Out-of-State Billing

MEDI-CAL IS NOT ACCEPTED BY ALL OUT OF STATE PROVIDERS, IT IS THE CLIENT’S RESPONSIBILITY TO ASK THE PROVIDER BEFORE RECEIVING SERVICES.

ExampleExample

Giovanni is in Colorado skiing and breaks his leg. He needs emergency medical attention. He requires an x-ray and general surgery. The hospital accepts MC for the surgery but the Radiology Department in Colorado does not accept MC; Giovanni is responsible to pay for the x-ray services.

Medi-Cal Card Use

The BIC may serve as authorization for payment covering a service provided outside California only under the following conditions:

  • There is an emergency due to an accident, injury or illness.
  • The health of the individual would be endangered if care and services were postponed until it is feasible to return to California.
  • The health of the individual would be endangered if s/he traveled to return to California.
  • It is the customary practice in border communities for residents to use medical resources in adjacent areas outside the State.
  • The client's physician has proposed an out-of-state treatment plan which has been reviewed and authorized by the DHCS before the services are provided. DHCS may authorize such treatment only when it is not available within the State.
  • Health care is needed for eligible California children placed in other states through the Interstate Compact on Placement of Children.

Prior Authorization

Prior authorization is required for all out-of-state claims except:

  • Emergency services, i.e., required for alleviation of severe pain or immediate diagnosis and treatment of unforeseen medical conditions which would lead to disability or death if not diagnosed and treated immediately.
  • Services provided in border areas adjacent to California where it is customary practice for California residents to receive services.

Note: No services are covered outside the United States, except for emergency services requiring hospitalization in Canada or Mexico.

Claims Procedure

Electronic Data Systems (EDS) processes MC claims for the State of California. All providers, including out-of-state providers, should send claims directly to EDS as follows:

 

E.D.S. Federal Corporation Inpatient Claims
P.O. Box 15500
Sacramento, CA 95852-1500
Telephone: (916) 636-1200

 

If a claim is sent to the County by mistake, the following action is required by the EW:

  • Completes the form “Medi-Cal Out-of-State Provider Letter “(SCD 1175),
  • Mails original form to the provider,
  • Mails one copy and the claim to EDS,
  • Mails one copy to the client,
  • Scans a copy of the form into Imaging system.

Related Topics

Letter of Authorization

Release of Medi-Cal Eligibility Information to Providers