Inquiries and Resources

This topic contains contact information for client and provider resources.

General Public Inquiries for Clients

Electronic Data Systems (EDS) informs MC providers about scope of benefits, prior authorization requirements, and claims procedures.

All new applicants and any beneficiaries having questions concerning MC benefits should be given the “MC Pamphlet” SCD 2335 which describes program benefits.

Common questions asked by clients concerning the program are to be handled by providing appropriate phone numbers.

Healthcare Access Program

The Healthcare Access Program replaces the Ability to Pay Program (APD) that was available through VMC. This replacement program reduces the amount a person owes for services and/or medicines based on their income (for some people there will be no cost) and is available to persons who are not eligible for MC or other health insurance and are receiving/have received services within Santa Clara County’s Health System (VMC, O’Connor, St. Louise Regional).

Individuals can call the Patient Access Department at 1-866-967-4677 to speak with a Financial Counselor.

Medi-Cal Access Program (MCAP)

The Medi-Cal Access Program provides low-cost health coverage for pregnant women and their newborns. To learn more about the program and to apply, clients can call 1-800-433-2611 (Monday - Friday 8am - 8pm and Saturday 8am - 5pm) or Fax 1-888-889-9238.

Medi-Cal Access Program
P.O. Box 15559
Sacramento, CA 95852-0559

Mailing address for payments:

Medi-Cal Access Program
P.O. Box 15207
Sacramento, CA 95851-0207

Primary Care Access Program (PCAP)

The Primary Care Access Program (PCAP) provides health coverage for low income adults. In order to qualify for PCAP individuals must meet the following criteria:

  • Age 19 or older
  • Resident of Santa Clara County
  • Household income equal to or less than 650% FPL and
  • Not eligible for:
    • Full-scope Medi-Cal coverage
    • Covered CA subsidies
    • Employer health insurance

Clients who are interested in applying can contact PCAP at 1-888-363-3394 (option 1)

“Acquired Immune Deficiency Syndrome" (AIDS) Hotline

Clients may call the following phone numbers for AIDS information, testing centers, counseling, etc.

California AIDS Hotline
995 Market St #200
San Francisco, CA 94103Update #19-2

Hotline: 1-800-367-2437
Main Line: 415-863-2437
TTY: 1-888-225-2437

Office of AIDS
California Department of Health Care Services
1616 Capitol Ave., Suite 616
MS-7700
P.O. Box 997426
Sacramento, CA 95899-7426

Phone: 916-449-5900 (non-MC services for persons with AIDS)

AIDS Medi-Cal Waiver Program

http://www.thelivingcentertreatment.com (for local resources in Santa Clara County)

Breast & Cervical Cancer Treatment Program (BCCTP)

The treatment program serves low-income California residents who have been screened and found to be in need of treatment for breast and/or cervical cancer. For Information and how to enroll, contact:

Cancer Detection Program: Every Woman Counts (CDP:EWS)
Phone: 1-800-511-2300
Every Woman Counts

OR

Family Planning, Access, Care, and Treatment (Family PACT)
Phone: 916-541-5555
Family PACT

Buy-In Problems for Medicare Parts A & B and Technical Problems for Medicare Part D

California Department of Health Care Services
Medicare Parts A & B Buy-In and Part D Technical Problems
P.O. Box 997421
Sacramento, CA 95899-7421

Phone: 1-866-227-9863

Complete the State Medicare Buy-in Problem Form

Child Health & Disability Prevention Program (CHDP)

To locate doctors and dentists who will accept MC for treatment of PERSONS UNDER 21:

CHDP: 1-800-689-6669 or 408-937-2250

CHDP Website

Santa Clara County Health Dept.

Information Line: 408-792-5050

Children's Health Initiative (CHI)

To obtain information about enrolling children in a health plan, call 1-888-CHI-5222 or 1-888-244-5222.

COBRA

California Department of Health Care Services COBRA

Information Line: 1-866-444-3272
Main Line: 415-975-4600

Complaints Against Health Care Providers

Medical Board of California
Central Complaint Unit
2005 Evergreen Street Suite 1200
Sacramento, CA 95815

Phone: 1-800-633-2322 or 916-263-2382

Consumer Information Center

The Consumer Information Center phone number may be given to clients for information about doctor's licenses or any records of disciplinary action against them.

Phone: 916-263-2382

Medical Board of California Licensee Profile Search

Dental Services

Children and adults are eligible for these services. Covered services may include:

  • Exams and x-rays
  • Cleanings (Prophylaxis)
  • Fluoride treatments
  • Fillings
  • Root canals in front teeth
  • Prefabricated Crowns (stainless steel or tooth colored)
  • Full dentures
  • Other medically necessary dental services

Note: Most dental services require prior authorization. Once a dentist has submitted a request for authorization, a state contracted dental consultant must evaluate the patient to assess the need for treatment. In these cases, DHCS may contact the client to arrange a regional screening appointment.

Dental services are provided through the fee-for-service delivery system. Dental services may exceed the annual $1,800 limit if shown to be medically necessary.

Clients who need to locate a dentist who will accept MC, or who need assistance with scheduling a "regional screening appointment", or who have billing questions, or who have complaints about the level or quality of dental services they receive may be referred to contact the toll-free number:


California Medi-Cal Dental Program
P.O.Box 15539
Sacramento, CA 95852-1539

Phone: 1-800-322-6384
(8:00-5:00 Monday-Friday; 8:00-12:00 Saturday)

 

To find a Dental provider in California, members may also be referred to the Medi-Cal Dental Programs website at: 

Smile California

Dental Treatment Options

Low income persons who are ineligible for MC may receive reduced cost dental care. The Santa Clara County Dental Society has provided these treatment options:

Saint James Health Center*

408-918-2600

The Indian Health Center (Will treat anyone)

408-445-3400

CompreCare Health Center

408-272-6300

Foothill Community Health Center

408-254-1800

Gardner South County Dental

408-848-9400

Valley Health Center @ East Valley

408-817-1460

Valley Health Center @ Tully

408-808-6102

NOTE: The client will need to explore the financial requirements at each facility.

*San Jose residents only unless the client has MC. 

Doctor Services

To find a doctor, clients may call:

  • Santa Clara County Medical Association
    • Phone: 408-998-8850
  • Santa Clara Family Health Plan Customer Services
    • Phone: 1-800-260-2055
  • Anthem Blue Cross of California Member Services
    • Phone: 1-800-407-4627
  • Valley Connection (Santa Clara County Health and Hospital System)
    • Phone: 1-888-334-1000
  • The Child Health and Disability Prevention (CHDP) Unit for children under 21 or anyone who needs a doctor for pregnancy
    • Phone: 1-800-689-6669 or 408-937-2250
  • The Department of Health Care Services (DHCS) Provider Enrollment Division can be contacted for assistance in locating a doctor or to assist clients with MC billing problems.
    • Phone: 916-323-1945

Electronic Data Systems (EDS) Help Desk

For MC inquiries and billing issues, clients can call 916-636-1980.

Every Woman Counts (EWC) Program

The Every Woman Counts (EWC) Program offers free breast and cervical cancer screening services for uninsured women. EWC assists eligible women with enrollment into the Breast and Cervical Cancer Treatment Program (BCCTP).

For referral information women can call the Automated Referral Line (800) 511-2300 or use the Online Provider Locator.

Family Planning, Access, Care and Treatment Program

The Office of Family Planning (OFP) administers the Family Planning, Access, Care, and Treatment (Family PACT) program. Services include comprehensive education, assistance, and services relating to family planning. 

Family PACT Issues/Questions
Phone: (916) 650-0414
Email: fampact@dhcs.ca.gov
Family PACT Website

Family PACT Client Information and Referral
Phone: (800) 942-1054

Family PACT Client Education Materials Orders
Phone: (916) 552-9866

Family PACT Provider Support
Phone: (800) 541-5555

Health Access Program Card (HAP)

The HAP card is a plastic identification card used in some health care programs which are directly administered by the state. The HAP card is similar to the BIC but is teal-colored with black print, and has less information printed on the face of the card.

Currently, the state administered Family Planning, Access, Care and Treatment Program (Family PACT) is issued on the HAP card.

Health Care Options (HCO)

For more information or to enroll or disenroll in a MC Managed Care Health Plan, clients may contact:

California Department of Health Care Services
Health Care Options
P.O. Box 989009
W. Sacramento, CA 95798-9850

Phone: 1-800-430-4263
TTY: 1-800-430-7077

To file a "plan specific" complaint, refer beneficiaries to the specific health plan:

  • Santa Clara Family Health Plan Customer Services Phone: 1-800-260-2055
  • Anthem Blue Cross of California Member Services Phone: 1-800-407-4627

If beneficiaries are not satisfied and cannot resolve their complaint, refer them to the State Office of the Ombudsman at:

California Department of Health Care Services State Office of the Ombudsman
MS-4412
P.O. Box 997413
Sacramento, CA 95899-7413

Phone: 1-888-452-8609

Health Insurance Billing and Coding

To inquire about health insurance billing or to request the removal/correction of an erroneous other health coverage (OHC) code, the EW must send a SECURED e-mail or a fax to the Third Party Liability and Recovery Division, Other Health Coverage Unit. Proof of OHC termination is not required. Allow AT LEAST 96 hours for the request to be processed.

Phone: 1-800-541-5555

Health Insurance Premium Payment (HIPP) Program

California Department of Health Care Services
Third Party Liability and Recovery Division
HIPP Program-MS4719
P.O. Box 997421
Sacramento, CA 95899-7421

Phone: 1-866-298-8443
Email: hipp@dhcs.ca.gov

Ombudsman

Cal MediConnect Ombudsman

Clients enrolled in Cal MediConnect who need:

  • Help with their services or plan,
  • Assistance with resolving enrollee problems/complaints,
  • Assistance with filing appeals,

can reach the Cal MediConnect Ombudsman services by calling:

Phone: 1-855-501-3077
TTY: 1-855-847-7914
Monday - Friday, 9am - 5pm

LTC Ombudsman Program

The long-term care Ombudsman works to resolve any problem or complaint involving a resident of a nursing home or board and care facility (Long Term Care Patients).

Phone: 408-944-0567

Managed Care Ombudsman

The State Office of the Ombudsman works to resolve any problems involving managed care and MC.

County staff can now use an online form fill-in option for urgent MC Managed Care Ombudsman requests. The online form should be used when requesting expedited:

  • Plan Changes,
  • Plan Enrollments,
  • Plan Disenrollments, and/or
  • Removal of Holds (code 59).

Online fill-in form can be found on the Department of Health Care Services web site. Before submitting the form, the EW must ensure that ALL requirements below are met.

  • The MC Eligibility Data System (MEDS) must reflect all current information (i.e., residential address and county code), and
  • MEDS must show active coverage for the client, and
  • County staff must verify with client that MC services have not been used for the current month (i.e. filled a prescription, visited a doctor, received emergency room services, received an e-ray, etc.).

Completion of this form does not guarantee that the request will be approved. If the MC client does not meet the required criteria or the form is not sent from a valid county e-mail address, the request will not be processed.

All standard changes need to be processed through Health Care Options at 1-800-430-4263.

For additional information call 1-888-452-8609 or e-mail MMCDOmbudsmanOffice@dhcs.ca.gov.

California Department of Health Care Services State Office of the Ombudsman
P.O. Box 997413 MS-4412
Sacramento, CA 95899-7413

Santa Clara County Social Services Agency Ombudsman

The Ombudsman works to resolve any problem or complaint involving services provided by Social Services Agency in Santa Clara County.

Phone: 408-755-7187

Medical Board of California Central Complaint Unit

Medical Board of California Central Complaint Unit
2005 Evergreen St. Suite 1200
Sacramento, CA 95815

Phone: 1-800-633-2322 or 916-263-2382

MC Cards with Utilization Restrictions

Have the client call DHCS, Audits and Investigations at 916-322-1071.

MC Fraud and Patient Abuse

To report client and provider fraud and patient abuse, contact one of the following:
MC Fraud Statewide Hotline: 1-800-822-6222

Department of Health Care Services Investigation Unit - North
P.O. Box 997413 - MS 2000
Sacramento, CA 95899

Main Line: 916-440-7550

State Attorney General's Office
Bureau of MC Fraud and Patient Abuse Complaint Hotline: 1-800-722-0432

Note: The Department of Justice in San Francisco investigates the criminal aspects of provider fraud. Phone: 415-436-6660

MC General Information for All Aid Programs

For information regarding services provided under the MC program, refer beneficiaries to:

Electronic Data System (EDS)
Client and HIPPA Help Desk

Phone: 916-636-1980
TTY (for hearing impaired): 1-800-952-8349

MC Managed Care Plans

To receive information about MC providers, enrollment and disenrollment, or to receive an enrollment packet or a provider directory, clients may call:

Santa Clara Family Health Plan (SCFHP)
210 E. Hacienda Ave.
Campbell, CA 95008

Phone: 1-408-376-2000
For eligibility verification and authorization, call 408-260-4400.

www.scfhp.com

SCFHP Application Assistance Center
Children's Dental Center - Tropicana Shopping Center
1153 S. King Road
San Jose, CA 95122

Phone: 1-408-240-0250

Anthem Blue Cross of California Member Services

Phone: 1-800-407-4627
www.anthem.com/ca

For Enrollment or Disenrollment Problems, clients may also call:

  • Health Care Options (HCO)
    • Phone: 1-800-430-4263 
  • State of California Department of Health Services Med-Cal Managed Care Division
    • Phone: 916-657-0025

To report a plan-specific managed care complaint: The client should call his/her specific health plan. If the client is not satisfied with their solution, call the State Office of the Ombudsman at: (888) 452-8609

Medicare

For general/enrollment information, Medicare Prescription Drug Plan (Part D), Medigap and Medicare Supplemental Insurance, replacement of Medicare card, find a doctor, or ask for publication, clients may call:

Center for Medicare & Medicaid Services (CMS)
1-800-MEDICARE (1-800-633-4227)
www.medicare.gov

Medicare Part D

To apply for Low Income Subsidy (LIS) Program (also known as Extra Help), refer clients to their local Social Security Administration (SSA) office or clients can call 1-800-772-1213.

www.socialsecurity.gov

For assistance in selecting a Prescription Drug Plan (PDP), clients may call the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222.

To inquire about what specific drugs a plan covers or co-payments, contact the appropriate PDP:

AARP Medicare Rx

1-877-699-5710

Aetna Rx Saver

1-877-238-6211

Anthem Blue Cross Rx

1-800-928-6201

Envision Rx Plus

1-866-250-2005

First Health Part D

1-866-865-0662

Health Net Orange

1-800-522-0088

Humana

1-800-457-4708

SilverScript Choice

1-866-235-5660

Symphonix Value Rx

1-855-355-2280

Unicare

1-800-633-4368

United Health Rx

1-877-844-4999
Well Care 1-888-550-5252

For more information on available PDPs, visit Q1Medicare.com.

Probate/Estate Recovery

For questions concerning Probate and Estate Recoveries:

Department of Health Care Services
Estate Recovery Unit
MS4720
P.O. Box 997425
Sacramento, CA 95899-7425

Phone: 916-650-0490

Note: The Department of Health Care Services is required to grant hardship waivers under limited circumstances, when repayment of MC claims would result in substantial hardship to heirs. Questions or inquiries about "hardship waivers" should be directed to this number. The claims letter issued by DHCS includes a statement about hardship waivers and how heirs can apply.

Railroad Retirement Information

U.S.R.R. Board
1301 Clay Street, Suite 110S
Oakland, CA 94612-5215

Phone: 1-877-772-5772

Safely Surrendered Baby Hotline

For information on how to safely surrender a newborn under the Safely Surrendered Baby Law:

Phone: (877)-BABY-SAFE (877-222-9723)

San Andreas Regional Center

6203 San Ignacio Avenue Suite 200
San Jose, CA 95119

Phone: (408) 374 - 9960
Fax: (408) 281-6960

Santa Clara County Mental Health Plan (MHP)

The managed care mental health plan for Santa Clara County is the "Access" program.

Santa Clara County Mental Health Department 
645 S. Bascom Avenue
San Jose, CA 95128

Phone: 1-800-704-0900

Senior Outreach

Senior Outreach and Escort Program

Phone: 408-436-2865

Appropriate referrals include: disabled persons age 60+ or aged persons 62+ who are in need of transportation, help in dealing with SSA, emergency housing or PG&E assistance, food/nutrition program, counseling, etc.

State Hearings and Appeals

Recipients may request a State Hearing regarding scope or duration of MC benefits by contacting:

California Department of Social Services (CDSS)
State Hearings Division

Phone: 1-800-952-5253
TTY: 1-800-952-8349

OR

submitting a request in writing to:

Appeals Section
Santa Clara County Social Services Agency
333 W. Julian Street San Jose, CA 95110

Phone: (408) 817-6050

Disability Determination Service Division (DDSD)

Los Angeles State Programs Branch
DDSD-LA State Programs
P.O. Box 992
El Segundo, CA 90245-0992

General Information: (310) 615 - 2800 (Master Files)
General Fax: (855) 837 - 3238

Fax number to request a copy of the MC 221R after diligent search: (855) 837 - 3236

Fax numbers for Presumptive Disability (PD) requests:
General Requests: (310) 615 - 2713
Urgent Requests: (855) 837 - 3239

Supplemental Security Income (SSI) and Social Security Administration (SSA)

General Information: 1-800-772-1213
TTY: 1-800-325-0778
7:00 AM to 7:00 PM
www.socialsecurity.gov

Refer clients to the following local SSA offices to apply:

Campbell Office
770 W. Hamilton Avenue
Campbell, CA 95008

Phone: 408-348-5832

Mountain View Office
700 E. El Camino Real, Suite 350
Mountain View, CA 94040

Phone: 1-877-319-0161

East San Jose Office
2500 Fontaine Road
San Jose, CA 95121

Phone: 1-800-772-1213

San Jose Downtown Office
280 S. 1st Street, Room 244
San Jose, CA 95113

Phone: 1-800-772-1213

Gilroy Office
1059 1st Street
Gilroy, CA 95020

Phone: 1-877-452-4198

South San Jose Office
6140 Cottle Road
San Jose, CA 95123 Phone: 1-800-772-1213

Third-Party Liability

Questions concerning accident settlements, MC casualty, personal injury, probates, estates, liens, lawsuits, workers' compensation payment or claims, overpayment, or other situations where a third party is responsible for reimbursing MC for payments made on behalf of a recipient should be referred to:

California Department of Health Care Services
Recovery Section
P.O. Box 997425, MS 4720
Sacramento, CA 95899-7425

Information Line: 916-323-4836
Main Line: 916-650-0490
Fax: 916-650-6584

California Department of Health Care Services
Other Health Coverage Unit
P.O. Box 997421
Sacramento, CA 95899-7421

E-mail: wats@dhcs.ca.gov
Fax: 916-650-6580, 916-650-6581, or 916-650-6582

California Department of Health Care Services
COBRA

Information Line: 1-866-444-3272
Main Line: 415-975-4600

California Department of Health Care Services
Third Party Liability and Recovery Division
HIPP Program-MS4719
P.O. Box 997421
Sacramento, CA 95899-7421

Phone: 1-866-298-8443

California Department of Health Care Services
Medicare Parts A & B Buy-In and Part D Technical Problems
P.O. Box 997421
Sacramento, CA 95899-7421

Phone: 1-866-227-9863

Medi-Cal Vision Benefits

Clients with questions concerning vision care are to be referred to optometric information, 916-636-1980 (Sacramento).

Vision benefits are covered for those with full-scope Medi-Cal benefits. For questions regarding your Medi-Cal eligibility, please contact your county social services office.

  • Routine eye exam once every 24 months:
    • All beneficiaries are eligible for a routine eye exam which checks the health of the eyes and tests for an eyeglass prescription.
    • Only beneficiaries under 21 years old and residents of a nursing home receive coverage for eyeglasses (frame and lenses).
  • Other services available:
    • Contact lens testing may be covered if the use of eyeglasses is not possible due to eye disease or condition (i.e., missing an ear) 
    • Low vision testing for those with vision impairment that is not correctable by standard glasses, contact lenses, medicine or surgery that interferes with a person's ability to perform everyday activities (i.e., age-related macular degeneration).
    • Artificial eye services and materials for those individuals that have lost an eye or eyes to disease or injury.
  • Types of Vision Care Providers:
    • Optometrists: are doctors of optometry who preform comprehensive vision examinations, and prescribe eyeglasses and contact lenses. They can also diagnose, treat and manage certain eye diseases and disorders of the eye as well as diagnose certain related systemic conditions.
    • Ophthalmologists: are medical doctors and surgeons who specialize in the diagnosis, management and treatment of eye disease. They also preform vision examinations, and prescribe eyeglasses and contact lenses.
    • Opticians: are optical professionals who fill eyeglass and contact lens prescriptions.
    • Ocularists: are professionals who specialize in making and fitting of artificial eyes for people who have lost an eye or eyes due to trauma or illness.
  • Finding A Vision Provider:
    • Contact a Medi-Cal provider directly for an appointment. For a list of vision providers, please visit the on-line directory at our "Vision - Find A Doctor" page.

For other vision program questions, please contact Vision Services Branch at vision@dhcs.ca.gov.

Valley Kids

Phone 1-888-244-5222

Provider

Limited to Valley Medical Center (VMC) and Community Health Partnership (CHP) clinics

Coverage

  • Doctors Visits
  • Preventative Care
  • Specialty Care 
  • Immunizations
  • Hospital Care
  • Mental Health
  • Drug and alcohol treatment
  • Prescriptions
  • Family planning

Voluntary Repayment of Benefits by Clients

Public Guardians, Social Workers or representative payees of MC recipients may want to reimburse MC for benefits paid on their behalf. These persons shall be referred to the following Department of Health Care Services Office:

California Department of Health Care Services
Third Party Liability Branch
Recovery Section
P.O. Box 997425, MS-4720
Sacramento, CA. 95899-7425

Phone: 916-650-0490
Fax: 916-650-6584

Related Topics

Provider Inquiries