Claims and Eligibility
CalOptima Health 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.
How to verify member eligibility View resources to verify member eligibility and benefits.
Electronic data interchange (EDI) Learn more about transmission of claims data, benefit eligibility and claim status inquiry.
Prior authorization required list View the list for medical and outpatient services.
CalOptima Health Provider Portal Access the Provider Portal.
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.
CalOptima Health Other Health Coverage Carrier Code Listing A listing of members’ other health coverage information for billing purposes.
CalOptima Health Direct Medi-Cal Fee schedule View CalOptima Health's reimbursement rates for covered Medi-Cal services rendered by a non-contracted provider.
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