MedicaidAdministrativeHigh impact
23-675m Get Paid Faster: Bill Correctly When Members Have Other Health Coverage
Health Net·CA·Prior Authorization
We identified it
Jun 20, 2026
Summary
When patients have both Medi-Cal and other health coverage (private insurance, Medicare, etc.), providers must bill the other coverage first as Medi-Cal is the payer of last resort. To bill Medi-Cal for remaining balances, providers must submit EOBs or denial letters from the primary insurance and include OHC payment amounts on the Medi-Cal claim.
Action Required
Immediately: Update billing workflows to identify patients with Medi-Cal plus other health coverage. Billing team must: 1) Bill other health coverage (private insurance, Medicare) FIRST before submitting to Medi-Cal, 2) Obtain EOBs or denial letters from primary insurance, 3) When billing Medi-Cal secondary, attach the EOB/denial letter and enter the primary payment amount in appropriate claim fields, 4) Do not reduce billed charges based on OHC payments, 5) Use only Medi-Cal-approved codes when billing Medi-Cal as secondary. Front desk staff must verify and document all insurance coverage during registration.