26-709 Avoid Medi-Cal Claim Denials: Verify Individual Provider Participation Status
Date: 06/12/26
Claims may be denied as non-participating if rendering providers do not meet participation requirements
Health Net, on behalf of Community Health Plan of Imperial Valley, requires that all Medi‑Cal claims meet individual provider participation requirements, even when billed under a contracted group.
Any mismatch between a provider’s credentialing, California Department of Health Care Services (DHCS) enrollment or roster status at the time of service may result in claims being denied as non‑participating. Claims are processed based on the rendering provider’s status — not the group contract — which directly impacts reimbursement.
What drives claim denials
A claim may be denied as non‑participating if the rendering provider:
- Is not enrolled with DHCS.
- Is not credentialed with the Plan.
- Is not included on the group’s submitted provider roster.
Submitting claims under a group contract does not override these requirements.
Action required
To ensure in‑network Medi‑Cal reimbursement:
- Maintain accurate and current provider rosters.
- Ensure all rendering providers are properly credentialed and enrolled with DHCS, as applicable.
- Submit roster and credentialing updates through established Plan processes.
Important: Claims are not reprocessed if provider requirements were not met at the time services were rendered.
Submit provider roster updates
For participating physician groups (PPGs), the Active Physicians Listing is available monthly after logging in to the provider portal:
- Select Provider Reports from the Welcome page.
- Review provider demographic information and confirm roster accuracy.
- Submit updates, corrections, and terminations using your current process.
Claim denial example
Medi‑Cal does not cover immunization services provided by non‑participating providers.
- Vaccine and administration claims will be denied.
- Exception: Local health departments
- Administration fees are payable.
- Vaccine is not covered.
Need help? Contact us
Relevant sections of the provider operations manuals 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.
If you have questions regarding the information contained in this update, contact Community Health Plan of Imperial Valley at 833-236-4141.
This information applies to Physicians and Practitioners, 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.