Claims and Eligibility

Getting Started

Submitting your claims

CalOptima providers can utilize the tools in this section to help them verify eligibility and benefits, check on the status of a claim or request treatment authorizations.

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How to verify member eligibility View resources to verify member eligibility and benefits.

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Electronic data interchange (EDI) Learn more about transmission of claims data, benefit eligibility and claim status inquiry.

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Prior authorization required list View the list for medical and outpatient services.

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CalOptima link Learn more.

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Provider Complaint Process Medi-Cal, OneCare (HMO SNP) and OneCare Connect maintains a provider complaint process to review and resolve provider disputes for claims payment, as well as utilization management decisions and other non-payment related issues.

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CalOptima Direct Medi-Cal Fee schedule Download PDF Icon View CalOptima's reimbursement rates for covered Medi-Cal services rendered by a non-contracted provider.

Contact Us
  • Providers and other health care professionals with questions regarding Medi-Cal, OneCare Connect, OneCare or PACE can call the Provider Relations department at 714-246-8600 or email: providerservices@caloptima.org

Electronic Data Interchange (EDI)
Provider Disputes
  • Dispute Process
    Review the payment dispute process for Medi-Cal and OneCare contracted providers

Prior Authorizations

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