Providers and billers call or write to Medi-Cal with questions about programs, policies or billing.

Answers to some of these questions are provided and

grouped into topical categories.

Checking Medi-Cal Claim Status

Completing Treatment Authorization Requests
Computer Media Claims (CMC) Submission
Contacting Medi-Cal
Overpayment
Recipient Eligibility Verification
Understanding Common Denials
Using the Medi-Cal Website

Additional FAQs:

2022 COVID-19 Vaccine Administration FAQs

American Rescue Plan Act (ARPA) Postpartum Care Extension (PCE)
COVID-19 Vaccine Administration FAQs for Providers
COVID-19 Vaccine Administration FAQs for Beneficiaries
Coronavirus (COVID-19) Uninsured Group Frequently Asked Questions
EPSDT/CHDP
Every Woman Counts DETEC Frequently Asked Questions
FCCU
Health Insurance Portability and Accountability Act (HIPAA)
HIPAA: Code Conversion General
HPE Frequently Asked Questions
ICD-10
In-Person Signature Requirement for Delivered Medications
LTC Code and Claim Form Conversion
Medi-Cal Coverage of Aduhelm
Medi-Cal Coverage of Immunizations
Medicare Part D (Federal Prescription Drug Benefit) FAQs
National Corrective Coding Initiative (NCCI)
National Drug Code (NDC)
Ordering, Referring, Prescribing (ORP)
Out-Of-State Providers FAQs
Pharmacy-Administered Vaccines in California
Pharmacy Fee-For-Service Covered Outpatient Drugs
Pharmacy Provider Self-Attestation
Pharmacy Retroactive Claim Adjustments
Post-Service, Prepayment Audit (PPM Audit)
Presumptive Eligibility for Pregnant Women (PE4PW)

Checking Medi-Cal Claim Status

1. How do Medi-Cal providers check the status of a claim online?

A. Medi-Cal providers should follow these steps in order to check the status of a claim:
Click the Transactions tab on the Medi-Cal website home page.

On the "Login To Medi-Cal" page, enter the user ID and password.

Under the "Elig" tab, click the Automated Provider Service (PTN) link.
 Click the “Perform Claim Status Request” link.

Enter the claim information into the following fields:

Payer Claim Control Number (CCN)

Subscriber Identifier

Claim Service Period “From:” and “To:” dates

Total Claim Charge Amount

Finally, click the “Submit” button to get the claim status information.

Providers with additional questions about checking the status of their claims should call the Telephone Service Center (TSC) at 1-800-541-
5555.
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Completing Treatment Authorization Requests (TARs)

1. How many digits are there in a complete TAR Control Number and what do they represent?
A. Most TAR Control Numbers (TCNs) have a total of 11 digits. The first two digits indicate the Medi-Cal field o!ice number. The next eight
digits are the sequence numbers of the TAR form. The last digit is a pricing indicator. A Long Term Care TCN has nine digits. The first two
digits indicate the Medi-Cal field o!ice number. The next seven digits are the sequence numbers on the form. A long term care TCN does not
have a pricing indicator.

2. Why was my Treatment Authorization Request (TAR) deferred?

A. Call the Telephone Service Center (TSC) at 1-800-541-5555 for information on a deferred TAR.

3. I received a denial stating my Treatment Authorization Request (TAR) does not match the dates of service on my claim. What does this
mean?
A. A discrepancy may exist between the dates of service on the TAR and the claim. Providers should compare the dates of service for
accuracy and consistency. If the dates of service match, file an appeal. Call the Telephone Service Center (TSC) at 1-800-541-5555.

4. I received a 0243 denial that states that the Treatment Authorization Request (TAR) number was not on the TAR master file. What can I
do?
A. Call the Telephone Service Center (TSC) at 1-800-541-5555. A TSC operator will review the accuracy and validity of the TAR number on the
claim.

5. What is a Code 1 restriction?

A. Certain medications are restricted to specific recipients based on criteria such as age, quantity, drug therapy, drug duration and type of
illness. A recipient must meet the Code 1 restriction requirements to receive the medication.
E!ective January 1, 2022, many pharmacy services, including covered outpatient drugs, enteral nutrition, some medical supplies and the
applicable administrative services (for example, claim submission, processing, appeals, authorization, etc.) related to pharmacy claims,
transition to Medi-Cal Rx. Pharmacy providers should submit claims for these products to Medi-Cal Rx. For more information on services
covered by Medi-Cal Rx, providers should refer to the Medi-Cal Rx website.

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Computer Media Claims (CMC) Submission

1. Why can't I log-in on the Internet to send my claims electronically to Medi-Cal?

A. The log-in ID is “CMCSUBxxx”. The “xxx” is the 3-digit Computer Media Claims (CMC) submitter number that should be inserted. The
 password is the case sensitive password created with the CMC Help Desk. Verify password. Providers who cannot log in should call the CMC
Help Desk at 1-916-636-1100.

2. When I access the website to check the status of my transmission, I get the message “Information about the volser is not available.”
What does this mean?
A. Volser information is generally available 24 hours a"er the time of transmission and is available for 30 days from the current date. It could
be possible that the batch was not processed due to submission errors. Providers who cannot locate the volser detail 24 hours a"er
transmission should call the CMC Help Desk at 1-916-636-1100.

3. How do I sign up to send my claims on the Medi-Cal website?

A. Providers already submitting claims via Computer Media Claims (CMC) should click on the “CMC” link on the Medi-Cal website and follow
the directions on logging in. Providers not currently submitting claims via CMC must get a CMC submitter number and so"ware to format
claims to meet Medi-Cal specifications.
To receive a submitter number, complete the Medi-Cal Telecommunications Provider and Biller Application/Agreement form, which is
available on the Medi-Cal website in the Medical Services provider manual. Search for “Medi-Cal Telecommunications Provider and
Biller Application/Agreement.”

Providers must have so"ware to format claims. The Medi-Cal CMC Billing and Technical Manual is available on the Medi-Cal website in
"Technical Publications." The CMC Developers, Vendors and Billing Services Directory is also available.

4. How long does it take to process an application?

A. The Computer Media Claims (CMC) Help Desk has 10 days from the date of receipt to process the applications. Provider information on the
application must match the provider information on Department of Health Care Services Provider Master File. Submitter information (if
applicable) on the application must match the submitter information on Department of Health Care Services Submitter Master File. The
application needs original signature(s) on page 4. Incomplete or incorrect applications will be returned to the provider/submitter for
correction. For form completion assistance, call the CMC Help Desk at 1-916-636-1100.

5. What are the steps to becoming a Computer Media Claims (CMC) Submitter?
1. Complete an application form to get a submitter number
2. Set up a password to access the Internet link
3. Send in a test transmission to verify compatibility
4. Provider/submitter number activated by DHCS upon successful test transmission

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Contacting Medi-Cal

1. What information should I have available when I call the Telephone Service Center (TSC)?
A. Providers should have their ten-digit, National Provider Identifier (NPI) ready. Providers are encouraged to have the Medi-Cal provider
manual available for reference.

2. What information do I need to have available when I call the Automated Eligibility Verification System (AEVS) or Provider
Telecommunications Network (PTN)?
A. Providers must have their all-numeric Provider Identification Number (PIN). A PIN is a six, seven or eight–digit number.

3. Where can I find information about PINs?

A. Providers can refer to broad information about PINs in the Part 1 provider manual section, Provider Guidelines.

4. How do I request a free onsite visit from a regional representative at my o!ice with no charge?
A. To request a free onsite visit, call the Telephone Service Center (TSC) at 1-800-541-5555 and ask to be referred to the regional
 representative.

5. What do I do if I cannot resolve a claim denial a"er I have called the Telephone Service Center (TSC), submitted a Claims Inquiry Form or
Appeal Form and received a denial on my Remittance Advice Details?
A. The Correspondence Specialist Unit can help clarify Medi-Cal policy and procedures. Please send a letter, detailing all pertinent
information and enclose all related documents to:
California MMIS Fiscal Intermediary
P.O. Box 13029
Sacramento, CA 95813-4029
Attention: Correspondence Specialist Unit.

The letter should include all pertinent documentation.

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Overpayment

1. An overpayment was noted on a Remittance Advice Details (RAD), what could I do to correct the error?
A. If you are issuing a personal check, please make it payable to the Department of Health Care Services (DHCS) and send it along with a
photocopy of the RAD to:
ATTN: Accounting Section
Department of Health Care Services
MS 1101
1501 Capitol Avenue, Suite 71-2048
P.O. Box 997413
Sacramento, CA 95899-7413

Remember to send a copy of the RAD in order to update your payment history correctly.

Additional options are available in the Remittance Advice Details: Payments and Claim Status section of the Medi-Cal provider manual.

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Recipient Eligibility Verification

1. How can I bill Medi-Cal if I only have the recipient’s Social Security Number (SSN)?
A. A recipient’s eligibility can be retrieved from the Eligibility Verification System (EVS) using the recipient’s SSN. The eligibility response will
provide the Benefits Identification Card (BIC) and issue date that can be used to bill Medi-Cal. Only the first nine digits of the BIC are required
to bill Medi-Cal. If submitting certain claim types, the date of adjudication can continue to be used instead of the issue date.

2. How do I verify a recipient’s Medi-Cal eligibility if they do not have their BIC card or an SSN?
A. Contact the Medi-Cal County Welfare O!ice in which the recipient reside using the Medi-Cal County Contacts for Providers list. For security
purposes, providers must identify themselves as a Medi-Cal provider and identify the recipient. If eligibility is under a program other than
Medi-Cal, contact the program o!ice.

3. What does the patient aid code mean?

A. The aid code describes the benefit for which that recipient is eligible. For specific information regarding aid codes, call the Telephone
Service Center at 1-800-541-5555. Providers should refer to the Aid Codes Master Chart for a full description of each recipient’s aid code.

4. How o"en must I verify eligibility for Medi-Cal recipients?

A. Verify eligibility for Medi-Cal recipients on the date of service, even if eligibility was previously verified for the month.

5. What do I do when my claim is denied because the recipient is ineligible?

 A. Providers must show proof of recipient eligibility for the date of service. Providers verifying eligibility on the Medi-Cal website can make a
print out of the eligibility information. Providers should photocopy this print out and attach this copy to the claim. Providers can resubmit
the claim with the photocopies to the regular P.O. Box (depending on the claim type), if timeliness requirements are observed. Otherwise
providers can file an appeal with all documentation to:
California MMIS Fiscal Intermediary
P.O Box 15300
Sacramento, CA 95851-1300

Providers without access to the Medi-Cal website can call the Automated Eligibility Verification System (AEVS) at 1-800-456-2387 and receive
a confirmation number and enter this number in the Remarks area/Reserved For Local Use field (Box 19) of the claim.

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Understanding Common Denials

1. How do I follow up on a claim denied with Remittance Advice Details (RAD) code 002: The recipient is not eligible for benefits under the
Medi-Cal program or other special programs?
A. When following up on RAD code 002, verify a recipient's eligibility. If a recipient is eligible, submit an Appeal Form to the Department of
Health Care Services (DHCS) Fiscal Intermediary (FI) with the Eligibility Verification Confirmation (EVC). If timeliness requirements can be
met, rebill the claim. For more information on appeals, providers should refer to Appeal Process Overview in the Part 1 manual.

2. I received a Remittance Advice Details (RAD) code 037: Health Care Plan enrollee, capitated service not billable to Medi-Cal. What does it
mean?
A. The recipient is covered by another insurance plan. Providers must bill the other insurance plan first. Refer to MCP: Code Directory in the
Part 1 provider manual. This section contains a listing of all Managed Care Health Plans, including their addresses and phone numbers.

3. What can I do if I receive Remittance Advice Details (RAD) code 095: Service is not payable due to a procedure/modifier previously
reimbursed?
Call the Telephone Service Center (TSC) at 1-800-541-5555. If the provider's record indicates non-payment, an appeal needs to be filed. For
more information on appeals, providers should refer to Appeal Process Overview in the Part 1 manual.

4. What can I do if I receive Remittance Advice Details (RAD) code 010: Service is a duplicate of a previously paid claim?
A. Providers should file an appeal requesting the reimbursed provider's name and the warrant information. For more information on
appeals, providers should refer to Appeal Process Overview in the Part 1 manual.

5. What can I do if I receive Remittance Advice Details (RAD) code 232: Medi-Cal frequency of service exceeded?
A. Providers must submit justification on company letterhead explaining the medical necessity and attach this information to the claim and
resubmit the claim. Otherwise, providers must attach all documentation to an appeal and send it to:
California MMIS Fiscal Intermediary
P.O. Box 15300
Sacramento, CA 95851-1300

6. What can I do if I receive Remittance Advice Details (RAD) code 351: Vision - Additional benefits are not payable?
A. Enter the alphanumeric ICD-9-CM code for the principal ocular diagnosis, including fourth and fi!h digits, if present, in the Principal
Ocular ICD-9-CM Diagnosis Code field (Box 21) on the vision claim.

7. What can I do if I receive Remittance Advice Details (RAD) code 171: Aid code 80 recipients (QMB) are restricted to Medicare coinsurance
and deductible payments?
A. If the recipient is a Qualified Medicare Beneficiary (QMB), verify that the claim is for Medicare deductible and/or coinsurance. Providers are
reimbursed for Medicare non-covered services provided to a QMB recipient only when the recipient is eligible for Medi-Cal. Some Medi-Cal
recipients may have additional eligibility once the Share of Cost (SOC) is cleared.
 For example, a recipient with both aid codes 80 and 17 (“Aged plus a Share of Cost”) has full coverage for Medi-Cal services a!er the Share of
Cost requirement is met. Therefore, providers receiving Medi-Cal RAD code 171 should verify the recipient’s eligibility online before denying
services. For more information, call the Telephone Service Center at 1-800-541-5555.

8. What can I do if I receive Remittance Advice Details (RAD) code 691: Diagnosis is invalid for the date of service?
A. Providers can call the Telephone Service Center (TSC) at 1-800-541-5555 to verify that the diagnosis code is valid for dates of service. If the
diagnosis is valid, providers may submit an appeal to:
California MMIS Fiscal Intermediary
P.O. Box 15300
Sacramento, CA 95851-1300

9. What can I do if I receive Remittance Advice Details (RAD) code 012: Proof of payment/description of denial required from Medicare?
A. Attach proof of payment/description of denial from Medicare when billing Medi-Cal. Providers with other questions related to this RAD
code should call the Telephone Service Center at 1-800-541-5555.

10. What can I do if I receive Remittance Advice Details (RAD) code 101: CCS/GHPP authorization incomplete?
A. Call the California Children Services (CCS) and Genetically Handicapped Persons Program (GHPP) Help Desk at 1-800-541-7747 to verify
that the authorization number is 11 digits. If the authorization is not 11 digits, call the CCS/GHPP county o"ice.

11. Why isn't Medi-Cal reimbursing the 20 percent a!er Medicare pays?
A. Medi-Cal only pays for Part B services minus what Medicare or any other insurance pays. Medi-Cal reimburses up to our maximum
allowable. If Medicare reimburses more than the maximum allowable, Medi-Cal will not reimburse the 20 percent.

12. What can I do if I receive Remittance Advice Details (RAD) code 9101: Manufacturer catalog pages or invoice required?
A. Attach the approved catalog page or invoice to the claim, with the description of the item, manufacturer name, model number and
catalog number (if appropriate).

13. What can I do if I receive Remittance Advice Details (RAD) code 0667: Date of issue does not match?
A. The denial was generated because the date of issue on the Benefits Identification Card (BIC) entered on the claim does not match the date
of issue in our system. Enter the date of issue from the recipient's BIC card. Providers cannot use the date of service as the date of issue.

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Using the Medi-Cal Website

1. What do I need to have with me when I perform an eligibility, Share of Cost or Medi-Service transaction on the Medi-Cal website?
A. Providers verifying eligibility or Share of Cost or reserving a Medi-Service on the Medi-Cal website must have a valid provider number and
Personal Identification Number (PIN) ready.

2. Why can't I log into the Medi-Cal website for Transaction Services?
A. Providers currently listed in the Partner File can access Transaction Services on the Medi-Cal website. Providers who complete and submit
a Network Agreement are added to the Partner File. To verify Partner File status, call the Point of Service (POS) Help Desk at 1-800-427-1295.
The POS Help Desk can send a Network Agreement form to providers who want to be added to the Partner File.

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