Medi-Cal Participation Requirements for Reimbursement
Provider Type
- Physicians and Practitioners
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
All Medi‑Cal claims submitted for reimbursement must meet individual rendering provider participation requirements, regardless of whether the claim is submitted under a contracted group or participating physician group (PPG) agreement. Claims are adjudicated based on the individual rendering provider’s participation status at the time services are rendered, not the group’s contracted status.
Provider Participation Requirements
To be considered participating for purposes of Medi‑Cal claim adjudication, the individual rendering provider must, at the time of service:
- Hold active credentialing with Health Net, as applicable.
- Maintain required enrollment with the California Department of Health Care Services (DHCS), where applicable.
- Be accurately reported on the submitted and approved provider roster associated with the contracted group or PPG.
Any discrepancy between a provider’s credentialing status, DHCS enrollment or roster inclusion may result in the rendering provider being treated as non‑participating for claims processing purposes.
Claims Adjudication Standards
Claims are processed based on the rendering provider’s participation status. Submission of a claim under a group contract or PPG agreement does not override individual provider participation requirements.
A claim may be denied or processed as non‑participating when the rendering provider:
- Is not enrolled with DHCS, as required.
- Is not credentialed with Health Net.
- Is not included on the group’s submitted and approved provider roster.
Claims are not subject to reprocessing if participation requirements were not met at the time services were rendered.
Provider Responsibilities
To maintain eligibility for in‑network Medi‑Cal reimbursement, contracted providers and PPGs are responsible for the following:
- Maintaining accurate and current provider rosters.
- Ensuring all rendering providers complete Health Net credentialing and DHCS enrollment, as applicable.
- Submitting provider roster and credentialing updates through established Health Net processes within required timeframes.
Provider Roster Maintenance
For PPGs, Health Net provides the Active Physicians Listing as a monthly administrative report available through the Health Net provider portal.
PPGs must:
- Access the Active Physicians Listing by selecting Provider Reports from the Welcome page.
- Review physician demographic information and confirm roster accuracy.
- Submit additions, updates, corrections and terminations using established submission processes.
The Active Physicians Listing is used by Health Net Provider Network Management to validate primary care and specialist participation information on a quarterly basis.
Service‑Specific Application Example – Immunization Claims
Under Medi‑Cal coverage rules, immunization services rendered by non‑participating providers are not covered benefits.
- Claims for vaccine products and administration rendered by non‑participating providers will be denied.
- Exception: Services provided by local health departments.
- Immunization administration fees are payable.
- Vaccine products are not covered.
This example illustrates how individual provider participation status affects Medi‑Cal claim adjudication.