25-975 Change to Coordinating Medi-Cal Benefits When Medicare is Primary

Date: 09/17/25

Providers’ contract rates will be used to determine claim reimbursement when no Medi-Cal rate is available

Effective November 1, 2025, Health Net, on behalf of CalViva Health, will update how Medi-Cal benefits are coordinated when Medicare is the primary payer. This change follows a recent review of our coordination methodology. Providers’ contract rates will be used to determine the
Medi-Cal allowed amount when no Medi-Cal rate is available.

What’s changing

Since 2016, the Plan has used the Explanation of Medicare Benefits (EOMB) rate to coordinate benefits when a
Medi-Cal allowable amount was not available. This approach will be discontinued. Instead, contract default pricing will be applied.

Impacted claim types

This update applies to:

• Professional claims
• Outpatient claims

Calculation examples

When Medicare is the primary payer and Medi-Cal does not have an established allowable amount, the providers’ contract rate will be used to determine reimbursement.

• Medicare has an allowable, Medi-Cal does not:
  → Use contract default pricing as the Medi-Cal allowable amount
• Neither Medicare nor Medi-Cal has an allowable:
  → Use contract default pricing as the Medi-Cal allowable amount

Additional information

If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569. Behavioral Health providers can call at 844-966-0298.
 

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, and Behavioral Health Providers.

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