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Medi-Cal: Out-of-State Providers FAQs

Out-of-State Provider FAQs

1. What is Medi-Cal?
In July 1965, two major amendments to the Social Security Act greatly expanded the scope of medical coverage available to various segments of the population. Title XVIII established the Medicare program and Title XIX established the state option medical assistance program known as Medicaid, which provides federal matching funds to states implementing a single comprehensive medical care program.

Under the provisions of the California Code of Regulations (CCR), Title 22, the Department of Health Care Services (DHCS) administers California's Medicaid program, Medi-Cal, and has statutory responsibility to formulate policy that conforms to federal and state requirements.

The objective of the Medi-Cal program is to provide essential medical care and services to preserve health, alleviate sickness, and mitigate handicapping conditions for individuals or families on public assistance or whose income is not sufficient to meet their individual needs. The covered services are generally recognized as standard medical services required in the treatment or prevention of diseases, disability, infirmity or impairment. These services are comprehensive of the major disciplines of health care.

2. Does Medi-Cal have a website?
The Medi-Cal website address is www.medi-cal.ca.gov.

3. Does a provider have to enroll in Medi-Cal to bill Medi-Cal?
Yes. To bill Medi-Cal, a provider must complete the appropriate enrollment forms. For questions on which forms to use, contact the Out-of-State Provider Unit at (916) 636-1960. If a provider chooses not to enroll, they may bill the patient. However, an enrolled Medi-Cal provider cannot bill a Medi-Cal-eligible patient for a covered service.

4. How do I bill Medi-Cal?
Instructions for billing Medi-Cal can be found in the provider manuals. The provider manuals come in two parts: a Part 1 manual, which addresses Medi-Cal program and eligibility requirements and is applicable to all communities, and a Part 2 manual, which addresses the specific billing requirements and policies of each provider community. Each community has its own Part 2 manual. There are 25 provider communities in Medi-Cal, which are as follows:

Allied Health:
Inpatient/Outpatient:
Medical Services:
- General Medicine
- Obstetrics
Long Term Care
Pharmacy
Vision Care

There is also a manual pertaining to the Child Health and Disability Prevention (CHDP) Program, which is operated by local health departments and provides eligible children and youth periodic health assessments and access to ongoing health care from a medical home.

To order hard copies of provider manuals, call the Out-of-State Unit at (916) 636-1960.

When billing Medi-Cal as an out-of-state provider, you must:

Submit an original, signed and complete claim form. Do not use red ink, highlighter or correction fluid on your claim.
If there is Other Health Coverage (OHC), include OHC payment or denial information relating to the date of service.
Include medical records explaining the nature of the emergency and the services rendered or include an approved Treatment Authorization Request (TAR) number.

5. Where do I send my Medi-Cal claims?
Send Medi-Cal claims to:

California MMIS Fiscal Intermediary
ATTN: Out-of-State Unit
P.O. Box 15507
Sacramento, CA 95852-1507

6. Can I bill Medi-Cal electronically?
Yes. An enrolled Medi-Cal provider can arrange to bill electronically. Please fill out and submit a
Medi-Cal Telecommunications Provider and Biller Application/Agreement form.

7. What services does Medi-Cal cover for recipients who are temporarily out of state?
CCR, Title 22, Chapter 3, Article 1.3, Section 51006, allows reimbursement for medically necessary emergency services that need to be provided by an out-of-state provider to California Medicaid (Medi-Cal) recipients temporarily in another state. Note that some services require authorization. For more information, call the Out-of-State Provider Unit at (916) 636-1960.

8. How do I determine a Medi-Cal recipient's eligibility?
Providers with a valid provider number and Provider Identification Number (PIN) can use a Point of Service (POS) device or Transaction Services on the Medi-Cal website, or call the Automated Eligibility Verification System (AEVS) at 1-800-456-2387 to verify eligibility. Providers without a valid PIN may be assigned a temporary PIN. The temporary PIN is active until midnight of the same business day. To inquire about a temporary PIN, call the Telephone Service Center (TSC) at (916) 636-1200 and select the option for POS/Internet inquiries. Services are not covered by Medi-Cal if a patient is not eligible.

Note: Recipient eligibility may be verified only for the current month and up to the previous 12 months, never for future months.

9. What is "Transaction Services" on the Medi-Cal website?
Transaction Services on the Medi-Cal website allows providers to verify recipient eligibility, clear Share of Cost (SOC) liability, reserve Medi-Services and submit certain types of claims. An Eligibility Verification Confirmation (EVC) number from the Internet eligibility response verifies an inquiry was received and eligibility information was transmitted. An EVC response should be printed and kept in the recipient's file. Providers who complete and submit a Medi-Cal Point of Service (POS) Network/Internet Agreement form are added to a database called the Partner File. Those providers can then access "Transaction Services" on the Medi-Cal website. To verify Partner File status, call the TSC at (916) 636-1200 and select the option for POS/Internet inquiries. The TSC can send a network agreement form to providers who want to be added to the Partner File.

10. What is a patient aid code?
Aid codes describe the benefit for which a recipient is eligible. For specific information regarding aid codes, call the Out-of-State Unit at (916) 636-1960 or refer to the Aid Codes Master Chart section in the Part 1 – Medi-Cal Program and Eligibility manual.

11. What is AEVS and how do I use it?
The Automated Eligibility Verification System (AEVS) is an interactive voice response system that allows you to access recipient eligibility, clear Share of Cost (SOC) liability and/or reserve a Medi-Service through a touch-tone telephone. Access AEVS by calling 1-800-866-2387.

There is no enrollment requirement to use AEVS. However, you must have a valid PIN to access AEVS. PINs are issued upon enrollment into Medi-Cal, but if you are not enrolled in Medi-Cal you can obtain a temporary PIN by following these steps:

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.

If you have a PIN but cannot remember it, complete and return a Medi-Cal Supplemental Application (DHCS 6209). For AEVS instructions, refer to the AEVS: General Instructions section in the Part 1 – Medi-Cal Program and Eligibility manual.

12. What is the importance of an Eligibility Verification Confirmation (EVC)?
AEVS accesses the most current recipient information for a specific month of eligibility. AEVS returns a 10-character EVC number after eligibility is confirmed. It is recommended that providers enter the EVC number on the claim in the field reserved for remarks. However, the EVC number is not required information for claim processing. Receipt of an EVC number does not guarantee claim payment. Providers should carefully review all information returned with an eligibility response to ensure that a recipient is eligible to receive services. An EVC number will not be issued if an individual is ineligible.

Note: An EVC number is only valid for the provider who submitted the inquiry. Providers should carefully review all information returned with the eligibility response to ensure their services are covered under a recipient's eligibility. Some recipients may be restricted to pregnancy, emergency and County Medical Services Program (CMSP) services.

13. When do I verify eligibility for Medi-Cal recipients?
Verify eligibility for Medi-Cal recipients on a monthly basis.

14. What is Share of Cost (SOC)?
Some Medi-Cal recipients must pay, or agree to pay, a monthly dollar amount toward their medical expenses before they qualify for Medi-Cal services. This dollar amount is called Share of Cost (SOC). A Medi-Cal recipient's SOC is similar to a private insurance plan's out-of-pocket deductible.

Recipients are not eligible to receive Medi-Cal benefits until their monthly SOC dollar amount has been certified online. Certifying SOC means that a provider has verified that a recipient has paid or become obligated to pay the entire monthly dollar SOC amount owed. Claims submitted for services rendered to a recipient whose SOC is not certified through the Medi-Cal eligibility verification system will be denied.

15. How do I certify SOC?
To certify a recipient's SOC, access the Medi-Cal eligibility verification system, enter a provider number, PIN, recipient identification number, BIC issue date, billing code and service charge. The SOC information is updated and a response is displayed on the screen or relayed over the telephone. A patient with a SOC is not considered eligible until the SOC has been certified.

16. What is a Managed Care Plan (MCP)?
DHCS has implemented several different managed care plans (MCPs) designed to meet the health care needs of Medi-Cal recipients who previously received services through a "fee-for-service" program. Medi-Cal MCPs are responsible for providing prevention, primary care and other medically necessary services that are not related to California Children's Services (CCS)-eligible medical conditions. However, many children with CCS-eligible medical conditions are enrolled in Medi-Cal MCPs.

Each MCP receives a monthly fee, or per capita rate, from the state for every enrolled recipient. Medi-Cal recipients enrolled in contracting MCPs must receive Medi-Cal benefits from plan providers and not from providers who bill through the fee-for-service program. Each MCP is unique in its billing and service procedures; therefore, providers must contact the individual plan for billing instructions. Services excluded from a plan's contract require billing through the fee-for-service program, which may require authorization. Denial letters from MCPs are not accepted by Medi-Cal for MCP plan-covered services rendered to MCP members.

For managed care contact information, refer to the Medi-Cal Managed Care Contact List.

17. What is a provider number?
When providers are enrolled in Medi-Cal, they are issued a nine-digit, alphanumeric provider number. This number is used when billing Medi-Cal and is required when calling a Medi-Cal help desk.

18. What is a temporary out-of-state provider?
The Out-of-State Provider Unit may enroll certain out-of-state providers and allow payment for up to $599.99, or 10 paid claim lines per calendar year, before they are required to complete the standard enrollment forms. Once this billing limit is reached, the provider is informed through a system-generated letter that enrollment as a permanent provider in the Medi-Cal program is necessary prior to receiving further payment. The letter instructs the provider to bill Medi-Cal again for non-paid claims after the Department of Health Care Services (DHCS) has received and approved a provider's enrollment. Providers unable to use the temporary enrollment format should complete the permanent provider enrollment forms available on the Medi-Cal website's Provider Enrollment web page. For questions about which forms to use, contact the Out-of-State Provider Unit at (916) 636-1960.

19. What are the requirements to become a Medi-Cal provider?
Providers must be licensed and accredited according to the specific laws and regulations that apply to the service or procedure provided. Providers seeking enrollment in the Medi-Cal program so that they can bill for services provided to Medi-Cal recipients must submit the appropriate enrollment documentation, available on the Medi-Cal website's Provider Enrollment web page. Provider enrollment regulations, CCR, Title 22, Section 51000 et. seq. and Section 51200.01, amended effective February 3, 2003, list the application criteria, which include having an established place of business, proof of liability insurance coverage and professional liability insurance coverage, as required.

20. Where do I obtain enrollment forms and provider manuals?
Providers may obtain provider enrollment forms by contacting the Out-of-State Provider Unit at (916) 636-1960 for forms to be mailed or by downloading the appropriate forms from the Medi-Cal website's Provider Enrollment web page. (For questions about which forms to use, contact the Out-of-State Provider Unit.) Likewise, providers may access provider manuals through the Medi-Cal website (refer to the links in question 4).

21. Can an applicant or provider ask someone questions about filling out an application?
Applicants are encouraged to carefully read the instructions provided with the enrollment forms. The provider enrollment automated telephone system at (916) 323-1945 may provide information that answers an applicant's questions, or applicants or providers may submit questions in writing to the following address and DHCS will provide a written response.

Department of Health Care Services
Provider Enrollment Division
MS 4704
P.O. Box 997413
Sacramento, CA 95899-7413

22. Can an applicant or provider submit a photocopy of the enrollment forms?
A photocopy of the forms is acceptable. However, the signature must be an original. Stamped, faxed or photocopied signatures are not acceptable. The form may be photocopied, but it is unlawful to alter it in any manner. If a mistake is made entering information on a form, line through the mistake and initial it. Do not use correction tape, whiteout, etc., to make corrections.

23. Who signs the enrollment forms?
The forms must be signed under penalty of perjury by an individual who is the sole proprietor, partner, corporate officer or an official representative of a governmental entity or non-profit organization, and who has the authority to legally bind the applicant seeking enrollment as a Medi-Cal provider. A biller or office manager is not a valid signatory. Include a legible, current copy of the driver's license or state-issued identification card of the authorized person signing the application. Enlarged copies are appreciated.

24. How does a provider receive a new Medi-Cal provider number?
Providers receive a notification letter when the enrollment forms are approved and entered into the system. The letter is mailed to the business address listed on the application. Approval letters contain the new provider number, the effective date of enrollment and the address at which the services are provided. For the processing dates of enrollment forms sent to DHCS, call the DHCS Provider Master File Unit at (916) 323-1945. To check the status of enrollment forms sent to the Out-of-State Provider Unit, call (916) 636-1960.

25. Can a provider number be deactivated without notification?
A provider number may be deactivated when either of the following circumstances occur:

Warrants or documents mailed to the service, business or pay-to address were returned by the United States Postal Service as undeliverable.
A claim has not been submitted for reimbursement from the Medi-Cal program for one year.

Prior to deactivating a provider number, DHCS makes an attempt to contact the provider by telephone or in writing. If unable to make contact, DHCS is required to deactivate the provider number immediately without further notice.

For additional information about deactivation for returned mail, refer to Welfare & Institutions Code (W & I Code), Section 14043.62(a), for the full text of the statute or the Provider Guidelines section of the Part 1 – Medi-Cal Program and Eligibility manual.

26. Are there guidelines for using Medi-Cal provider numbers?
When assigned a provider number from Medi-Cal, it is important to remember that each provider has agreed to abide by Medi-Cal laws, regulations, program policies and procedures as published in the Medi-Cal provider manuals (CCR, Title 22, Section 51501[d]), which state:

No provider shall submit claims to the Medi-Cal Program using any provider number other than that issued to the provider by DHCS, except when providers are issued a temporary ID through the Out-of-State Provider Unit.
Without approval of the Medi-Cal application and the issuance of a provider number or provisional provider number, the decision to see Medi-Cal patients is at the applicant's own personal risk for payment.
The provider has no property right to the status as a Medi-Cal provider or to the provider number (see Provider Agreement Item 33 in CCR, Title 22).

27. What is a Treatment Authorization Request (TAR) and how do I get one?
Authorization requirements are applied to specific procedures and services according to state and federal law. To obtain authorization approval, a Treatment Authorization Request (TAR) must be submitted. Note the following:

All inpatient hospital stays require authorization, unless otherwise directed.
Most providers request authorization using a Treatment Authorization Request (TAR) (form 50-1).
Long Term Care (LTC) and Subacute Care providers use the Long Term Care Treatment Authorization Request (LTC TAR, form 20-1) to request authorization for services.
In certain circumstances, Inpatient providers may use the Request for Extension of Stay in Hospital (form 18-1).

To obtain TAR forms and the status of existing TARs, contact the Out-of-State Provider Unit at (916) 636-1960.

28. Where do I send my TAR?
Send your completed TAR with chart notes to:

TAR Processing Center
P.O. Box 13029
Sacramento, CA 95813-4029

Items sent via UPS or FedEx should be mailed to:

TAR Processing Center
820 Stillwater Road
West Sacramento, CA 95605-1630

29. Why was my TAR denied or deferred?
To inquire about a denied or deferred TAR, contact the TAR Processing Center at 1-800-541-5555. Have your nine-digit provider number and 11-digit TAR number ready.

30. What do I do if my claims are over one year old?
You need to provide one of the following:

Proof of timely filing (that is, a Remittance Advice Details [RAD] showing the claim had been previously billed on time), with timely follow-up.
Valid reasons for the delay, such as not receiving information from a primary insurer, the Department of Health Care Services (DHCS) or Medi-Cal TAR field office in a timely manner. Exceptions are made on a claim-by-claim basis.

31. What are Remittance Advice Details (RAD) codes?
The Remittance Advice Details (RAD) codes are provided for line-by-line reconciliation of transactions. Reconciliation of a RAD to a provider's records will help determine which claims are paid, denied or not yet adjudicated. Medi-Cal claims appear first followed by Medicare/Medi-Cal crossover claims in this sequence: adjustments, approvals, denials, suspensions and accounts receivable (A/R) transactions. Explanations of RAD codes are found at the bottom of your RAD. For a complete list of RAD codes, refer to the Remittance Advice Details (RAD) Codes and Messages sections of the Part 1 – Medi-Cal Program and Eligibility provider manual.

32. What is the California Children's Services (CCS) program and how do I contact it?
The CCS program provides health care services, including diagnostic, treatment, dental, medical case management, physical therapy and occupational therapy services to children from birth to 21 years of age with CCS-eligible medical conditions. CCS may authorize the payment of Medi-Cal funds for Medi-Cal services provided to children with CCS-eligible medical conditions. To contact CCS, call (916) 327-3100.

33. How do I report suspected fraud?
To report suspected Medi-Cal fraud, call (916) 650-6630.

34. How do I contact Medicare?
The California Medicare number is (530) 743-1587.

35. What revenue codes do I use to bill Medi-Cal for inpatient services?
Refer to these sections in the Part 2 Inpatient Services Manual:

Ancillary Codes
Revenue Codes for Inpatient Services
Revenue Code/Accommodation Code Correlation Guide

36. What are the correct procedure codes for billing medical transportation services?
Refer to the Part 2 manual Allied Health Services for Medical Transportation. Note there are separate sections for air and ground ambulance billing.

Note:

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