22-933 Medi-Cal Member Balance Billing is Prohibited

Date: 11/01/22

Medi-Cal members cannot be charged for fees and surcharges above and beyond a member's copayment and coinsurance

As a reminder, under the terms of the Provider Participation Agreement (PPA) and in accordance with state and federal law, participating physicians and other providers may not bill or attempt to obtain reimbursement from a CalViva Health member, or any person acting on behalf of a member, for any service covered under the Medi-Cal program. Medi-Cal members are not liable for any amount unless a Medi-Cal share-of-cost (SOC) must be met.

If the member has Medicare as primary (Medi-Cal as secondary), the physician and other providers must not charge the member’s copayment, coinsurance or deductible because those are covered by the Medi-Cal plan.

Physicians and other providers should bill fee-for-service (FFS) Medi-Cal for services they provide to a Medi-Cal member whose managed care coverage has been placed on hold.

Additional information

Information regarding balance billing is available in the provider operations manual in the Provider Library, select Provider Manual > Claims and Provider Reimbursement > Balance Billing.

If you have questions regarding information contained in this update, contact
CalViva Health at 888-893-1569.

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.