24-116 Balance Billing is Prohibited for Community Health Plan of Imperial Valley Members
Date: 02/06/24
Fees and surcharges above and beyond a Community Health Plan of Imperial Valley member's copayment and coinsurance are 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 Community Health Plan of Imperial Valley member, or any person acting on behalf of a member, for any service covered under the Plan program. Plan members are not liable for any amount unless a share of cost must be met.
If a Plan member’s managed care coverage has been placed on hold, physicians and other providers should bill fee-for-service (FFS) for services provided to that member.
Community Health Plan of Imperial Valley as secondary
If the member has other health coverage (i.e., Medicare or commercial (HMO, POS, EPO, HSP)) as primary (the Plan as secondary), the physician and other providers must not charge the member’s other health coverage copayment, coinsurance or deductible because those are covered by the 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.
Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact Community Health Plan of Imperial Valley at 833-236-4141. Behavioral Health providers can call 844-966-0298.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.
This information applies to Medi-Cal in Imperial county.