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Medi-CalMedicaid · Administrative · Provider Bulletin · CA · Family Medicine, General Practice, Internal Medicine +3 moreHigh impact

FQHC and RHC Policy for UIS Members Transitioning to Fee-for-Service on January 1, 2027

Act
by Jan 1, 2027
Effective date
Jan 1, 2027
Identified
Nov 7, 2026

Summary

Effective January 1, 2027, Medi-Cal members with Unsatisfactory Immigration Status move from Medi-Cal managed care plans to Medi-Cal fee-for-service, so FQHC and RHC claims for these members must go directly to the Medi-Cal fiscal intermediary rather than to the former plan. Effective for services on or after January 1, 2027, claims sent to the former plan or to the FI for an MCP differential (wrap) rate will be denied, and from July 1, 2027, emergency and pregnancy-related services for these members are reimbursed only at the PPS rate with the appropriate diagnosis code and emergency indicator.

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What to do

by Jan 1, 2027 · 7 steps
01Verify each UIS member's Medi-Cal eligibility and delivery system assignment through AEVS before the visit, and update front desk and scheduling workflows so these members are routed to fee-for-service.
02Billing team: in charge entry and claim submission, send claims for these members directly to the Medi-Cal fiscal intermediary and stop sending claims to the former Medi-Cal managed care plan or for MCP differential (wrap) rates, since those claims will be denied for services on or after January 1, 2027.
03Include CPT and HCPCS codes on informational lines, appropriate modifiers, and valid diagnosis codes on all claims.
04Providers and front desk staff: use the Find Doctors and Services tool to help members locate fee-for-service providers where needed.
05Before July 1, 2027: Billing team should watch for forthcoming billing instructions for emergency and pregnancy-related services, and update charge entry so those claims carry the appropriate diagnosis code and emergency indicator to be paid at the PPS rate.
06Dental claims for UIS members require no change in submission.
07Annual reconciliation will have no MCP differential or Medicare crossover entries for these members.

Original notice

FQHC and RHC Policy for UIS Members Transitioning to Fee-for-Service on January 1, 2027
mcweb.apps.prd.cammis.medi-cal.ca.gov · Always check the source before changing claims.
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Medi-Cal policiesCA policy changesFamily MedicineGeneral PracticeInternal MedicinePediatricsOB-GYNEmergency Medicine

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