MedicaidAdministrativeHigh impact
20-740 Avoid Post-Payment Collection by Ensuring Medi-Cal is the Payer of Last Resort
Health Net·CA·Prior Authorization
Effective date
Jan 1, 2021
We identified it
Jun 20, 2026
Summary
Health Net and CalViva Health must verify other health coverage (OHC) information before processing Medi-Cal claims in Fresno, Kings, and Madera counties. Claims for members with other insurance must be denied unless providers show all other payment sources have been exhausted, with detailed OHC information provided in denial notifications.
Action Required
Immediately: Billing team must check Medi-Cal Eligibility Record for other health coverage before processing claims for CalViva Health members in Fresno, Kings, and Madera counties. When denying claims due to OHC, include OHC provider name, policy number, and contact information in denial notification. Do not process Medi-Cal as primary unless provider provides proof other coverage has been exhausted or service meets direct billing requirements.