Section 3: Claims

Counties and Services Covered by Partnership

​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

Partnership Medi-Cal Claim Billing Limit

1. Medi-Cal Billing Limit

2. Wellness & Recovery Billing Limit

Electronic Medi-Cal Claim Submission

Partnership Medi-Cal Encounter Data Submission

Partnership Medi-Cal Electronic Claims Submission

Medicare Part B Electronic Crossover Claims

Required Medi-Cal Claim Attachments, Supplemental Information and Documentation

Partnership Medi-Cal Reimbursement

Partnership Medi-Cal Rates

Partnership Medi-Cal Check Run Schedule

Partnership Medi-Cal Provider Payment Documentation

1. Partnership Medi-Cal RAs

2. Partnership Medi-Cal Pend Reports

3. Partnership Medi-Cal Electronic 835

4. Partnership Medi-Cal Electronic 277

Prohibition Against Balance Billing Partnership 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

Partnership Medi-Cal Claims Inquiries

Partnership Medi-Cal Telephone Inquiries

Partnership Medi-Cal e-Claim Inquiries

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

First Level Appeal – Partnership Medi-Cal Claims Inquiry Form Process

1. Electronic Claims Inquiry Form System (e-CIF)

​​​​(End dated December 31, 2023) 

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

​​​​(End dated December 31, 2023)

Provider Claims Dispute Resolution Mechanism (Effective January 1, 2024) 

​Provider Claims Dispute Resolution Form (Effective January 1, 2024) 

Important Medi-Cal Provider Notices

Partnership Medi-Cal Claims Policies/Billing Guidelines

​340B Billing Information

Anesthesia Services

Authorization Requirements

Child Health and Disability Prevention Program (CHDP)

​​​​​​(End dated June 30, 2017)

See Preventive Services below for DOS on or after July 1, 2017

Circumc​isions

Community Based Adult Services (C​BAS)​

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

Screening for Lung Cancer

Third Party Liability and Worker’s Compensation