20-144 Use the Correct Form to Bill Ancillary Services for American Indian Health Service Medi-Cal Claims

Date: 01/31/20

Some vendors only accept the CMS-1500

For improved claims service, providers serving American Indian Health Service (IHS) Medi-Cal members are now required to use the CMS-1450 (UB-04) claim form instead of the CMS-1500 to bill California Health & Wellness Plan (CHWP) for IHS Medi-Cal claims.

However, some specialty companies only accept the CMS-1500. Please refer to the chart below for correct forms and claims billing addresses for IHS claims.             

Entity responsible for claims	Form	Claims billing address
CHWP	UB-04 Submit all IHS Medi-Cal claims to CHWP. Medi-Cal claims must be submitted within 180 days from the last day of the month of the date of service.	California Health & Wellness Plan Attn: Claims PO Box 4080 Farmington, MO 63640-3835
American Specialty Health, Inc.	CMS-1500 Bill claims for acupuncture services to American Specialty Health, Inc. (ASH).	American Specialty Health Group, Inc. Claims Department PO Box 509001 San Diego, CA 92150-9001
Envolve Vision	CMS-1500 Bill claims for vision services to Envolve Vision. Envolve Vision cannot accept UB-04 form.	Envolve Vision                                      PO Box 7548              Rocky Mount, NC 27804
MHN	UB-04 Bill claims for behavioral health services to MHN.	MHN Claims                                         PO Box 14621                           Lexington, KY 40512-4621

Instructions for CHWP IHS Medi-Cal claims                                                                    

CHWP participating IHS program providers

Submit claims to CHWP via the standard process and in accordance with the terms of the CHWP Provider Participation Agreement (PPA).

More information on claims submission and reimbursement is available online in the Provider Resources section of the provider website at www.CAHealthWellness.com.

Nonparticipating IHS program providers

Refer to the Provider Resources section of the provider website at www.CAHealthWellness.com to learn more about claims procedures and how to submit claims to CHWP.

Additional information

Relevant sections of the provider operations manuals have been revised to reflect the information contained in this update as applicable. The provider operations manual is available in the Provider Resources section of the provider website at www.CAHealthWellness.com.

Providers are encouraged to access CHWP’s provider portal online at www.CAHealthWellness.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact CHWP at 1-877-658-0305.