California Medicaid

California Medicaid, known as Medi-Cal, operates under unique protocols that can present challenges for payers. Understanding these intricacies is essential to ensure successful claims processing and avoid unnecessary rejections. Below, we outline key instructions and frequent challenges faced by payers.

Frequently Asked Questions (FAQ) for Payers

Q: What happens if I submit multiple claim files on the same day?
A: Medi-Cal's system may reject claims submitted individually on the same day if they have the same dollar amount. This is because Medi-Cal’s scrubbing system flags duplicate claims based solely on the dollar amount and does not validate other details, such as the patient’s name or service date.

Q: How does Medi-Cal handle claims with identical dollar amounts?
A: If you submit individual claims with the same dollar amount, they will likely be rejected as duplicates. To avoid this, you must wait at least 24 hours before resubmitting claims with identical amounts. Alternatively, batching these claims together prevents them from being rejected by the system, as Medi-Cal does not apply the same duplicate-checking rules to batched claims.

Q: What steps can I take to avoid claim rejections?
A: Follow these best practices:

1. Batch claims together: Submitting claims in batches minimizes the risk of duplicate rejections.
2. Avoid sending individual claims with the same dollar amount on the same day: If individual claims with identical amounts need to be submitted, wait 24 hours between submissions.
3. Make adjustments for resubmissions: Ensure claims flagged as duplicates are modified appropriately before resubmitting to avoid repeated rejections.