Provider Claim Registration Forms

Below are links to the forms needed for registering with CalOptima Health as a non-contracted provider and/or updating provider information for non-contracted providers for claim submissions to CalOptima Health.

If you have questions, contact Provider Data Management Services at 714-246-8468. Completed forms and a copy of returned claims should be faxed to CalOptima Health at 714-954-2330 or emailed to provideronline@caloptima.org .

If you are a contracted provider or inquiring about becoming contracted, please email the Provider Relations department at providerservicesinbox@caloptima.org or visit How to Contract with CalOptima Health.

Provider Registration for Claims Submission Form   Complete this form if you received a returned claim from CalOptima Health or need to submit claims for payment consideration. Include a copy of the returned claim, if applicable.

Provider Demographic Change Form   Complete this form if you are a non-contracted provider with a returned claim due to a discrepancy in the provider information (service location, remit address or tax ID).

W9 Form  A completed W9 is required when submitting a Provider Registration for Claim Submission Form or a Provider Demographic Change Form.

Notification of Federal Tax ID Change Form  This form is required when submitting a tax ID change for a group and/or facility.

Returned or resubmitted claim(s) for processing will be considered a newly submitted claim.