Revised Proprietary Forms Reminder
What's New
May 5, 2008New versions of Medi-Cal and Child Health and Disability Prevention (CHDP) program proprietary forms are available from Medi-Cal. Effective April 15, 2008, Medi-Cal is no longer accepting the old version of these forms. These new forms are updated to accommodate the 10-digit National Provider Identifier (NPI).
The following is the list of proprietary forms that have been revised and must be submitted instead of the old versions:
| Form Name | |
| 18-1 | Request for Extension of Stay in Hospital |
| 18-1C | Request for Extension of Stay in Hospital |
| 18-2 | Request for Extension of Stay in Hospital (Fax) |
| 18-3 | Request for Mental Health Stay in Hospital |
| 20-1CZ | Long Term Care Treatment Authorization Request |
| 25-1CZ | Payment Request for Long Term Care |
| 30-1 | Pharmacy Claim Form |
| 30-1CZ | Pharmacy Claim Form |
| 30-4 | Compound Drug Pharmacy Claim Form |
| 30-4CZ | Compound Drug Pharmacy Claim Form |
| 50-1 | Treatment Authorization Request |
| 50-1C | Treatment Authorization Request |
| 50-2 | Treatment Authorization Request (Fax) |
| 50-2C | Treatment Authorization Request |
| 50-3 | Treatment Authorization Request (Vision Care) |
| 55-1 | Medi-Cal Managed Care Authorization Form (Discharge Planning Option) |
| 60-1 | Claims Inquiry Form |
| 60-1C | Claims Inquiry Form |
| 90-1 | Appeal Form |
| PM 160* | CHDP Assessment Confidential Screening/Billing Report (Version 8) |
| PM 160INF* | CHDP Assessment Confidential Screening/Billing Report (Information Only) (Version 8) |
| TAR 3 Form | Treatment Authorization Request Attachment Form |
* CHDP providers should continue to order claim forms through their local county CHDP program. Phone orders will not be accepted.
At the direction of the Department of Health Care Services, the old version non-NPI compliant forms will be returned and may result in claim timeliness issues. If the new form versions are not used, the timeliness of claims may be jeopardized, and reimbursements may be cut back or denied as a result.