Commission for Behavioral Health (CBH) Meeting on 05/28/26
| Date: | May 20, 2026 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan All Practitioners and Behavioral Health Providers |
| Type: | Event |
| Subject: | Commission for Behavioral Health (CBH) Meeting on 05/28/26 |
| Business: | Medi-Cal Managed Care |
Effective May 29, 2026, Medi-Cal Rx will be implementing the following changes to the current Medicare coordination of benefits (COB) claims processed by pharmacies:
- Medi-Cal Rx will no longer accept the Other Coverage Code (OCC) of 3 – Other Coverage Exist Claim Not Covered when Medicare Part D has denied the claim with Reject Code A5 – Not Covered Under Part D Law or Reject Code 65 – Patient is Not Covered.
Claims submitted with OCC of 3 will start denying with Reject Code 13 – M/I Other Coverage Code with the message of “Member is Medicare Part D eligible. Submit claim to member’s Medicare Plan. Part D copays and deductibles are not covered.”
- Future change, effective date yet to be determined: For all Medicare COB claims, Medi-Cal Rx will implement a Benefit Stage Qualifier (BSQ) value in the NCPDP field 393-MV. Claims without the BSQ value will be denied along with the message of “Benefit Stage Qualifier value not submitted.”
For additional detailed information, please visit the Medi-Cal Rx weblink: https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/2026/05_A_Coming_Soon_Changes_Medicare_PartD_COB_Process.pdf
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org
