Claims Process

CalOptima Health Direct and each contracted CalOptima Health health network has its own process for receiving, processing and paying claims. Providers must verify member eligibility and identify the member’s assigned health network prior to submitting a claim for the member. To ensure accurate and timely claim payment, providers must submit the claim according to the assigned health network’s claims processing guidelines.

For a listing of health network claims processing guidelines, including information for submitting paper and electronic claims, see Section H of the CalOptima Health Provider Manual .