25-1082 Understanding Medi-Cal Non-Benefit Billing Codes: What Providers Need to Know
Date: 10/20/25
Ensure compliance and reimbursement with DHCS guidelines on non-benefit codes
Certain services may be reimbursed under Medi-Cal when deemed medically necessary and authorized appropriately. To ensure accurate billing and avoid claim denials, providers must understand the Department of Health Care Services (DHCS) policy on “non-benefit” billing codes and how it affects prior authorization, claims submission, and dispute resolution.
Delegated participating physician groups (PPGs) responsible for utilization management (UM) and claim payments must update their processes to align with DHCS policy.
What are non-benefit billing codes?
Under current Medi-Cal policy:
- DHCS may not have activated all billing codes (HCPCS or CPT) associated with covered services.
- These inactivated codes are listed as “non-benefit” in the Medi-Cal Treatment Authorization Request (TAR) and Non-Benefit list.
- For the general Medi-Cal population, these codes are in a deny status.
Key clarification:
- A “non-benefit” code does not mean the service is categorically excluded from coverage. Instead, it indicates that reimbursement is not available under standard FFS billing unless the service is medically necessary and approved via prior authorization.
Coverage is case-by-case
Coverage decisions for non-benefit codes are made individually, based on:
- Medical necessity
- Prior authorization (PA), if required
Prior authorization requirements
- Check requirements: Physicians and other providers must check the Plan’s or the PPG’s prior authorization requirements list to determine if PA is needed.
- Obtain prior authorization: If required, PA must be obtained before the service is rendered.
Claims submission and dispute process
- If PA is required and service is approved:
- Submit claims with the authorization number clearly indicated.
- If PA is not required:
- Submit claims through standard procedures.
- If a claim is denied:
- Initiate a dispute through the provider dispute resolution process through the Plan or the delegated PPG to contest the denial if you believe a non-benefit code should be covered.
Updated provider operations manuals
Relevant sections of the Plan’s provider operations manuals and the Behavioral Health provider operations manual have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library on the provider portal.
Need help? Contact us
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.