All claims are subject to NCCI edits and Medi-Cal payment methodologies. See posted Policy and Procedures for further information.
Non-Contracted Provider Claim Reimbursement
Non-contracted providers are reimbursed for emergent services at Medi-Cal rates. All non-emergent services require prior authorization, and if pre-approved, service are reimbursed at Usual and Customary rates, which is the Medi-Cal fee schedule in effect at the time of service.
The Medi-Cal fee schedule is updated the 15th of each month, and can be found on the Medi-Cal Website at https://mcweb.apps.prd.cammis.medi-cal.ca.gov/references.
Contracted Provider Reimbursement
Contracted providers are reimbursed based on contractual rates. However, there are some services that require mandatory reimbursement methodology identified by DHCS, i.e. Major Organ Transplants, Long Term Care, etc.