25-459 Reminder: Balance Billing Medi-Cal Members is Prohibited
Date: 05/08/25
Comply with regulatory requirements to avoid disciplinary action
Participating physicians and other providers may not bill or attempt to obtain reimbursement from a Medi-Cal member, or any person acting on behalf of a member, for any service covered under the Medi-Cal program. Balance billing is strictly prohibited per stateand federal law1 and your Provider Participation Agreement (PPA).
Medi-Cal members are not liable for any amount unless a Medi-Cal share-of-cost 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. Refer to the DHCS For Medi-Cal Providers website for guidance on FFS Medi-Cal billing.
Examples of prohibited balance billing include, but are not limited to:
- Billing members fees and surcharges for covered services, such as copayments, deductibles or coinsurance responsibilities.
- Requiring members to pay for a covered service that was denied or rejected by the Plan or the participating physician group (PPG) for valid/appropriate reasons.
- Charging Dual Special Needs Plan (D-SNP) members coinsurance, copayments, deductibles, financial penalties, or any other amount.
- Requiring members to pay the difference between the discounted and negotiated fees and the physician’s and other providers’ usual and customary fees.
Non-Compliance
Penalties for non-compliance, if applicable, are outlined under the terms of your PPA. Those who exhibit a pattern and practice of balance billing members will be subject to disciplinary action
Medi-Cal as secondary
To avoid balance billing, we recommend you ask members if they have multiple health insurance plans when verifying coverage. If the member has other health coverage (i.e., Medicare or Commercial (HMO, POS)) as primary (Medi-Cal as secondary), you must not charge the member’s copayment, coinsurance or deductible because those are prohibited by the Medi-Cal Managed Care plan.
Provider appeals
If a physician or other provider does not agree with the outcome of a claim, they can file a formal provider appeal/dispute to the Plan or member’s assigned medical group if they are affiliated with a participating physician group.
For information about the provider appeals/dispute process, access the Provider Library, then select a line of business > Provider Manual > Appeals, Grievances and Disputes > Provider Appeals and Dispute Resolution.
Additional information
Information regarding balance billing is available in the provider operations manual in the Provider Library. Once in the Provider Library, select a line of business > Provider Manual > Claims and Provider Reimbursement > Balance Billing.
If you have questions regarding the information contained in this update, Community Health Plan of Imperial Valley at 833-236-4141.
Behavioral health providers can call 844-966-0298.
1In accordance with Federal and State of CA law as outlined in section 1902(n)(3)(B) of the Social Security Act, as modified by section 4714 of the Balanced Budget Act of 1997 and California Welfare and Institutions Code section 14019.4 9 respectively balance billing covered Medi-Cal enrollees is strictly prohibited.
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.