23-792 Prohibited Balance Billing for Medi-Cal Members

Date: 07/31/23

Fees and surcharges above and beyond a Medi-Cal member's copayment and coinsurance is not allowed

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.

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

Medi-Cal as secondary

If the member has other health coverage (i.e., Medicare or commercial (HMO, POS, EPO, HSP)) 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.

Provider appeals

If a provider does not agree with the outcome of a claim, they can file a formal provider appeal to the Plan or medical group if they are affiliated with a participating physician group.

For information about the appeals process, access the Provider Library > Provider Appeals and Dispute Resolution.

Additional information

Information regarding balance billing is available in the provider operations manual in the Provider Library > Balance Billing.

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

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.

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