25-1234 PHCPN Manual Updated: New Billing Instructions for UB-04 and ADA Claim Forms

Date: 12/02/25

Stay informed with the latest Prison Health Care Provider Network (PHCPN) Operations Manual

The PHCPN Operations Manual outlines plan benefits, limitations, and administrative procedures for delivering specialty care to California Department of Corrections and Rehabilitation (CDCR) patients. Providers must follow the manual unless their contract states otherwise.

We have updated the Claims and Provider Reimbursement section to reflect current billing practices.

Key updates include:

• UB-04/CMS-1500 billing instructions
  • Hospitals and ambulatory surgery centers must use the UB-04/CMS-1450 claim form for billing. For detailed guidance, refer to the Claim Form Reference Guide on the CorrectCare Integrated Health portal, under the User Reference tab.

 

• Oral and maxillofacial surgeons claim form
  • Oral and maxillofacial surgeons should use the most current American Dental Association (ADA) Dental Claim Form to submit claims. Providers can view a sample of the form at ADA Dental Claim Form. The form includes several fields related to patient identification that require unique entries for CDCR claims. Providers must enter the information as indicated in the form. For details on completion of the form, refer to the ADA Dental Claim Form Reference Guide on the CorrectCare Integrated Health portal, under the User Reference tab.

Need help? Contact us

If you have questions regarding the information contained in this update, contact the PHCPN Provider Services Center by email or by telephone at 877 899 0561.
 

This information applies to Physicians, Hospitals, and Ancillary Providers.