Welcome to the Department of Health Care Services Welcome to Medi-Cal Welcome to the Department of Health Care Services

FAQs

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.

Additional FAQs:

Checking Medi-Cal Claim Status

  1. How do Medi-Cal providers check the status of a claim online?
    A. Med-Cal providers should follow these steps in order to check the status of a claim:
    • Click the Transactions tab on the Medi-Cal Web site 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.

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 office number. The next eight digits are the sequence numbers of the TAR form. The last digit is a pricing indicator. A Long Term Care TAR TCN has nine digits. The first two digits indicate the Medi-Cal field office number. The next seven digits are the sequence numbers on the form. An LTC TCN does not have a pricing indicator.
  2. Why was my Treatment Authorization Request (TAR) deferred?
    A. Contact the TAR field office for information on a deferred TAR. See the TAR Field Office Addresses section of the appropriate Part 2 manual for TAR field office phone numbers and addresses.
  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. Contact the Medi-Cal field office if the dates of service are incorrect on the TAR. Refer to the TAR Field Office Addresses section of the appropriate Part 2 manual for Medi-Cal field office phone numbers and addresses.
  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. If the TAR number is not on file, contact the appropriate Medi-Cal field office. Refer to the TAR Field Office Addresses section of the appropriate Part 2 manual for Medi-Cal field office phone numbers and addresses.
  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. If the recipient does not meet the requirements, providers must submit a Treatment Authorization Request (TAR) to prescribe the medication. For more information, call the Telephone Service Center (TSC) at 1-800-541-5555.

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 (916) 636-1100.
  2. When I access the Web site 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 after 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 after transmission should call the CMC Help Desk at (916) 636-1100.
  3. How do I sign up to send my claims on the Medi-Cal Web site?
    A. Providers already submitting claims via Computer Media Claims (CMC) should click on the "CMC" link on the Medi-Cal Web site and follow the directions on logging in. Providers not currently submitting claims via CMC must get a CMC submitter number and software 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 Web site in the Medical Services provider manual. Search for "Medi-Cal Telecommunications Provider and Biller Application/Agreement."
    • Providers must have software to format claims. The Medi-Cal CMC Billing and Technical Manual is available on the Medi-Cal Web site 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 (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 Medi-Cal TelePoint System and Internet link
    3. Send in a test transmission to verify compatibility
    4. Provider/submitter number activated by DHCS upon successful test transmission

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 Personal Identification Number (PIN). A PIN is a six, seven or eight–digit number.
  3. What is a temporary PIN?
    A. A temporary Provider Identification Number (PIN) is issued by the POS/Internet Help Desk to providers who do not have a permanent PIN or have misplaced their permanent PIN. A temporary PIN is valid until midnight of the day it was issued.

    Providers can use a temporary PIN to verify eligibility and perform Share of Cost transactions. A temporary PIN can only be used on the Supplemental Automated Eligibility Verification System (SAEVS). A temporary PIN cannot be used with the POS Device, Automated Eligibility Verification System (AEVS), Provider Telecommunications Network (PTN) or on the Medi-Cal Web site.

    To obtain a temporary PIN, please call the POS/Internet Help Desk at 1-800-427-1295. You can access SAEVS by calling 1-800-427-1295. Choose option 4 and then option 2.

  4. How can I obtain a permanent PIN?
    A. Providers should call the Telephone Service Center (TSC) at 1-800-541-5555 (select option 2) and request a supplemental form for a permanent PIN. Mental health providers must send a letter requesting a permanent PIN on company letterhead to the following address:

    Medi-Cal Oversight
    Attention: PIN Requests
    1600 9th Street, Room 410
    Sacramento, CA 95819

  5. How do I request a visit from a Regional Representative at my office with no charge?
    A. To request an on-site visit from a Regional Representative at no charge to the provider, call the Telephone Service Center (TSC) at 1-800-541-5555 and ask to be directed to the Regional Representative voice mail.
  6. What do I do if I cannot resolve a claim denial after 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:

    Xerox State Healthcare, LLC/Medi-Cal
    P.O. Box 13029
    Sacramento, CA 95813-4029
    Attention: Correspondence Specialist Unit.

    The letter should include all pertinent documentation.

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.

Recipient Eligibility Verification

  1. How can I bill Medi-Cal if I only have the recipientís Social Security Number (SSN)?
    A. A recipientís eligibility can be retrieved from the Eligibility Verification System (EVS) using the recipientís 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 such as pharmacy claims in CALPOS, the date of adjudication can continue to be used instead of the issue date.
  2. How do I verify a recipientís Medi-Cal eligibility if they do not have their BIC card or an SSN?
    A. Contact the Medi-Cal County Welfare Office 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 office.
  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. Long Term Care, Pharmacy and Vision Care providers should refer to the Section 100-25 for a full description of each recipient's aid code. Medical Services, Inpatient, Outpatient and Allied Health providers should refer to Aid Code Master Chart for a full description of each recipient's aid code.
  4. How often must I verify eligibility for Medi-Cal recipients?
    A. Verify eligibility for Medi-Cal recipients monthly. Providers receiving an Eligibility Verification Confirmation (EVC) number must remember that the recipient may be restricted to pregnancy, emergency and County Medical Services Program (CMSP) services. Long Term Care, Pharmacy and Vision Care providers should refer to Section 100-25 for a full description of each recipient's aid code. Medical Services, Inpatient, Outpatient and Allied Health providers should refer to Aid Code Master Chart for a full description of each recipient's aid code.
  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 Web site or a Point of Service (POS) device 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:

    Xerox State Healthcare, LLC/Medi-Cal
    P.O Box 15300
    Sacramento, CA 95851-1300

    Providers without access to the Medi-Cal Web site or a POS device 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.

    Note: To acquire a POS device, call the POS Help Desk at 1-800-427-1295.

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, use a Point of Service (POS) device to 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, Long Term Care, Pharmacy and Vision Care providers should refer to provider manual Section 400-61. Allied Health, Inpatient, Outpatient and Medical Services providers should refer to Appeal Process Overview in the Part 1 manual.

    Note: To acquire a POS Device, call the POS Help Desk at 1-800-427-1295.

  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, Long Term Care, Pharmacy and Vision Care providers should refer to provider manual Section 400-61. Allied Health, Inpatient, Outpatient and Medical Services 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, Long Term Care, Pharmacy and Vision Care providers should refer to provider manual Section 400-61. Allied Health, Inpatient, Outpatient and Medical Services 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:

    Xerox State Healthcare, LLC/Medi-Cal
    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 fifth 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 after 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:

    Xerox State Healthcare, LLC/Medi-Cal
    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 office.
  11. Why isn't Medi-Cal reimbursing the 20 percent after 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 9505: The NDC is not correct on the compound sheet?
    A. Call the Telephone Service Center (TSC) at 1-800-541-5555. A TSC operator will compare the National Drug Code (NDC) against the master file.
  14. 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. Call the POS Help Desk at 1-800-427-1295 for more assistance.

Using the Medi-Cal Web Site

  1. Are the manuals on the Medi-Cal Web site the same as the printed manual?
    A. Yes.
  2. What do I need to have with me when I perform an eligibility, Share of Cost or Medi-Service transaction on the Medi-Cal Web site?
    A. Providers verifying eligibility or Share of Cost or reserving a Medi-Service on the Medi-Cal Web site must have a valid provider number and Personal Identification Number (PIN) ready.
  3. Why can't I log into the Medi-Cal Web site for Transaction Services?
    A. Providers currently listed in the Partner File can access Transaction Services on the Medi-Cal Web site. 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.

Using Your POS Device

  1. What can I do if my Point of Service (POS) device receives a Communication Error (CE)?
    A. Unplug the small black power cord from the back of the device, wait 10 seconds and plug the power cord into the POS device. This should resolve a CE error. If the error occurs again repeat the process. For more information or assistance, refer to the POS manual or call the POS Help Desk at 1-800-427-1295.
  2. What can I do if my Point of Service (POS) device receives a Loss of Communication (LC) error?
    A. The POS device must dial to 1-800-707-6225 and reside on an independent line. Providers who want to determine if they share a phone line, take a spare phone, unplug the telephone line from the back of the device, plug it into the phone and listen for a dial tone. If no dial tone is heard, contact the telephone company. If the error occurs again, refer to the POS manual or call the POS Help Desk at 1-800-427-1295.

    Note: Providers who dial 9 to access an outside line must perform this process when using a POS device.

  3. What can I do if my Point of Service (POS) device receives a Corrupt Response (CR) error?
    A. This problem occurs when the POS device does not get a good connection with the modem. To resolve the problem, repeat the transaction. Providers who continue to receive no response should refer to the POS manual or call the POS Help Desk at 1-800-427-1295.
  4. What can I do if my Point of Service (POS) device receives a Time Out (TO) error?
    A. This error occurs when the POS device attempts to dial and is unable to connect to 1-800-707-6225. When this error occurs, perform the transaction again. If the error occurs again, call the POS Help Desk at 1-800-427-1295.
  5. What can I do if my Point of Service (POS) device receives a Format Error (FE) or a Program Error (PE)?
    A. For Format and Program Errors, follow these steps:
    1. Press F10
    2. Type "02"
    3. Check the phone numbers (1-800-361-4932) enter
    4. Press Enter again
    5. To dial a 9 to dial out, select "PABX Code" and enter a 9. Otherwise, press Enter
    6. Press F12
    7. Press F9
    8. Type in "Y"
    9. Press Enter

    It will say "Loading Mem" (Loading Memory). Follow these steps to download the most current version of the POS device software. Providers will be prompted to "Initiate Transaction." At this time:

    1. Press F3
    2. Type "TX"
    3. Press Enter
    4. Type the "Provider Number"
    5. Press Enter
    6. Type the "Submitter ID"
    7. Press Enter to bypass,
    8. Type the "PIN"
    9. Press Enter
    10. Press "1" to send


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