Opinion
NOT TO BE PUBLISHED
APPEAL from a judgment of the Superior Court of Los Angeles County No. BS102862, David P. Yaffe, Judge.
Davis Wright Tremaine, Mary H. Haas and Camilo Echavarria for Plaintiff and Appellant.
Edmund G. Brown Jr., Attorney General, Douglas M. Press, Assistant Attorney General, Jennifer M. Kim and Karen L. Fried, Deputy Attorneys General, for Defendants and Respondents.
ALDRICH, J.
INTRODUCTION
Plaintiff and Appellant Five Acres Boys’ and Girls’ Aid Society of Los Angeles County (Five Acres) provides, among other things, mental health services to children. Five Acres provided services to 29 patients and submitted claims for reimbursement under Medi-Cal, but the claims were denied. Alleging that the claims were denied based on an improper finding that the patients were ineligible for Medi-Cal, Five Acres filed a petition for writ of mandate, naming as respondents the State of California, the California Department of Health Services and the California Department of Mental Health (collectively, the State). After a hearing, the trial court denied the petition. The court found that when Five Acres submitted the claims for reimbursement, it failed to provide to the State the patients’ correct beneficiary identification numbers. Substantial evidence does not, however, support this finding. We therefore reverse the judgment and remand this matter.
FACTUAL AND PROCEDURAL BACKGROUND
I. Factual background.
A. Five-Acres
Five Acres was originally founded as an orphanage in 1888. Today, it is a child and family services agency having the purpose of strengthening families and preventing child abuse; caring for, treating and educating emotionally disturbed, abused and neglected children and their families in residential and outreach programs; and advancing the welfare of children and families by research, advocacy and collaboration. Five Acres also offers mental health services to patients who are eligible to receive such services under Medi-Cal. Five Acres contracts with Los Angeles County (the County), and under the contract, Five Acres covers the cost of the services, and it submits reimbursement claims to the County, which then submits them to the State for review.
For contract years 1999 and 2000, Five Acres provided day treatment services to 29 patients, all of whom were foster children assigned to the location by either the Department of Mental Health or the Department of Children and Family Services. In connection with these 29 patients, Five Acres submitted 2,687 claims for reimbursements, which the State denied. The State sent to Five Acres an Explanation of Benefits (EOB) denying, among others, these 2,687 claims. The majority of claims were denied because, for example, the patient was ineligible in month or year or the patient was “ ‘not on eligibility file.’ ”
In September 2001, Five Acres e-mailed the Department of Mental Health to inquire about these denials. Thereafter, in 2003, the State conducted a “rerun” of some of the denied claims. The State apparently paid some additional claims, but not all. The State continued to refuse to reimburse claims related to the 29 patients at issue and, in a letter to Five Acres, stated: “Your information indicated that there were individuals who were confirmed as eligible at the time of service but have still been denied as ineligible. DHS used the most accurate eligibility files in reprocessing these claims. These files may have included some people who lost eligibility retroactively.”
Five Acres was unable to locate the second page of the e-mail.
According to the State’s Error Correction Report Manual, denied claims can be resubmitted for up to one year from the date of service. Five Acres contends that the State failed to process many of the claims in a timely manner, which impeded Five Acres’s ability to file correction reports to address any errors. According to a spreadsheet Five Acres created, for the month of September 1999, it submitted 1,014 claims within four months of service, but it took the State 15 months to deny the claims. The spreadsheet also shows that it took the State anywhere from one month up to 18 months from the date of service to dispose of the claim.
II. Procedural background.
A. The petition.
In April 2006, Five Acres filed a petition for writ of mandamus seeking reimbursement for claims totaling $292,000 it alleged the State improperly denied. In support of the subsequent motion on the petition, Five Acres submitted the declaration of Mark Herring, who oversees billing for Five Acres to the Department of Mental Health. His duties include submitting Medi-Cal claims and handling any suspended or denied claims. Attached to his declaration are various exhibits, the most relevant of which we summarize here.
Five-Acres reduced its damages claim to $129,238. There is no explanation for the discrepancy between this amount and the amount sought by the petition.
Exhibit A.
Exhibit A is a computer disk containing a spreadsheet. The spreadsheet lists 4,741 claims for the period 1999 to 2001 that Five Acres submitted and were denied. Only a subset of those claims are at issue. The spreadsheet lists, for example, the fiscal year of the claim; the claim number; the patient’s last name and first initial; the MIS number; the patient’s social security number; the claim batch number; the service date; the date the claim was denied; the amount billed; and the reason the claim was denied. The claims were denied because the patient was ineligible in month or year, the patient was “not on eligibility file,” or “invalid code.” Some were also denied because of “conflicts with eligibility file” or “units greater than allowed” or “DUPLICATE SERVICE – no override” allowed.
Five Acres clearly asserts that the State created Exhibit A. Only at oral argument in this Court of Appeal did the State’s counsel clearly claim that the State did not create those spreadsheets.
According to the Appellant’s Opening Brief, the MIS number is a patient number that is assigned by the County’s computer system when a claim is initially submitted. It is unclear what “MIS” stands for.
Exhibit B.
In 2003, the State reviewed some of the denied claims by doing a “rerun.” Exhibit B is a one-page spreadsheet containing the results of the rerun. The spreadsheet has columns similar to the ones in Exhibit A, for example, claim identification number; date of the claim; patient name; MIS number; patient beneficiary identification number; year of birth; gender; date of service; the amount billed; the date the State received the claim; the date the State processed the claim; the patient’s social security number; and the error code, which in most cases was Error Code 11.
Exhibits 1-29.
Each numbered exhibit pertains to the individual patient. For example, Exhibit 1 is denied claims pertaining to Patient No. 1/J. Anderson. Each of the numbered exhibits has one or more of the following:
(1) A spreadsheet listing the claims at issue for the patient.
(2) A Point of Service (POS) receipt printed from a government database showing the patient’s eligibility for Medi-Cal. Five Acres relied on the POS receipt before providing service to the patient. The POS states the patient’s identification number; month and year of birth; and, under “date of issue” it states the date the patient became Medi-Cal eligible.
(3) The patient’s Medi-Cal eligibility card, which also contains the patient’s beneficiary identification number and issue date.
(4) The “Primary Medi-Cal/CMSP Information printout” which also shows the patient’s eligibility for Medi-Cal. This document is from a government database and was printed at or around the time the service was provided.
(5) For most patients, Five Acres submitted a copy of the claim that was submitted into the “MIS computer system, which shows eligibility, units of service, and other related information.”
(6) Five Acres also submitted, for most patients, the Medi-Cal pending claims report from the County.
B. The respondents’ brief.
The State countered in its respondents’ brief that Five Acres failed to establish that the patients at issue were eligible for reimbursement, because Five Acres entered incorrect beneficiary numbers on many claims or failed to provide full information requested after being advised of a specific error. The State also claimed that Five Acres failed to file a claim, a prerequisite to filing the petition; failed to join an indispensable party, namely, the County of Los Angeles; and failed to exhaust its administrative remedies.
In support of its opposition to the motion on the petition, the State submitted, among others, the declaration of Kim Maun, a staff programmer analyst at the Department of Health Care Services. In May 2003, Maun conducted a “rerun” of various claims. The rerun resulted in a large batch of claims being approved. But “for the claims which still came up as denied—these claims were now outside the two[-]year range for receipt of FFP [Federal Financial Participation] and therefore payment.” As the result of a November 2003 rerun, 644 more claims were approved, but 87 were denied because the provider incorrectly entered the beneficiary’s number or submitted a duplicate claim.
The trial court sustained some of Five Acres’s evidentiary objections to the Maun declaration, specifically: paragraph 13 and attached exhibit; paragraph 14, lines 6-10, 14-15; and paragraph 21, lines 2-3.
Attached to the Maun declaration is a memorandum that Maun indicates concerns the 2003 rerun of denied claims. The trial court sustained Five Acres’s objection to that document.
A patient’s eligibility for reimbursement is checked using the Medi-Cal Eligibility Data System (MEDS). MEDS contains a list of all California citizens who have ever been eligible for Medi-Cal, although only the past 36 months are kept online. This is a secure and confidential database, and limited information is available to counties. Eligibility can change month to month, so a provider must check a client’s eligibility before services are rendered. For each approved, suspended or denied claim, the State creates an EOB. During the time at issue, the County sent paper Error Correction Reports to providers, who could then handwrite corrections on the reports. Maun also notes that MEDS includes beneficiaries who are on a variety of programs, for example, food stamps, local education agency programs, and SCHIP. But “[n]ot all beneficiaries are eligible for Medi-Cal Short Doyle program.”
Maun goes over what she found as to each of the 21 patients, and we detail that review below in Discussion, section II.
According to Maun, “[t]he major problem with the claims submitted by Five Acres is that the number provided for the beneficiary was not a number recognized by the MEDS database. I reviewed the claims from Five Acres and noted that the beneficiary information was entered incorrectly as outlined in the attached exhibit entitled Beneficiary Information. DHCS can only pay claims in which the ID used for billing is correctly entered and there is supporting information including the correct date of birth, gender, and family name/first name. MEDS will also recognize Client ID Numbers, Beneficiary ID Numbers, and Social Security Numbers.” In addition to the 2003 rerun, Maun did a rerun in June 2007 and “the errors remained the same—namely the beneficiary number was still not in the MEDS database.” She found no additional claims that could be approved.
The State also submitted the declaration of Gary Renslo, a data processing manager at the California Department of Mental Health. He states that this case “as presented” is unclear because the claims information that Five Acres submitted fails to specifically identify all of the claims at issue. To “determine if the provider’s contentions are valid, the provider needs to submit unmodified EOB file information related to the claims at issue. Once this is accomplished, DMH can determine the disposition and amount of the claim in the SD/MC claim history files in order to establish a position on the provider’s contentions.”
The trial court sustained some of Five Acres’s objections to the Renslo declaration.
C. The trial court’s ruling.
The trial court denied the petition. At the hearing, the court was concerned about whether Five Acres, when it submitted the claims to the State, provided each patient’s Medi-Cal beneficiary number: “I could find nothing in all this evidence that you submitted that shows that you used that number that the State gave you.” The court’s minute order states: “[The] petitioner fails to prove that it claimed reimbursement from respondent using the correct patient provider number for each of the twenty-nine patients for which petitioner challenges the rejection of its claims. [¶] Petitioner’s exhibit shows that it was informed of each patient’s correct identification number, but that, for reasons which it does not explain, it failed to use that number in claiming reimbursement from respondent.”
The trial court entered judgment on December 5, 2007.
DISCUSSION
I. The standard of review.
Subdivision (a) of section 1085 of the Code of Civil Procedure states: “A writ of mandate may be issued by any court to any inferior tribunal, corporation, board, or person, to compel the performance of an act which the law specially enjoins, as a duty resulting from an office, trust, or station, or to compel the admission of a party to the use and enjoyment of a right or office to which the party is entitled, and from which the party is unlawfully precluded by such inferior tribunal, corporation, board, or person.” A “writ of mandate under section 1085 is available where the petitioner has no plain, speedy and adequate alternative remedy; the respondent has a clear, present and usually ministerial duty to perform; and the petitioner has a clear, present and beneficial right to performance.” (Conlan v. Bontá (2002) 102 Cal.App.4th 745, 752.)
The trial court reviews an administrative action under Code of Civil Procedure section 1085 to determine whether the agency’s action was arbitrary, capricious, or entirely lacking in evidentiary support, contrary to established public policy, unlawful, procedurally unfair, or whether the agency failed to follow the procedure and give the notices the law requires. (American Federation of State, County & Municipal Employees v. Metropolitan Water Dist. (2005) 126 Cal.App.4th 247, 261.) Mandate will lie to correct abuses of a public agency’s discretion. (Ibid.) “ ‘ “In reviewing a trial court’s judgment on a petition for writ of ordinary mandate, we apply the substantial evidence test to the trial court’s factual findings.” [Citation.] Thus, foundational matters of fact are conclusive on appeal if supported by substantial evidence. [Citation.]’ [Citation.]” (Ibid.) However, “[t]o the extent the case involves the interpretation of a statute, which is a question of law, we engage in a de novo review of the trial court’s determination. [Citation.]” (Silver v. Los Angeles County Metropolitan Transportation Authority (2000) 79 Cal.App.4th 338, 348.)
II. Substantial evidence does not support the trial court’s factual finding.
“Medicaid is a cooperative federal-state program established by Congress in 1965 with the enactment of title XIX of the Social Security Act, 42 United States Code section 1396. ‘The program is designed to provide necessary medical services to poor people who had previously been denied access to medical care. Like private insurance, Medicaid furnishes coverage to eligible individuals and pays providers of health care for services rendered.’ [Citation.] California’s Medicaid program is called Medi-Cal, and is administered by DHS [Department of Human Services]. (Welf. & Inst. Code, §§ 10721, 14000 et seq.) State participation in Medicaid is voluntary but if a state participates, it must comply with the federal statutes and regulations governing the programs. [Citation.]” (Conlan v. Bontá, supra, 102 Cal.App.4th at p. 753; see also Doctor’s Medical Laboratory, Inc. v. Connell (1999) 69 Cal.App.4th 891, 893-894.)
California’s Department of Human Services manages Medi-Cal, but it is the County of Los Angeles that contracts with mental health care providers, such as Five Acres, to provide services to patients who are Medi-Cal eligible. Within six months of the service, the provider must submit claims for reimbursement for the services it renders to Medi-Cal eligible patients to the County, which reviews them and submits them to the State of California for approval. If the State discovers a discrepancy concerning, for example, a patient’s eligibility for a state-funded program, such as Medi-Cal, it can deny or suspend the claim.
The trial court here found that Five Acres failed to establish that the 29 patients were eligible for Medi-Cal reimbursement, because it did not submit the correct patient identification number for each patient. The State, on appeal, agrees with that ruling and asserts throughout its respondents’ brief that the 29 patients at issue could not be found in the MEDS database. The court’s ruling, however, is not supported by substantial evidence, as we explain.
A. Substantial evidence does not support the trial court’s finding that Five Acres failed to submit the correct beneficiary identification number for each of the 29 patients.
The trial court found that Five Acres did not establish it used the correct patient identification number for each of the 29 patients when it filed the claims for reimbursement. Substantial evidence does not support this finding for several reasons.
First, the trial court was presumably referring to the patients’ Medi-Cal beneficiary number. Each patients’ Medi-Cal beneficiary number is in the record, namely, in the POS receipts. It is correct, however, that the beneficiary number is not on Exhibit A, the spreadsheet that lists all of the claims that were submitted to the State and were denied. But the absence of the Medi-Cal beneficiary number from Exhibit A does not, by itself, lead to the inexorable conclusions either that Five Acres failed to provide the correct Medi-Cal beneficiary number to the State or that any failure to do so was the reason the claims were denied.
In the opening brief on appeal, Five Acres asserts that it did give the correct beneficiary identification numbers to the State. To support that assertion, Five Acres points to the MIS number: “In order for Five Acres to have entered the correct social security number and MIS number when submitting its claims––as shown in Exhibit A––it necessarily would have also entered the correct Medi-Cal identification number.” It is unclear what this means, and it is unsupported by a citation to the record or to the Herring declaration.
In fact, Maun states in her declaration that the MEDS database can identify patients using information other than the Medi-Cal beneficiary number: “MEDS will also recognize Client ID Numbers, Beneficiary ID Numbers and Social Security Numbers.” For example, Exhibit A lists a “MIS” number for each patient. That number, according to Five Acres, is a number assigned by the County to a patient. Five Acres provided printouts from the County that list MIS numbers for Patients Nos. 1-13, 16, 20-21, 24-29. These MIS numbers are in Exhibit A. It therefore appears that the State could identify the patients by this MIS number. Moreover, the Maun declaration never clearly states that any failure on the part of Five Acres to provide a correct beneficiary identification number for the patients was the reason the State denied reimbursement for the claims.
Rather, Kim Maun states in her declaration that she “reviewed the claims from Five Acres and noted that the beneficiary information was entered incorrectly as outlined in the attached exhibit....” (Italics added.) This statement is vague. It is unclear what Maun means by “beneficiary information.” It may refer to the Medi-Cal beneficiary identification number, but that is not what she states. Moreover, the attached document does not clarify her meaning. It does not clearly state that Five Acres submitted the incorrect Medi-Cal beneficiary identification number for any patient. In fact, the trial court sustained an objection to the exhibit.
This vagueness continued at oral argument in this Court of Appeal. At oral argument, the State’s counsel stated that providers are not supposed to use the number in the POS receipts, and presumably the MOPI receipts. Rather, the State’s counsel asserted, for the first time, that there is some other heretofore unidentified number that providers are supposed to use. The existence of such a number, however, was news to Five Acres’s counsel, who, consistent with his briefs in the trial court and in this court, said he thought the beneficiary identification number is the one in the MOPI receipt.
Despite it being crystal clear what number Five Acres was relying on, the State never made it equally clear that the number in the MOPI receipt cannot be used when filing reimbursement claims. Indeed, if there is some other number, it does not appear in the record—or at least the State has not cited to it. To the contrary, the State submitted Kim Maun’s declaration, but she never once states in it that a provider cannot use the number in the MOPI receipt. She never states, for example, that for patient No. 1 Five Acres used number X (the number in the MOPI receipt), but was supposed to use number Y. Also, it appears that Five Acres submitted claims using the number in the MOPI receipt and received reimbursements using that number. If Five Acres could not use this number, then why were those claims approved?
We thus must conclude that if Five Acres was supposed to use some number other than the one in the MOPI receipt, the State never made that clear. Such a number was never referenced in the State’s papers filed in the trial court or this court and at the hearing before the trial court. There is no evidence that such a number exists, other than the State’s bare assertion at oral argument before this court that it does.
A review of the information that Five Acres and the State provided as to each of the 29 patients also does not show that the claims were denied because Five Acres failed to provide the patients’ Medi-Cal beneficiary identification numbers—which, on this record, is a number that may be used when submitting reimbursement claims. We summarize some of that information below.
Patient No. 1/J. Anderson.
Five Acres seeks reimbursement in the amount of $909.19. The claims were denied under “invalid code,” “not on eligibility file” or “DUPLICATE SERVICE.” Five Acres submitted a copy of the patient’s Medi-Cal card, which has an issue date of March 1, 2000, and a MOPI receipt showing that he was eligible as of the date of at least some of the services.
The MOPI receipt shows a date of issue of March 2, 2000.
Maun responds in her declaration that 644 claims were approved as to this patient, but 87 were denied “because the provider incorrectly entered the beneficiary’s number or submitted a duplicate claim.” This statement is vague, because it is unclear whether the claims at issue are a part of the 87 denied claims Maun references. Then, attached to Maun’s declaration is a document she describes as a memorandum. It states, in pertinent part: “It appears the provider billing with the SSN, but the MEDS system at that time only had a MEDS ID on the system. I pulled off the SSN and the 2 prior MEDS IDs and when I used the tape eligibility history file from June 2000 file that contains 16 months of history. The ID found was the oldest MEDS ID and the SSN wasn’t found on that file.... [¶] So after I found this out I used [the] MEDS ID of 95881352P and found 664 approved claims on the accumulated approved file from FY 2000-2001 for John Anderson. The MEDS ID above was been [sic] deactivated many years ago.”
What any of this means is unclear. But the memorandum does suggest one thing: The State did have J. Anderson’s Medi-Cal beneficiary number. Maun lists it in her memorandum as being 95881352P. That is the same number in the POS receipt and Medi-Cal identification card Five Acres has submitted for this patient on appeal. It therefore does not appear, or at least it is unclear, that the State denied any claims relating to this patient because Five Acres failed to provide the correct Medi-Cal beneficiary number for him.
Patient No. 2/S. Damptz:
Five Acres seeks reimbursement in the amount of $17,548.55. The claims were denied primarily under “invalid code,” but also under “not on eligibility file.” The MOPI receipt shows that the patient became Medi-Cal eligible on April 10, 1998. Receipts were printed from the State’s database around the time she received services, namely, on October 29, November 17, and December 10, 1999 and on February 25, April 4, May 11, and June 19, 2000. Five Acres also provided a copy of the patient’s Medi-Cal identification card.
It appears that this patient’s MEDS identification number was 95730435P, but it changed to 358823021.
Maun states that the “billing ID used was forma[t]ted incorrectly.” “It appears for some reason the P at the end of the MEDS-ID was a 7 and so her ID could not be found. MEDS-IDs start with an 8 or a 9 and end in a P for [pseudo]. No corrections were made on the Error Correction Reports so after 303 days on suspense, the claims were denied.” It is unclear what this precisely means. For example, when Maun states that a billing ID was formatted incorrectly, it is not clear that Five Acres formatted it incorrectly.
Patient No. 3/P. Jackson.
Five Acres seeks reimbursement in the amount of $21,171.70. The claims were denied primarily under “invalid code,” MOPI receipts, printed on October 27, November 17, December 10, 1999 and on February 25, April 4, May 11, June 19, July 12 and August 14, 2000 show that the patient was eligible for Medi-Cal on December 18, 1997. Five Acres also submitted a copy of the patient’s Medi-Cal card.
As to this patient, Maun found that “[t]he billing ID used was formatted incorrectly.... [¶]... [¶] This person’s claims were billed with a bad MEDS-ID that ended in a 7 instead of a P, but it was also very old and had been turned off on MEDS in 1996 and a new ID was issued then. All these claims were on suspense for more than 300 days before they were denied.” What this means is unclear. For example, when Maun states that a billing ID was formatted incorrectly, it is not clear that Five Acres formatted it incorrectly. No supporting document, such as a printout from the State’s database showing the incorrect formatting, has been provided. Maun does reference a number—833xxx917—as “bad.” She does not, however clearly draw a connection between her statements and the specific claims at issue.
Patient No. 4/B. Johnson.
Five Acres seeks reimbursement in the amount of $10,470.90. The claims were denied primarily under “not on eligibility file.” MOPI receipts, printed on October 27, November 17, December 10, 1999 and on February 25 and April 4, 2000, show that the patient became eligible for Medi-Cal on May 1, 1994. Five Acres also submitted a copy of the patient’s Medi-Cal card.
Maun’s declaration does not contain any reference to claims concerning this patient.
Patient No. 5/M. Leyvas.
Five Acres seeks reimbursement in the amount of $13,767.73. The claims were denied under either “not on eligibility file” or “invalid code.” MOPI receipts, printed on July 13, August 14 and September 19, 2000, show that the patient became eligible for Medi-Cal on May 26, 1999.
Maun’s declaration does not contain any reference to claims concerning this patient.
Patient No. 6/M. Morrison.
Five Acres seeks reimbursement in the amount of $14,712.68. The claims were denied primarily under “invalid code.” MOPI receipts, printed on July 13, August 14 and September 19, 2000, show that the patient became eligible for Medi-Cal on May 4, 2000.
Maun’s declaration does not contain any reference to claims concerning this patient.
Patient No. 7/R. Perez.
Five Acres seeks reimbursement in the amount of $17,250.25. The claims were denied because of “conflicts with eligibility file,” “invalid code,” or “not on eligibility file.” MOPI receipts, printed on July 13 and August 14, 2000, show that the patient became eligible for Medi-Cal on September 29, 1999. Five Acres also submitted the patient’s Medi-Cal card.
Maun’s declaration states as to this patient: “This person’s claims were billed with a Client Index Number (CIN) that ended in a 0 instead of a D. I tried a D instead of the 0, and I think I found this person. The name is right and he lives in LA [C]ounty currently. This covered all the early claims until December 1999 when the biller used a MEDS-ID, that didn’t match the name and birthday of the records. [¶] His records from the accumulated approved file for FY 2000-2001 using Richard’s MEDS ID 86279810P at that time, which is now not in use, when it was used to do billing[.]”
The declaration is unclear as to what, if anything, Five Acres did wrong in connection with submitting the claims at issue. The identification number referenced in her declaration is the identification number in the MOPI receipts and on the patient’s benefits identification card.
Patient No. 8/G. Vaughn.
Five Acres seeks reimbursement in the amount of $14,947.70. The claims were denied primarily because of “invalid code.” MOPI receipts, printed on October 27, December 10, November 17, 1999 and on February 25, May 20, June 19 and April 4, 2000, show that the patient became eligible for Medi-Cal on August 26, 1999.
Maun’s declaration does not contain any reference to claims concerning this patient.
Patient No. 9/A. Willis.
Five Acres seeks reimbursement in the amount of $25,896.14. The claims were denied primarily under “conflicts w/eligibility file,” “invalid code,” and “not on eligibility file.” MOPI receipts, printed on October 27, December 10 and November 17, 1999 and on February 25, April 4, May 20, June 19, July 13 and August 14, 2000, show that the patient became eligible for Medi-Cal on March 16, 1999 and again on May 5 and June 15, 2000.
Maun’s declaration does not contain any reference to claims concerning this patient.
Patient No. 10/T. Wilson.
Five Acres seeks reimbursement in the amount of $27,888.63. The claims were denied primarily under “invalid code,” but also under “not on eligibility file” and “INELIGIBLE IN MO/YR.” MOPI receipts, printed on October 27, November 17 and December 10, 1999 and on February 25, April 4, May 11, June 19, July 13, August 14, September 19, October 18, November 3 and December 12, 2000 and on January 4, February 5, March 19, April 3, 2001, show that the patient became eligible for Medi-Cal on September 8, 1999 and again on April 25, 2000. Five Acres also submitted a benefits identification card for this patient, with an issue date of April 25, 2000.
The MOPI receipts show that this patient had a beneficiary identification number 95005302A, but it changed to 631014856 in 2000.
Maun’s declaration does not contain any reference to claims concerning this patient.
Patient No. 11/P. Bush.
Five Acres seeks reimbursement in the amount of $90.44. The claim was denied under the code “DUPLICATE SERVICE.” The MOPI receipt, printed on December 12, 2000, shows that the patient became eligible for Medi-Cal on October 1, 1999.
Maun’s declaration refers to this patient and indicates claims were denied because of duplicate service.
Patient No. 12/F. Castro.
Five Acres seeks reimbursement in the amount of $90.44. The claim was denied under the code “DUPLICATE SERVICE.” The MOPI receipt, printed on May 4, 2001, shows that the patient became eligible for Medi-Cal on December 21, 2000. Five Acres also submitted a benefits identification card for this patient, with the same issue date.
We could not locate this patient’s name in Exhibit A, and Maun states in her declaration that this patient “wasn’t found.”
Patient No. 13/T. Coats.
Five Acres seeks reimbursement in the amount of $268. The claim was denied under the code “INELIGIBLE IN MO/YR.” The MOPI receipt, printed on September 21, 2000, shows that the patient became eligible for Medi-Cal on September 1, 2000. Five Acres also submitted a benefits identification card for this patient, with a different issue date of December 5, 2000.
Maun’s declaration states that claims related to this patient were denied because of duplicate service.
Patient No. 14/K. Cox.
Five Acres seeks reimbursement in the amount of $2,175.53. The claims were denied under the code “INELIGIBLE IN MO/YR.” The MOPI receipt, printed on July 13, 2000, shows that the patient became eligible for Medi-Cal on July 7, 2000. Five Acres also submitted benefits identification cards for this patient.
K. Cox has had two beneficiary identification numbers, 86588495P and 6092089554.
Maun references this patient in her declaration, but it is unclear what her notes mean. For example, she refers to 53 claims “with code 09 – Ineligible in MMYY many claims sent in in the same batch but different 10 char IDs.”
Patient No. 15/T. Harkins.
Five Acres seeks reimbursement in the amount of $90.44. The claim was denied under the code “DUPLICATE SERVICE.” The MOPI receipt, printed on December 12, 2000, shows that the patient became eligible for Medi-Cal on May 1, 1994. Five Acres also submitted a benefits identification card for this patient.
Maun’s declaration refers to this patient and indicates claims were denied because of duplicate service.
Patient No. 16/S. Hickey.
Five Acres seeks reimbursement in the amount of $90.44. The claim was denied under the code “DUPLICATE SERVICE.” The MOPI receipt, printed on December 12, 2000, shows that the patient became eligible for Medi-Cal on June 28, 2000. Five Acres also submitted benefits identification cards for this patient.
Maun’s declaration does not contain any reference to claims concerning this patient.
Patient No. 17/T. Hill.
Five Acres seeks reimbursement in the amount of $90.44. The claim was denied under the code “DUPLICATE SERVICE.” The MOPI receipt, printed on December 12, 2000, shows that the patient became eligible for Medi-Cal on June 3, 1999.
Maun’s declaration refers to this patient and indicates claims were denied because of duplicate service.
Patient No. 18/M. Hogan.
Five Acres seeks reimbursement in the amount of $90.44. The claim was denied under “invalid code.” The MOPI receipt, printed on August 14, 2000, shows that the patient was eligible for Medi-Cal on August 8, 2000. Five Acres also submitted a benefits identification card for this patient.
Maun’s declaration refers to the claim, but merely repeats that it was denied under the “Dup. Service” code. She offers no other explanation or evidence to show that the claim was properly denied under this code, for example, a claim Five Acres submitted for duplicate service or a document showing payment for an identical claim.
Patient No. 19/K. Hooker.
Five Acres seeks reimbursement in the amount of $90.44. The claim was denied under the “DUPLICATE SERVICE” code. The MOPI receipt, printed on February 5, 2001, shows that the patient was eligible for Medi-Cal on December 6, 2000. Five Acres also submitted a benefits identification card for this patient.
We could not locate this patient’s name in Exhibit A, and Maun states in her declaration that this patient “wasn’t found.”
Patient No. 20/T. Johnson.
Five Acres seeks reimbursement in the amount of $876.07. The claim was denied under the code “INELIGIBLE IN MO/YR” and under “invalid code.” The MOPI receipts, printed on July 13, August 14 and September 19, 2000, show that the patient was eligible for Medi-Cal on July 23, 1999.
As to Patient No. 20, Maun states that “[t]his person’s claims were billed with a Client Index Number (CIN) that ended in a[n] 8 instead of a C. 900559798 bad; 83288245P old; 85141455P old. On the accumulated Approved file for FY2000-2001 using Tasha’s MEDS ID, when it was used to do billing[,] [she] had 116 approved claims....” What this means is unclear.
Patient No. 21/C. Jones.
Five Acres seeks reimbursement in the amount of $3,501.62. The claims were denied under “invalid code,” “DUPLICATE SERVICE,” and “INELIGIBLE IN MO/YR.” The MOPI receipts, printed on October 18, September 19, August 14, 2000 and on April 19, 2002, show that the patient was eligible for Medi-Cal on May 23, 2000 and again on July 2, 2001. Five Acres also submitted a benefits identification card.
Maun’s declaration states that this patient’s “claims were billed with a Client Index Number (CIN) that ended in a[n] O instead of a[n] A.” She then references some numbers, but it is unclear how this relates to the specific claims at issue.
Patient No. 22/S. La Fon.
Five Acres seeks reimbursement in the amount of $90.44. The claim was denied under the “DUPLICATE SERVICE” code. The MOPI receipt, printed on December 12, 2000, shows that the patient was eligible for Medi-Cal on September 3, 1999. Five Acres also submitted benefits identification cards having different issue dates and different beneficiary identification numbers.
Maun’s declaration does not reference this patient.
Patient No. 23/A. Lohan.
Five Acres seeks reimbursement in the amount of $90.44. The claim was denied under the “DUPLICATE SERVICE” code. The MOPI receipt, printed on February 5, 2001, shows that the patient was eligible for Medi-Cal on January 17, 2001. Five Acres also submitted a benefits identification card.
Maun states in her declaration that this patient “wasn’t found.” We located this patient, however, in Exhibit A at row 2975.
Patient No. 24/M. Martinez.
Five Acres seeks reimbursement in the amount of $10,406.76. The claims were denied under the code “INELIGIBLE IN MO/YR.” The MOPI receipts, printed on May 16, 2001, show that the patient was eligible for Medi-Cal on February 20, 2001. Five Acres also submitted benefits identification cards.
There are six different benefit identification cards having the following identification numbers: 94021465D1; 86767974P4; 94934863A0.
The only reference to Patient No. 24 in Maun’s declaration merely restates that 186 claims were denied under code 09, ineligible in month and year.
Patient No. 25/C. McNight.0
Five Acres seeks reimbursement in the amount of $90.44. The claim was denied under the code “DUPLICATE SERVICE.” The MOPI receipt, printed on February 5, 2001, shows that the patient was eligible for Medi-Cal on October 25, 1999. Five Acres also submitted a benefit identification card.
Maun’s declaration does not reference this patient.
Patient No. 26/M. Patterson.
Five Acres seeks reimbursement in the amount of $90.44. The claim was denied under the code “INELIGIBLE IN MO/YR.” The MOPI receipt, printed on August 14, 2000, shows that the patient was eligible for Medi-Cal on October 26, 1999. Five Acres also submitted two benefit identification cards.
The cards have different identification numbers, 86640057P2 and 90854725D6.
The only reference to Patient No. 26 in Maun’s declaration merely restates that 353 claims were denied under error code 09, ineligible in month and year. It does not otherwise discuss the legitimacy of the denials.
Patient No. 27/J. Rodriguez.
Five Acres seeks reimbursement in the amount of $90.44. The claim was denied under the code “DUPLICATE SERVICE.” The MOPI receipt, printed on December 12, 2000, shows that the patient was eligible for Medi-Cal on October 7, 1999. Five Acres also submitted benefit identification cards.
Maun’s declaration does not reference this patient.
Patient No. 28/S. Tugmon.
Five Acres seeks reimbursement in the amount of $532.63. The claims were denied under the code “INELIGIBLE IN MO/YR.” The MOPI receipt, printed on December 12, 2000, shows that the patient was eligible for Medi-Cal on October 4, 2000. Five Acres also submitted a benefit identification card.
The MOPI receipt has a beneficiary number of 84855591P and the benefits identification card has a number of 95142809C6.
Maun’s declaration does not reference this patient.
Patient No. 29/J. Vargas.
Five Acres seeks reimbursement in the amount of $31,060.86. The claims were denied under the codes “conflicts w/eligibility file” and “invalid code.” The MOPI receipts, printed on August 14 and November 15, 2000, shows that the patient was eligible for Medi-Cal on July 31, 2000. Five Acres also submitted a benefits identification card.
Five Acres requests reimbursement also for “F. Vargas,” who appears to be a different person than “J. Vargas.” Therefore, some of these claims for reimbursement may be improper.
Maun’s declaration does not reference this patient.
It is unclear how this above evidence supports the trial court’s finding that Five Acres failed to provide the correct Medi-Cal beneficiary identification number to the State. Rather, Maun’s declaration and attached memorandum, to which the trial court sustained an objection, never clearly state that Five Acres provided the incorrect beneficiary number for each of the 29 patients and that this is why the claims were denied. For example, as to Patient No. 1/J. Anderson, Maun states that the provider entered the beneficiary’s “number” incorrectly. Assuming that Maun is referring the Medi-Cal beneficiary identification number, she refers to a beneficiary number—95881352P—under which 664 claims were approved. She then states that the “MEDS ID above was... deactivated many years ago.” The beneficiary number Maun references is the number in the MOPI receipt and the benefits identification card that Five Acres produced. It is therefore unclear how Five Acres provided a wrong beneficiary number.
Similarly, Maun states, with respect to Patient No. 7/R. Perez, that the provider billed using a MEDS number that didn’t match his name and birthday. She does, however, then cite a beneficiary number—86279810P—which is the number in the MOPI receipts and benefits identification card.
Then, for Patients Nos. 20/T. Johnson and 21/C. Jones she states that the claims were billed with a “Client Index Number” that ended with the wrong character. It is not clear, however, that the “Client Index Number” is the Medi-Cal beneficiary identification number.
For other patients (for example, patients Nos. 11, 13, 15 and 17), Maun states that claims were denied under the “duplicate service code.” This may or may not be a proper denial. But it nonetheless does not support the trial court’s finding that claims were denied because Five Acres submitted incorrect beneficiary identification numbers.
Maun does not address any of the claims concerning Patients Nos. 4-6, 8-10, 16, 25, and 27-28.
Thus, it is not clear to us that the State denied the claims at issue based on Five Acres’s failure to provide correct beneficiary identification numbers. Indeed, in response to Five Acres’s evidence that the 29 patients were eligible for Medi-Cal around the time Five Acres provided services to them, the State implies the claims were denied because the patients were ineligible for the specific program funded under Medi-Cal. It may very well be true that despite what the POS receipts show, these 29 patients were in fact ineligible for reimbursement under Short-Doyle. But the State has not provided evidence to support that implication. Therefore, we make no determination of that issue.
To be sure, reviewing each specific claim is a daunting task, but there is simply insufficient evidence that Five Acres provided incorrect beneficiary numbers to the State, that this was the reason the claims were denied, and that all the claims relating to the 29 patients were ineligible for reimbursement under Medi-Cal. We make no conclusion as to what should be the ultimate outcome. Indeed, as we have pointed out, some of Five Acres’s claims for reimbursement appear to be invalid, for example, claims for reimbursement of claims relating to “F. Vargas.” Our holding is narrow: substantial evidence does not support the trial court’s conclusion that the claims were denied because Five Acres failed to provide the correct Medi-Cal beneficiary numbers to the State. This matter must therefore be reversed and remanded for further proceedings. Because of the fact intensive nature of this matter, the trial court may wish to refer it to a special master.
In two footnotes in its respondents’ brief on appeal, the State notes, first, that the petition failed to name Los Angeles County, an allegedly indispensable party, as a real party in interest and, second, that the petition failed to allege that Hathaway-Sycamores exhausted its administrative remedies. The footnotes refer to those portions of its written opposition to the petition in which the State made these arguments, but, on appeal, the State offers no analysis. This is not sufficient to preserve the issue for appeal.
DISPOSITION
The judgment is reversed and remanded for proceedings consistent with this opinion. Appellant to recover costs on appeal.
We concur:KLEIN, P. J., CROSKEY, J.