Guidance to County contracted providers on usual and customary charges

TO: BHSD County and Contract Providers FROM: Sherri Terao, Ed.D., Director, Behavioral Health Services Department RE: Guidance to County Contracted Providers on usual and customary charges  DATE: October 30, 2023

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Health Services Department (BHSD) requires County Contracted Providers (CCPs) to use their contracted rate (i.e., the rates listed in Exhibit B of the CCP’s agreement with the County) when billing the County, and BHSD provided these rates to CCPs for using in billing. Effective January 1, 2024, CCPs shall no longer use the contracted rate to bill the County through myAvatar. Instead, each CCP shall bill the County using its established usual and customary charges.

Usual and customary charges are the uniform rates listed in the provider’s established charge schedule that are in effect and applied consistently to most patients. (See Cal. Code Regs. tit. 9, § 1810.253.1; 42 C.F.R. § 413.13(a); California State Plan, Attach. 4.19A, p. 39.) In many healthcare contexts, providers are expected to bill all payers for services using their usual and customary charges. Each CCP should have, or will need to establish, its own schedule of usual and customary charges. This schedule is necessary to demonstrate the CCP’s compliance with state regulations that prohibit discriminatory billing in the Medi-Cal program. (See Cal. Code Regs. tit. 22, §§ 51480, 51501.) Use of usual and customary charges will also facilitate consistent billing when a Medi-Cal beneficiary has other health coverage, such as Medicare or private insurance. For more information regarding the requirement to bill at usual and customary charges, please refer to the Department of Health Care Services (DHCS) Behavioral Health Information Notice (BHIN) No. 23-002.

This change in billing procedure will not affect the amount CCPs are paid by the County for services provided. Although CCPs will be required to bill the County using their usual and customary charges, the County will continue to reimburse CCPs at the contracted rates listed in Exhibit B to the CCP’s agreement with the County.

Thank you in advance for attending to this important transition in the way that your agency will submit claims and other information to the County of Santa Clara.