Claims and Eligibility

Getting Started

Submitting your claims

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.

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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