Medi-Cal Billing
Through Medi-Cal billing support, a county should be able to submit clean claims to the state on schedule, with eligibility checked and authorizations in place before the claim ever goes out.
Why this matters
Medi-Cal billing carries requirements that do not apply to commercial claims: eligibility has to be verified before a service is even billed, Share of Cost has to be tracked and cleared, and claims have to be formatted to DHCS's specifications rather than a generic payer's. Getting any one of these wrong does not just delay a payment. It can mean the claim never gets paid at all, or that the county falls out of compliance with the state's requirements for behavioral health billing. Because Medi-Cal is the primary payer for most county behavioral health programs, the reliability of this billing process affects the county's revenue far more than any other payer relationship.
What this is
Medi-Cal billing support covers the full path a claim takes from service delivery to state reimbursement, and the compliance work that surrounds it. Eligibility is checked and confirmed before billing, using the Medi-Cal Eligibility Data System and Monthly Extract File import, along with 270/271 eligibility transactions and Share of Cost clearance integration, so a claim is not submitted against coverage that has already lapsed or against a Share of Cost obligation the client has not met.
Each month, Medi-Cal 837 claims are generated for both mental health and substance use programs and submitted to DHCS on the county's behalf, along with any required claims to secondary payors under Medi/Medi coordination. Once DHCS processes the claims, the resulting 835 remittance information is retrieved and posted back into the EHR, and any denials are tracked, worked and re-billed until resolved. The same underlying data also feeds the state reporting DHCS requires of Medi-Cal-funded programs, including CalOMS, CSI, and the assessment and outcome tools (ANSA, CANS, ASAM) tied to specific service types.
Who it is for
County billing and finance staff who submit Medi-Cal claims, and program and compliance staff responsible for maintaining eligibility, authorization and Share of Cost accuracy before a claim goes out.
Billing staff get eligibility verification, claim formatting and DHCS submission handled as part of a single monthly cycle instead of pieced together across separate checks. Program and compliance staff get a workflow that keeps authorization and eligibility current, reducing the number of claims that come back denied for issues that could have been caught before submission.
Capabilities
What Medi-Cal billing support does
Eligibility verification
Confirms Medi-Cal eligibility ahead of billing using MEDS/MMEF data and 270/271 transactions, so claims are not submitted against lapsed or inaccurate coverage.
Share of Cost tracking
Integrates Share of Cost clearance into the billing workflow, applying UMDAP (Uniform Method of Determining Ability to Pay) rules so client cost obligations are accounted for before a claim is submitted.
Monthly Medi-Cal claims generation
Generates and submits 837 claims for mental health and substance use programs to DHCS on the county's behalf, including coordination with secondary payors under Medi/Medi rules.
Remittance and denial management
Retrieves and posts 835 remittance data from DHCS, and tracks, works and re-bills denied claims until resolved.
State reporting alignment
Feeds required DHCS reporting (including CalOMS, CSI, ANSA, CANS and ASAM) from the same billing and service data, keeping compliance reporting consistent with what has actually been billed.