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The Department of Health Care Services (DHCS), Third Party Liability and Recovery Division (TPLRD) is required by federal and state law to recover funds for Medi-Cal paid services related to a liable third party action in which a settlement, judgment, award or claim occurs.

Whether you are a Medi-Cal member, a legal representative, an insurer or other referring party, the forms below will help you submit proper notification to DHCS, thereby satisfying the reporting requirements pursuant to Welfare and Institutions (W&I) Code Section 14124.73, et seq.
Complete the appropriate form in its entirety, review for accuracy, and submit only once. Multiple submissions may result in delayed processing. Allow 30 days for DHCS to send a letter confirming receipt of the notification. If the injured party is Medi-Cal eligible, the letter will detail DHCS’ recovery rights and lien process. A lien will be provided after DHCS receives the following information:
·         Final date of treatment related to the injury with a Medi-Cal provider, AND/OR
·         Date of settlement
 
Per W&I Code Section 14124.73(c) the member’s valid Medi-Cal ID number must be provided to satisfy reporting requirements.  The Medi-Cal ID number can be found on the member’s ID card as indicated in the examples below. The number required within the online forms is comprised of the first 9 characters of the ID beginning with “9”, followed by 7 additional numbers, and ending with a letter.

Sample Card.png 

DHCS Tax ID Number: 68-0317191 

Personal Injury (PI)                               Workers' Compensation (WC)

Last modified on: 11/15/2017 9:27 AM