DHS/MediCal Proprietary Form Reminder

The following information is provided by DHS/MediCal.


Proprietary Claim Form Reminder
New versions of Medi-Cal and Child Health and Disability Prevention (CHDP) proprietary forms are available from Medi-Cal. These new forms are updated to accommodate the 10-digit National Provider Identifier (NPI). Medi-Cal began advertising and distributing the newer version proprietary forms July 1, 2007 so that providers may have plenty of time to use old stock and order new. Ordering the newer version proprietary forms is quick and cost-free. Simply call the Telephone Support Center (TSC) at 1-800-541-5555 to fill your order today. As previously announced in monthly bulletins, as of April 15, 2008, Medi-Cal is no longer accepting the old, non-NPI compliant version of these forms.

At the direction of the Department of Health Care Services, the non-NPI compliant forms will be returned and may result in claim timeliness issues. By not using the updated forms, providers' reimbursements may be cutback or denied due to timeliness if non-NPI compliant forms have to be returned.

Timeliness Appeal
Should a provider's claim become untimely due to a rejected non-NPI compliant form, a system is in place to process requests to appeal the timeliness issue. Providers must submit an appeal by attaching the official reject letter to substantiate timely billing. Appeals must be filed within 90-days of last action, so the provider must get the appeal to the Appeals Unit within 90-days of the rejection letter date. As with all other appeals, failure to submit an appeal within this 90-day time period will result in the appeal being denied.

The following list identifies the proprietary forms that have been revised and must be submitted in place of the old, non-NPI compliant forms.

Form Number Form Name
18-1 Request for Extension of Stay in Hospital
18-2 Request for Extension of Stay in Hospital (Fax)
18-3 Request for Mental Health Stay in Hospital
20-1 Long Term Care Treatment Authorization Request
25-1 Payment Request for Long Term Care
30-1 Pharmacy Claim Form
30-4 Compound Drug Pharmacy Claim Form
50-1 Treatment Authorization Request
50-2 Treatment Authorization Request (Fax)
50-3 Treatment Authorization Request (Vision Care)
55-1 Medi-Cal Managed Care Authorization Form (Discharge Planning Option)
60-1 Claims Inquiry Form
90-1 Appeal Form
PM 160 CHDP Assessment Confidential Screening/Billing Report
PM 160INF CHDP Assessment Confidential Screening/Billing Report (Information Only)
TAR 3 Form Treatment Authorization Request Attachment Form

For assistance, providers may contact the Telephone Service Center (TSC) at 1-800-541-5555 or visit the Medi-Cal Web site at www.medi-cal.ca.gov and access the NPI link on the “Featured” tab.