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Provider Inquiries
Questions from MC PROVIDERS concerning the scope of benefits and billing procedures are to be handled as outlined below.
DO NOT REFER CLIENTS TO THESE STATE OFFICES.
Automated Eligibility Verification System (AEVS)
Providers may call the EDS number to enroll in the Automated Eligibility Verification System (AEVS) at 1-800-456-2387.
- AEVS enables providers to verify an individual's MC eligibility using a touch-tone telephone and entering the client's 14-digit I.D. number or SSN.
- AEVS contains MC eligibility information for the current month and prior three months.
- The provider is given eligibility status information, including service restrictions, unmet share of cost, participation in prepaid health plan, restricted services information and other health coverage.
- Providers must pay for this service.
- Although AEVS is available to providers, it is optional. Eligibility staff are required to provide verification of MC eligibility to providers upon request.
Dental Contract Questions
For general questions, billing information and dental contract questions, providers may call:
Denti-Cal Provider Group
P.O.Box 15539
Sacramento, CA 95852-1539
Phone: 1-800-322-6384
Drug Benefits
Questions concerning drug benefits are to be referred to:
Department of Health Care Services
Medi-Cal Drug Unit
P.O. Box 201007
Stockton, CA 95201
Phone: 209-942-6030
Electronic Data Systems (EDS)
Electronic Data Services (EDS) is the MC claims payment fiscal intermediary. EDS has the following toll free number to answer provider inquiries regarding billing, claim status, and MC policies and procedures (e.g., provider asking why a claim is being rejected):
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1-800-541-5555 |
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1-800-427-1295 |
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916-636-1200 |
General Information
Providers can call the Department of Health Care Services (DHCS) regarding general scope of benefits and prior authorization at 1-800-541-5555.
Health Access Programs (HAP) Hotline
Providers may call the HAP hotline concerning State Only Family Planning at 1-800-541-5555.
Non-Emergency Medical Transportation
Non-Emergency Medical Transportation (NEMT) is a covered Medi-Cal (MC) benefit for recipients who require transportation to medically necessary covered services and ordinary public or private transportation is against medical advisement (i.e. could cause the individual harm). NEMT is provided to MC recipients via ambulance, litter van, wheelchair van, or by air.
Individuals who inquire about NEMT should be referred to consult with their treating physicians to request transportation options. The physician will put them in touch with the appropriate NEMT provider.
Refer to Managed Care Plan for questions concerning non-emergency medical transportation.
Out-of-State Authorization for Treatment
In order for out-of-state providers to bill MC, they must first obtain a provider number, an out-of-state billing manual, and the appropriate forms.
Staff receiving calls from out-of-state providers should refer them to:
California Department of Health Care Services
Field Services Section
P.O. Box 193704
San Francisco, CA 94119-3704
Phone: 1-800-726-4326
Out-of-State Provider Billing
For out-of-state providers, the following number may be given:
Phone: 916-636-1200
Out-of-State providers who have a provider number and the appropriate claim forms for billing can forward them to:
San Francisco MC Field Office
Inpatient Claims
P.O. Box 193704
San Francisco, CA 94119
Phone: 1-800-726-4326
4.2.10 Provider Enrollment
Physicians and other providers (including out-of-state providers) who wish to become a MC provider may contact:
California Department of Health Care Services
Provider Enrollment Division
P.O. Box 997412, MS-4704
Sacramento, CA 95899-7412
Phone: 916-323-1945
Treatment Authorization Requests
California Department of Health Care Services
Field Services Section
P.O. Box 193704
San Francisco, CA 94119-3704 Phone:1-800-726-4326
Contract Hospitals
The following seven (7) hospitals have contracts with the State of California to provide inpatient care to MC patients:
Note: All hospitals must provide emergency care for a person with a life threatening medical problem.
Regional Medical Center of San Jose
225 North Jackson Avenue
San Jose, CA 95116
Phone: (408) 259-5000
O'Connor Hospital
2105 Forest Avenue
San Jose, CA 95128
Phone: (408) 947-2500
El Camino Hospital Los Gatos
815 Pollard Avenue
Los Gatos, CA 95030
Phone: (408) 378-6131
Santa Clara Valley Medical Center
751 South Bascom Avenue
San Jose, CA 95128
Phone: (408) 885-5000
Stanford University Medical Center
300 Pasteur Drive
Palo Alto, CA 94304
Phone: (650) 723-4000
El Camino Hospital
2500 Grant Road
Mountain View, CA 94039-7025
Phone: (650) 940-7000
Saint Louise Regional Hospital
9400 No Name Uno
Gilroy, CA 95020
Phone: (408) 848-2000
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