Section 3: Claims

​​Table of Contents - Medi-Cal

 

PHC is a Medi-Cal Managed Care Healthplan.  PHC Claims Department follows State of California Medi-Cal Provider Manual unless otherwise stated here in the PHC Medi-Cal Claims Manual.

Procedure

Counties and Services Covered by PHC

Medi-Cal Counties & Services Covered
Wellness & Recovery Counties and Services Covered

Where to Submit Medi-Cal Claims

Required Medi-Cal Billing Forms and Completion Requirements

 

Medi-Cal CMS 1500

 

Medi-Cal UB-04

 

Medi-Cal LTC Billing Form

 

Medi-Cal CHDP PM160 Information Only Form

 

Medi-Cal Modifiers List
        1. Approved Modifiers
        2. Modifiers Used with Procedure Codes

 

PHC Medi-Cal Claim Billing Limit

 

1. Medi-Cal Billing Limit
2. Wellness & Recovery Billing Limit

 

Electronic Medi-Cal Claim Submission

 

PHC Medi-Cal Encounter Data Submission

 

PHC Medi-Cal Electronic Claims Submission 

 

Medicare Part B Electronic Crossover Claims

Required Medi-Cal Claim Attachments, Supplemental Information and Documentation

PHC Medi-Cal Reimbursement

 

PHC Medi-Cal Rates

 

PHC Medi-Cal Check Run Schedule 

 

PHC Medi-Cal Provider Payment Documentation
        1. PHC Medi-Cal RAs       
        2. PHC Medi-Cal Pend Reports      
        3. PHC Medi-Cal Electronic 835
        4. PHC Medi-Cal Electronic 277

 

Prohibition Against Balance Billing PHC Members for Covered Services   
        1. Medi-Cal PCP Contracts
        2. Medi-Cal Specialist and Ancillary Contracts
        3. Medi-Cal Hospital Contracts
        4. Medi-Cal Title 22 Beneficiary Billing

PHC Medi-Cal Claims Inquiries

 

PHC Medi-Cal Telephone Inquiries

 

PHC Medi-Cal e-Claim Inquiries

PHC Medi-Cal Provider Appeal Process (CIF and Appeal Timelines)

 

First Level Appeal – PHC Medi-Cal Claims Inquiry Form Process
            1. Electronic Claims Inquiry Form System (e-CIF)

 

Second Level Appeal  – PHC Medi-Cal Claims Appeal (Medi-Cal Appeal Form)

Important Medi-Cal Provider Notices

PHC Medi-Cal Claims Policies/Billing Guidelines


​340B Billing Information

 

Anesthesia Services

 

Authorization Requirements

Child Health and Disability Prevention Program (CHDP)    (End dated 6/30/17)                      See Preventtive Services below for DOS on or after 7/1/17

 

Circumcisions

 

Community Based Adult Services (CBAS)

 

Comprehensive Perinatal Services Program (CPSP Services)

 

Evaluation and Management Services (E&M)

 

Family Planning Services

 

Injectibles
              1. Flu Vaccine

Inpatient Hospital

 

Laboratory Services

 

Mental Health Services

 

National Drug Code (NDC)

Newborn Services

 

Obstetrical Services

 

Other Primary Coverage

​Pay On Behalf of Delegated Entity

 Preventive Services (Formerly CHDP)

Screening for Lung Cancer

 

Third Party Liability and Worker’s Compensation

 

Vision Services 



​​Please Direct Questions To:

Partnership HealthPlan of California

4665 Business Center Drive

Fairfield, CA 94534

Phone: (707) 863-4100