Section 3: Claims

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)

(End dated December 31, 2023) 

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

(End dated December 31, 2023) 

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

​Long Term Care (LTC) Rate Updates

Mental Health Services

National Drug Code (NDC)

​Newborn Services

Obstetrical Services

Other Primary Coverage

​Pay On Behalf of Delegated Entity

            A. Pay on Behalf Claims Inquiry and Dispute Resolution Process

 Preventive Services (Formerly CHDP)

Radiology Services

Third Party Liability and Worker’s Compensation