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Collection of Copayments for Referrals

Provider Type

  • Physicians (does not apply to Cal MediConnect)
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Outside referrals include:

  • Emergency rooms or urgent care centers.
  • Inpatient or outpatient hospitalizations.
  • Home health care services and visits.

Collection of copayments for outside referrals, other than those mentioned above, must be arranged with the provider of service or collected by the participating physician group (PPG) or primary care physician (PCP).

An emergency room copayment is collected as a partial reimbursement for services received at the facility. If the emergency room claim is split (for example, one claim is sent for facility services and another is sent for professional services), the emergency room copayment only applies to the facility claim. Professional services billed separately and received during an emergency room visit do not require an emergency room copayment.

Cal MediConnect members are not subject to copayments; participating providers must not collect copayments from these members.

Last Updated: 10/30/2019