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Release of Medi-Cal Eligibility Information to Providers
The DHCS policy and the Welfare & Institution Codes allow providers to contact EWs for information necessary to verify client’s MC eligibility. Providers must make a good faith effort to obtain the BIC information from the MC client prior to contacting the EW.
An exception to Provider’s good faith effort exists if ALL of the following conditions are met:
- The client has an immediate need for medical services if he/she:
- Is currently in the doctor’s office,
- Has a scheduled appointment before the BIC will arrive, and/or
- Needs to have a prescription filled.
- The client does not have his/her card or a new card has been issued that invalidates the card she/he has.
- The EW can confirm the identity of the client.
Under certain conditions, the EW or designated staff member is allowed to provide verification of MC eligibility to medical providers, in order for the provider to bill MC.
For billing purposes, limited client information may be given to any MC provider as long as sufficient information is obtained to identify the client and establish that the individual is a MC provider. The information obtained from the provider must be sufficient to assure there is no question as to the identity of the provider or the client.
To ensure that individuals phoning to request this information are, in fact, who they represent themselves to be, the EWs must:
- Take the caller’s name and phone numbers, and
- Call them back with the requested information.
Note: If the case is closed, the “Information Supervisor of the day” will receive this referral and provide the information.
Medical providers include but are not limited to:
- Doctors
- Dentists
- Chiropractors
- Acupuncturists
- Optometrists
- Hospitals
- Nursing homes
- Primary care clinics.
Note: If in doubt that an individual/association qualifies as a “medical provider”, the EW Supervisor may contact the MC Program Coordinator for a determination. Information may not be released to a billing agent or collection agency, such as the Department of Revenue. Do not give out unnecessary information.
The EW is responsible for ensuring that the confidentiality of the client’s eligibility information is maintained. Under no circumstance must a MC client’s information to be given to anyone unless the purpose is directly related to the administration of MC.
Medi-Cal Eligibility Data System (MEDS)
Medi-Cal Eligibility Data System (MEDS) terminal access is available only to agencies involved in the administration of the MC program. The Social Services Department, the Department of Mental Health, the Local Child Support Agency, California’s Children’s Services, and their outstationed staff may have access to MEDS terminals. MC providers and third party creditors, such as collection agencies working under contract for such providers, may NEVER HAVE ACCESS TO MEDS. DHCS’ policy regarding confidentiality prohibits county staff to release MEDS print outs (including MOPI screens).
Information Which May be Released to a Provider
The EW or designated staff member is allowed to provide the following information to medical providers:
- The 14-digit BIC ID number (which contains the 9-digit Client Index Number [CIN], a check digit and a 4-digit Julian date that is equal to the card issue date).
- Date of Birth.
Eligibility staff should only need to provide the client’s 14-digit BIC and date of birth. Refer the provider to the Medi-Cal Eligibility Verification System or the telephone Automated Eligibility Verification System at 1-800 456-2387 for verification of the client’s eligibility.
Note: This is the only situation in the MC program when a signed “Release of Information” is not required in order to provide client information to a third party.
Ineligible Individual
EWs must not release any information for an ineligible individual other than the fact that he/she is not eligible for MC (for a time period or for a specific month).
Exception: If the hospital is requesting a denial reason to determine the individual’s need for charity assistance, the EW may provide the denial reason.
Request for Medi-Cal Eligibility Information for a Deceased Individual
The EW may release the CIN, BIC Issue Date and date of birth to any MC provider who rendered a service for a client who is now deceased. The request must be made within twelve months following the month of service.
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