. Verifies SSI/SSP eligibility (SCD 169 or other document from SSA).
2. Completes a “Request for Online Transaction” (SCD 1296) to have a Paper Card/BIC issued (EW 15), if necessary.
CST
1. Generates an EW 15 (Immediate Need transaction) to issue a Paper Card and/or a BIC if appropriate.
EW
1. Completes the “Letter of Authorization Request” (SCD 1594). Writes “SSI/SSP” on the top of the SC1594 and documents all of the following information:
  1. The client’s name, SSN/Pseudo number, 14 digit County ID,
  2. The client’s confirmed mailing address,
  3. The EW’s name, worker number and phone number,
  4. The SSI date of application, if known (if not known, enter “Unknown, SSI”), the date of SSI approval, and other health coverage code,
  5. The EW Supervisor name/number, his/her phone number and signature,
  6. The provider’s name and if available, the provider number,
  7. The month(s) for which the client received services and is being billed for,
  8. The reason for the request (check the SSI/SSP box, explain why an LOA is requested, and attach supporting documents such as SCD 169).
2. Reviews the SC1594 packet for completeness, enters signature, and sends the request to the EW Supervisor.
EW Supervisor
1. Reviews the SC1594 packet for completeness, enters signature, and emails the request to the MC Program Coordinators.
Medi-Cal Program Coordinator
1. Completes a “Notification of Eligibility for Letter of Authorization” (SCD 2595) if all criteria are met.
2. Sends the SCD 2595 to the requesting EW Supervisor by email, as attachment.
EW
1. Completes a “Request for Online Transaction” (SCD 1296) form to request an EW 51 transaction and to indicate the requested month(s) and the LOA reason on the form. Attach a copy of the SCD 2595 to the SCD 1296.
CST
1. Complete EW51 transaction to record MC eligibility for the month(s) of request.