MedicaidAdministrativeHigh impact
20-742 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 now requires Medi-Cal to be the payer of last resort when members have other health coverage (OHC). Beginning January 1, 2021, claims will be denied if OHC is present on the member's eligibility record unless providers can prove all other payment sources have been exhausted.
Action Required
Immediately: Billing team must check the Medi-Cal Eligibility Record for all Medi-Cal members before processing claims to identify other health coverage (OHC). If OHC is present (any code other than A or N), do not bill Medi-Cal unless provider can document that all other payment sources have been exhausted. Use Automated Eligibility Verification System at 1-800-427-1295 or the Medi-Cal Online Eligibility Portal to verify OHC information. Failure to follow this process will result in claim denials and potential post-payment recovery.