Skip to main content
Medclaim Services Logo

Menu

Free Billing Audit

Locations

Medical Billing Services in California

California practices bill through structures that exist almost nowhere else: Medi-Cal plans that pay through contracted medical groups, two different state regulators depending on what kind of plan the patient has, and a workers' comp fee schedule set by regulation. We bill remotely for California practices and route each claim through the structure that applies.

  • Medi-Cal fee-for-service and managed care plans, including delegated medical groups
  • Plans sorted by regulator: DMHC for HMOs, CDI for insured PPO and POS policies
  • Workers' comp billed under the Official Medical Fee Schedule
Request a Free Billing Audit

Medi-Cal: fee-for-service, managed care and delegated groups

Medi-Cal is California's Medicaid program, run by the Department of Health Care Services (DHCS). It pays providers both through fee-for-service and through contracted managed care plans.

Some Medi-Cal managed care plans work through contracted medical groups. For a practice, that can mean contracting, authorization and claims run through a medical group rather than the plan named on the patient's card.

Two health plan regulators, two sets of rules

California splits commercial health plan oversight between two regulators. The Department of Managed Health Care (DMHC) oversees HMOs and managed care plans; the Department of Insurance does not. The California Department of Insurance (CDI) regulates health insurance policies, including certain PPO and point-of-service plans underwritten by insurers it licenses.

That split matters when a claim goes wrong. Complaints, dispute processes and the rules that apply depend on which regulator oversees the patient's plan, so we record the regulator for every plan you bill.

Official sources: California Department of Insurance: healthcare coverage overview (external site), California Department of Insurance: health care provider complaint guide (external site)

Workers' comp and surprise-bill disputes in California

Workers' compensation medical care is paid under the Official Medical Fee Schedule (OMFS), which the Division of Workers' Compensation issues under Labor Code section 5307.1 and Title 8 of the California Code of Regulations. The schedule is updated periodically, so we price workers' comp claims against the current version rather than a fixed figure.

California's AB 72 protects patients from surprise balance bills when an out-of-network professional treats them for non-emergency care at a facility that is in their plan's network, and for insurers regulated by CDI there is an Independent Dispute Resolution Process the professional can use to contest the payment amount.

Official sources: DWC: Official Medical Fee Schedule (external site), California Department of Insurance: provider Independent Dispute Resolution Process (external site)

Practices we typically see in California

Practices that see Medi-Cal patients usually work with both fee-for-service Medi-Cal, billed to DHCS, and one or more Medi-Cal managed care plans, where some claims and network relationships run through a contracted medical group instead of the plan. Getting the right payer for each visit is the first step in getting paid.

How remote billing works for practices in California

All work is done remotely in your systems and payer portals. You create our user accounts and can remove them at any time.

  1. Step 1: Map every plan and medical group

    For each Medi-Cal plan you accept, we record whether claims go to the plan, a delegated medical group, or DHCS fee-for-service.

  2. Step 2: Tag each plan's regulator

    Commercial plans are tagged as DMHC or CDI regulated, so disputes follow the right process.

  3. Step 3: Bill work injuries under the OMFS

    Workers' comp visits are billed to the claims administrator on their own track, priced against the state fee schedule.

  4. Step 4: Flag surprise-bill disputes

    Out-of-network payments for non-emergency care at in-network facilities are reviewed for the dispute process that applies.

Official sources for California

Rules change. These are the agencies and contractors we check for the current requirements.

Frequently asked questions

Who processes Medicare claims for California practices?

Noridian Healthcare Solutions, the Medicare Administrative Contractor for Jurisdiction E, which also covers Hawaii, Nevada and several Pacific territories.

Official source: CMS: A/B MAC Jurisdiction E (Noridian) (external site)

What does a delegated Medi-Cal plan mean for our claims?

If the patient's plan works through a contracted medical group, that group may handle contracting, authorizations and payment, so we confirm the right entity before the claim goes out.

Is our patient's plan regulated by DMHC or the Department of Insurance?

HMOs and managed care plans fall under DMHC, while certain PPO and point-of-service policies from licensed insurers fall under CDI. The plan documents or the regulator's lookup tools confirm which one applies.

How is workers' comp care paid in California?

Under the Official Medical Fee Schedule set by the Division of Workers' Compensation. Claims are billed to the employer's claims administrator, not the patient's health plan.

Official source: DWC: Official Medical Fee Schedule (external site)

Can a remote team bill Medi-Cal for our practice?

Yes. Medi-Cal and plan claims are submitted electronically and through portals, so the work does not depend on where the billing team sits. Medi-Cal billing is part of our standard work for California practices.

Related services and nearby states

See all locations

Untangle your Medi-Cal and medical group claims

A free audit shows which denials come from wrong-payer routing, delegated groups and regulator-specific rules.

Request a Free Billing Audit