Targeted Rate Increase
Provider Type
- Participating Physician Groups (PPG)
Pursuant to the 2023 Budget Act and AB 118 (Chaptered 42, Statutes of 2023), the Department of Health Care Services (DHCS) is increasing reimbursement rates for contracted providers to no less than 87.5% of the lowest California-specific Medicare allowable for certain Medi-Cal covered physician services.
Eligible providers and services include the following
TRI category | Eligible provider types | Eligible claim forms | Contract status |
Primary/general care |
| CMS 1500 | Contracted Network Provider (Does not include SCA, LOA) |
Obstetric | Any/all | CMS 1500 (professional)/UB04 (facility)/nonstandard invoice | Contracted Network Provider (Does not include SCA, LOA) |
Non-Specialty Mental Health Services | Any/all | CMS 1500 (professional)/UB04 (facility)/nonstandard invoice | Contracted Network Provider (Does not include SCA, LOA) |
TRI payment calculation methodology
Step 1: Calculate current contract + Prop 56 Physician Services payment amount | Step 2: Determine the TRI fee schedule amount | Step 3: Pay using the greater amount from steps 1 and 2, and apply final "Lesser of Charges" |
Billed $80, contract $40 Lesser of = $40 Prop 56 Physician Services payment = $30 Total = $70 | Greater than the TRI fee schedule TRI $50 | PPG pays the current contracted rate + Prop 56 Physician Services payment Payment = $70 |
Billed $80, contract $40 Lesser of = $40 Prop 56 Physician Services payment = $30 Total = $70 | Less than the TRI fee schedule TRI $100 | Payment is based on the TRI fee schedule price, but the final "Lesser of" will affect payment. Payment before "Lesser of" = $100 Payment after "Lesser of" = $80 |
Attestation requirement
Health Net requires PPGs to attest to complying with TRI requirements, including confirmation that rendering providers are paid in accordance with the APL. Health Net will provide an attestation form with PPGs amended contract to be signed by the PPG’s finance executive.