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  • Claims Resources

    Do you have a question about claims or billing? You’re in the right place!

    The following resources are available to providers to assist with frequently asked questions and guidance on appropriate billing, claims submission, payment receipt, billing job aids and much more. 

    To better serve our PHC California Providers, PHC California has contracted with Change Healthcare clearinghouse for the submission of all Electronic Data Interchange (EDI) claims. Initial claim(s) should be submitted electronically to PHC California.  For claim(s) submission timeframe for contracted providers, please refer to your agreement with the plan. The non-contracted providers claim(s) submission the timeframe is 365 days from the date of service. 

    Change Healthcare Benefits and Advantages to EDI

    • Reduce administrative burden – Reduce administrative fees related to the submission of claims and claims status transactions.
    • Ability to submit 24/7PHC California accepts all claims electronically, including professional and institutional related submissions 24 hours a day, seven days a week.
    • Reduction of data entry and payment errorsClaims submitted electronically benefit from earlier detection of billing errors.  If your claim fails due to any pre-pass edit, the claim is returned back to your office for correction.  This editing reduces the likelihood of your claim being rejected or denied for payment once it enters the processing system. 
    • Immediate verification of claims receivedReceive immediate acknowledgement of claims received and confirmation through your clearinghouse within two days as to if claims have been accepted or rejected. 

    What you Need to Know 

    Clean Claims Billing Requirements

    Before PHC California can process your claim, it must include all required information, where applicable and be “clean” of any errors. Please use the below document as a guide to identify the requirements for a clean claim submission.

    Claim(s) that do not meet “clean” claim criteria will be rejected and denied back to the provider for correction.

    Providers sending professional and supplier claims to PHC California on paper must use Form CMS 1500 in the latest valid version. This form is maintained by the National Uniform Claim Committee (NUCC), an industry organization in which CMS participates.


    Clean Claim Billing Requirements CMS 1500  
    Clean Claim Billing Requirements UB 04 

    If your office is unable to submit claims via a clearing house, Providers can send hard copy (paper) claims via fax or mail to the address below: 

    Fax paper claim: (888) 235-9274 

    PHC California shall identify and acknowledge the receipt of each claim, whether or not complete, and disclose the recorded date of receipt to the billing practitioner as follows: 

      • EDI Claim, within 2 working days of the date of receipt of the claim. 
      • Paper Claim, within 15 working days of postmarked envelope. 

    The “Received Date” is the oldest PHC California date stamp on the claim. Acceptable date stamps include any of the following: 

      • PHC California’s Claims department date stamp 
      • Primary payer claim payment/denial date 

    Balance billing is when a practitioner charges beneficiary for Medi-Cal covered services. Balance billing PHC California Members is prohibited by law. 

    Contracted providers cannot collect reimbursement from a PHC California Member or persons acting on behalf of a Member for any services provided, except to collect any authorized share of cost co-insurance, co-payment or deductibles when applicable.

    Providers participating in Medi-Cal and/or Medicare are prohibited from balance billing any PHC California Member eligible for Medi-Cal and/or Medicare. Network providers who engage in balance billing are in breach of their contract with PHC California. 

    Providers who engage in balance billing may be subject to sanctions by PHC California, CMS, DHCS and other industry regulators. 

    PHC California cannot impose a timeframe for receipt of the first “initial claim” submission that is less than 180 days for contracted providers after the date of service for timely filing for a new claim. PHC California may deny a claim that is submitted beyond the claim filing deadline. 

    An incomplete claim is defined as any claim with incomplete, missing or invalid information. Incomplete claims are considered non-clean and may be rejected or denied back to the provider for correction and resubmission of a clean claim.  

    PHC California requires a current W-9 form to be on file in order to process any claims. The W-9 form will be used to verify your mailing/remittance address. Claims received from Providers that do not a W-9 form on file will be administratively denied as non-clean. Providers are expected to respond to the Plan’s request for a valid W-9 form for payment. 

    There are two ways Providers can submit their W-9 form to PHC California: 

    • Email to PDM Department [email protected] 
    • Fax W-9 Form (without paper claim) to: 888-971-4418 

    All payments, checks, claims remittance advices and 1099s will be mailed to the address listed on the W-9, as applicable. 

    Please note that an updated W-9 is required but not limited to the following changes: 

    • Mailing Address, 
    • Legal Business Name, 
    • Ownership 
    • TAX ID Number 
    • IRS form publication update 

    Member Verification and Claims Status Portal 

    The Member Verification and Claims Status Portal is the preferred method for contracted providers to check claims status. This portal allows you to: 

    • View member eligibility 
    • Lookup claims status 
    • View important plan materials & information (Provider Manuals, Member SOB, etc…)


    ECHO – Provider Payments Portal 

    PHC California has partnered with Change Healthcare and ECHO Health, Inc to provide payments to providers. Providers can register on the ECHO provider portal (  

    Payment Delivery Options include: 

      • Virtual Credit Card- Default payment method for all providers 
      • Electronic Fund Transfer (EFT) 
      • Medical Payment Exchange (MPX) 
      • Paper Check 

    To manage or change your Payment Delivery Option, you must opt out of Virtual Card Services by visiting and select another payment delivery option.  

    Learn more about our Provider Portals.

    PHC California is a Medi-Cal managed care plan and follows Medi-Cal fee schedules unless a differing reimbursement rate is contracted. (By clicking on the link above, you will go to the Medi-Cal website which is operated by the California Department of Health Care Services and not PHC California.)

    In accordance with requirements of the Balanced Budget Act of 1997, as a secondary payer, PHC California will pay deductibles, co-insurance and co-payments for Medi-Cal covered services up to the lower of our fee schedule or the Medicare/other insurance allowed amount. 

    California law limits Medi-Cal’s reimbursements for a crossover claim to an amount that, when combined with the Medicare payment, should not exceed Medi-Cal’s maximum allowed for similar services (Welfare and Institutions Code, Section 14109.5). When a Member has other health insurance, whether it is Medicare, a Medicare HMO or a commercial carrier, PHC California will coordinate payment of benefits. These other insurers are considered the primary payer, and PHC California is the secondary or last payer. 


                                   Applies to 

    Other coverage explanation of benefits 

    All Providers 

    Dialysis log 

    Dialysis Service 

    Doctor’s orders, nursing or therapy notes 

    Home Health 

    Full medical record with discharge summary 


    Consult, procedures report 


    Emergency room report 

    Emergency Medicine Physician 

    Operative report 


    Minimum Data Set (MDS) Assessment 

    Skilled Nursing Facility 

    Standard Code Sets

    Standard Code Sets as required by HIPAA are the codes used to identify specific diagnosis and clinical procedures on claims and encounter forms. All providers are required to submit claims and encounters using current HIPAA compliant codes, which include the standard CMS codes for ICD10, CPT, HCPCS, NDC and CDT, as appropriate.

    A provider has a right to file a dispute in writing to PHC California within 365 day from the date of service or the most recent action date, if there are multiple actions. PHC California makes available to all providers a fast, fair and cost-effective dispute resolution mechanism for disputes regarding invoices, billing determinations or other contract, non-contracted issues. The dispute resolution mechanism is handled in accordance with applicable law and your agreement. A provider dispute is a written notice to PHC California challenging, appealing or requesting reconsideration of a claim. The following are examples of disputes: 

    • Claims payment disputes: challenging, appealing or requesting reconsideration of a claim (or bundled group of claims) 
    • Benefit determination disputes: seeking resolution of a benefit determination 
    • Payment of a claim 
    • Denial of a claim 
    • Timely filing denial 
    • Seeking resolution of a billing determination
    • Seeking resolution of another contract dispute 
    • Disputing a request for reimbursement of an overpayment to a claim 

    Providers may submit disputes on a Provider Claims Dispute Submission Form.

    Each provider claim dispute must contain the following information at a minimum:

    • Provider’s name
    • Provider’s identification number
    • Provider’s contact information
    • If the provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from PHC California to a provider, the request must include:
      • A clear identification of the disputed item
      • The date of service
      • A clear explanation of the basis upon which the provider believes the payment amount, request for additional information, request for reimbursement for the overpayment of a claim, contest, denial, adjustment or other action is incorrect.

    PHC California issues a written determination regarding a provider claim dispute within 60 calendar days after receipt of the dispute. For those provider claim disputes that require amending by the provider, the plan issues a written determination within 60 calendar days after receipt of an amended dispute.

    To obtain a national provider identifier (NPI) you may:

    • Telephone: (800) 465-3203 or TTY: (800) 692-2326
    • E-mail [email protected]
    • Mail to NPI Enumerator P.O. Box 6059 Fargo, ND 58108-6059
    • Refer to CMS’s NPI information (By clicking this link, you will be taken to the Centers for Medicare and Medicaid Services’ website.)
    You will need the Adobe Acrobat Reader program to view the above forms. To download this free program click here or use the link above – the link will open a new window and take you to the Adobe website.
    Page Updated: July 1, 2024 @ 9:54pm