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  • Claims Submissions and Status

    Claims Submission and Payment Inquiries
    Starting January 1, 2021 PHC California is no longer accepting paper claims.  All claims from providers must be submitted to our clearing house Change Healthcare, submitting ID 95422.  For corrected claim submission(s) please review our Corrected Claim Guidelines.  For claims inquiries please call the claims department at (888) 662-0626 or email Claims [email protected].  If emailing an inquiry please do not include Patient Protected Health Information (PHI), but the best call back number or email to reach you.  Claims payment disputes, appeals, and supporting documentation such as copies of medical records, authorization forms, or other documents can be submitted to:

    Attn:  Claims
    PHC California
    P.O. Box 472377
    Aurora, CO  80047.

    Notification of this change was provided to all contracted providers in December 2020.

    Physician Fee Schedule

    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.)

    Initial Claim Submission

    Claims for services provided to members assigned to PHC California must be submitted on the appropriate billing form (CMS1500, UB04, etc.) within ninety (90) calendar days, or as stated in the written service agreement with PHC California. The provider is responsible to submit all claims to PHC California within the specified timely filing limit. PHC California may deny any claim billed by the provider that is not received within the specified timely filing limit.

    The following information must be included on every claim:

    1. Provider name
    2. Provider address
    3. Patient name
    4. Patient date of birth
    5. Patient ID
    6. Date(s) of service
    7. All ICD10 diagnosis code(s) present upon visit
    8. Revenue, CPT, HCPCS code for service or item provided
    9. NDC(s) for any drugs provided
    10. Billed charges
    11. Place of service or UB04 bill type code
    12. Tax ID number
    13. NPI number
    14. Name and state license number of rendering provider

    Claims that do not meet the criteria described above will be returned to the provider indicating the necessary information that is missing. PHC California will process only legible claims received on the proper claim form that contains the essential data elements described above.

    Only current standard procedural terminology is acceptable for reimbursement per the following coding manuals:

    • Current Procedural Terminology (CPT) for physician procedural terminology
    • International Classification of Diseases (ICD10-CM) for diagnostic coding
    • Health Care Procedure Coding System (HCPC)

    CMS-1500 paper claim submissions must be submitted on form OMB-0938-0999(08-05) as noted on the document’s footer. We accept the revised CMS-1500 and UB-04 forms printed in Flint OCR Red, J6983, (or exact match) ink.

    To ensure timely claim processing, PHC California requires that adequate and appropriate documentation be submitted with each claim filed.

    Documentation required with a CMS1500 or UB04 claim form:

    Documentation

    Applies to

    Other coverage explanation of benefitsAll Providers
    Dialysis logDialysis Service
    Doctor’s orders, nursing or therapy notesHome Health
    Full medical record with discharge summaryHospital
    Consult, procedures reportPhysician
    Emergency room reportEmergency Medicine Physician
    Operative reportSurgeon
    Minimum Data Set (MDS) AssessmentSkilled 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.

    Information for Obtaining an NPI

    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.)
    Claim Definitions

    Clean Claim — A “clean claim” is defined as a claim for services submitted by a practitioner that is complete and includes all information reasonably required by PHC California, and as to which request for payment there is no material issue regarding PHC California’s obligation to pay under the terms of a managed care plan.

    Timely Filing Limit — The claim’s “Timely Filing Limit” is defined as the calendar day period between the claim’s last date of service, or payment/denial by the primary payer, and the date by which PHC California must first receive the claim.

    Received Date — 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
    Claims Processing

    Claims will be paid to contracted providers in accordance with the timeliness provisions set forth in the provider’s contract and/or by applicable California Law. Unless the subcontracting provider and contractor have agreed in writing to an alternate payment schedule, claims will be adjudicated as follows:

    • For clean claims, expect reimbursement within 45 days of PHC California’s receipt of the claim if submitted on paper
    • You will receive an Explanation of Benefits (EOB) that details how each service is paid
    • You will receive an Explanation of Payment and Recovery Detail (EOPRD) when PHC California identifies a previous claim overpayment

    DHCS 030716 PHC FR Form 1.0