CenCal Health™ claim and billing requirements vary slightly by whether a member is covered under its Medi-Cal program or one of its other health care programs.  The member's health insurance card will indicate which health care program they are receiving coverage from.  Please select from the following:

• Medi-Cal Program, also known as the Santa Barbara Health initiative (SBHI) (under construction)
• Other Health Care Programs (Healthy Families, Healthy Kids, IHSS Healthcare, and Prenatal Plus 2)
  • Guidelines for Timely Submission of Claims
    The following guidelines apply to all types of providers and hospitals.
    • Original claims must be submitted within 6 months from the date of service.
    • Any provider adjustments to the original claim must be submitted within 6 months from the original process date.
  • Understanding California's AB1455 Regulations
    California Assembly Bill 1455 became effective January 1, 2004 and governs a health plan's claim settlement practices, regarding among other things, prompt payments to providers. The following information is intended to help you understand components of the law as it applies to your rights as a provider and our obligations as a health plan.
    • This law includes claims received from contracted and non-contracted health care providers.
    • We must pay or deny a "clean claim" no later than 45 business days (approximately equal to 63 calendar days) after the date we receive the claim.
    • The following is the definition of a "clean claim":
      A claim that has no defect in the billing and contains all the necessary data elements, as specified in the claim form instructions, in order to allow CenCal Health to make eligibility determination, covered benefit determinations, payment determinations, and payee determinations.
    • "Clean Claims" not paid within 45 business days of receipt must include an interest payment of 15 percent per annum on the amount due to the provider. Interest must be paid at the time the claim is paid or we must pay an additional $10 penalty fee per applicable claim.
    • If we require additional information (e.g. medical records, surgical report) in order to process a claim, we must notify you within the initial 45 business days, of the additional information needed to process the claim. You will be notified on the status of your claim and whether additional information is necessary on your Explanation of Benefits, which will be identified by one or more specific Explain Codes. Once the information is received, we have 45 business days from that date to pay or deny the claim. If we do not meet this 45 day timeline, the above rules on interest and penalty apply.
    • You have the right to challenge, appeal, or request reconsideration of our adjudication decision on a claim (e.g. amount paid, reason for denial) through our Provider Dispute Mechanism. Simple claim corrections may be made by completing the Claim Correction Form. For assistance contact the claims department at (805) 562-1083.
    • If we believe an overpayment has occurred on a claim, we will notify you in writing providing a clear identification of the disputed item, the date of service, and an explanation of the basis upon which we believe the overpayment to exist. You will then have 30 business days to either send a written notice stating your basis for why the claim was not overpaid or to reimburse us for the amount of overpayment. If neither action is performed by you within the 30 business days, then we will automatically recoup (offset) the amount of overpayment from one of your subsequent claim billings.
  • Claim Form Instructions
    • CMS-1450 (UB-92) Claim Form Instructions (under construction)
    • CMS-1500 Claim Form Instructions (under construction)
  • Paper Claims Submission
    Claims need to be submitted on an appropriate claim form. All paper claims for CenCal Health processing should be sent to:
    
    Non-Pharmacy Paper Claims:
    CenCal Health
    P.O. Box 1818
    Bellflower, CA 90707-1818
    
    Pharmacy Paper Claims:
    MedImpact Healthcare Systems, Inc.
    Operations Department, Attn: Claims
    10680 Treena St, 5th Floor
    San Diego, CA 92131
  • Electronic Claims Submission
    CenCal Health strongly recommends submitting claims electronically, either through our web-portal or through an electronic clearinghouse. It offers the following advantages:
    • Get paid faster with clean claims!
    • Claims payment on our next payment cycle for clean claims

    To find out more about submitting claims electronically, contact AdminiSTEP by phone at 888-751-3271 ext. 3141 or on the website at www.administep.com.

  • Claim Attachments
    A table of the most commonly billed CPT and HCPCS codes requiring supporting documentation has been created below as a resource for providers. This table can help you determine the type of information required on the highest frequency procedures requiring supporting documentation for claims review.
    • Procedure code modifiers
      The use of the following CPT Level 1modifiers requires supporting documentation:
      • -22 Unusual Procedural Services
      • -53 Discontinued Procedure
      • -59 Distinct Procedural Service
    • Unlisted Codes
      When an unlisted code is billed , a clear description of the service or item provided must be included. CenCal Health may require additional supporting documentation for unlisted procedure codes.
      
      PLEASE NOTE - The following list of codes are only those we have identified with the highest incidence of requests for additional information. We will continue to review and update this listed as needed. For specific billing requirements, please consult your CenCal Health provider manual. Current list revised January 1, 2006
      
      Note: Table is currently under construction
      

      Procedure Code Procedure/Service Documentation Required 20902 Bone graft, major or large Operative report J0256 Alpha 1 proteinase Chart notes 96545 Chemotheraphy agent Name and dosage

  • Medical Services Requiring Prior or Pre-Authorization (under construction)
  • Claim Adjudication Edits
    CenCal Health employs various edits when adjudicating a claim. Many are standard edits such as checking for member eligibility, whether medical care received is a covered benefit, and whether an authorization or referral was obtained. We also utilize the National Correct Coding Initiative (NCCI) edits developed by the Center for Medicare/Medicaid Services (CMS), as well as other code combination edits in determining the allowed amount on a claim.
    • CMS NCCI Edits
      CMS has made the NCCI edits available on their website. NCCI identifies pairs of services that normally should not be billed by the same provider for the same patient on the same day. View CMS' NCCI Edits.
    • CenCal Health CCI Edits
      CenCal Health has identified code edits to be used as a supplement to the CMS NCCI edits. Our edits were developed using nationally accepted logical and predictable coding principles. In arriving at these supplemental coding edits, the following were taken into consideration:
      • CPT manual, including code defintions and associated text
      • HCPCS manual
      • CMS written policy
      Please select from the following CenCal Health CCI edits:
      

      Document Description Complete Listing (under construction) This document contains every code edit combination for services beginning January 1, 2006. New Edits (under construction) This document contains recent new code edits implemented during the most recent calendar quarter, October 1, 2005 to December 31, 2005

    • Surgical Follow-Up Period for E/M Visits
      The National Physician Fee Schedule Relative Value File for calendar year 2006 provides the time frames that apply to each surgical procedure. Generally, a surgical follow-up evaluation and management office visit which occurred within the indicated follow-up period for the listed surgical procedure is not separately reimbursable. the reimbursement for the follow-up office visit is included within the reimbursement rate of the surgical procedure. View Surgical Follow-Up Edits.

The Department of Health Care Services (DHCS) has mandated the use of HIPAA-compliant HCPCS codes for Medi-Cal program.  The changes will apply to CenCal Health's Health Initiative programs, SBHI and SLOHI.  Please follow the link below to access the conversion charts listing the deleted Medi-Cal HCPCS code, the replacemnet code(s), and the effective date of the change.

HIPAA Procedure Code Changes

HIPAA Transactions