23-794 Prohibited Balance Billing for Medi-Cal Members
Date: 07/31/23
Fees and surcharges above and beyond a Medi-Cal member's copayment and coinsurance is not allowed
As a reminder, under the terms of the Provider Participation Agreement (PPA) and in accordance with state and federal law, participating physicians and other providers may not bill or attempt to obtain reimbursement from a California Health & Wellness Plan (CHWP) member, or any person acting on behalf of a member, for any service covered under the Medi-Cal program. Medi-Cal members are not liable for any amount unless a Medi-Cal share-of-cost (SOC) 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.
Medi-Cal as secondary
If the member has other health coverage (i.e., Medicare or commercial (HMO, POS, EPO, HSP)) as primary (Medi-Cal as secondary), the physician and other providers must not charge the member’s copayment, coinsurance or deductible because those are covered by the Medi-Cal plan.
Provider appeals
If a provider does not agree with the outcome of a claim, they can file a formal provider appeal to CHWP or medical group if they are affiliated with an independent practice association.
For information about the appeals process, access the CHWP's provider portal, then select For Providers > Provider Resources > Manuals, Forms and Resources > Provider Manual/Billing Manual – English (PDF).
Additional information
Information regarding balance billing is available on the CHWP’s provider portal, then select For Providers > Provider Resources > Manuals, Forms and Resources > Provider Manual/Billing Manual – English (PDF).
If you have questions regarding the information contained in this update, contact CHWP at 877-658-0305.
This information applies to Physicians, Independent Practice Associations (IPAs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.