The Department of Health Care Services’ (DHCS) Personal Injury (PI) Program is required by federal and state law to recover funds for Medi-Cal paid services related to a liable third party action when a member receives a settlement, judgment, or award. The information below will help you submit proper notification to DHCS, but you must complete the appropriate form in its entirety and review for accuracy. For security purposes, we do not accept digital media.​​ 

Tshaj Tawm Cov Ntaub Ntawv Tshiab (Kaum 1):​​ 

Xa ib daim ntawv ceeb toom tshiab rau ib qho kev raug mob vim ntau qhov kev xa tawm tuaj yeem ua rau kev ua haujlwm qeeb. Daim ntawv ceeb toom rooj plaub tshiab yuav tsum suav nrog cov hauv qab no kom ua tau raws li qhov yuav tsum tau ua raws li W&I Code tshooj 14124.73(c):​​ 

1.     Date of the Medi-Cal member’s injury.​​ 

2.     Member’s Medi-Cal ID number as listed on their Benefits Identification Card (BIC), or Social Security Number.​​ 

3. Tiv tauj cov ntaub ntawv ntawm lub luag haujlwm thib peb lossis tus neeg tuav pov hwm.​​ 

4. Cov ntaub ntawv tiv tauj ntawm tus thawj tswj hwm, suav nrog lawv tus lej thov.​​ 

5. Cov ntaub ntawv tiv tauj ntawm ib tus kws lij choj tiv thaiv sawv cev rau tus neeg thib peb lossis tus neeg tuav pov hwm lub luag haujlwm.​​ 

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.​​ 

The Medi-Cal ID number can be found on the member’s Medi-Cal Benefits Identification Card (BIC) shown below. The member’s Medi-Cal ID number is comprised of the first 9 characters, beginning with “9,” followed by 7 additional numbers, and ending with a letter. If you do not have the member’s Medi-Cal ID number, you can enter the member’s Social Security Number.​​ 

Hloov tshiab Case (Kauj ruam 2):​​                                                                                   

• Provide a case update when the member has completed treatment with a Medi-Cal provider or after the settlement has occurred. DHCS will order and review the payment records, then send the Medi-Cal lien.​​ 
• Muab cov ntaub ntawv hloov tshiab yog tias koj muaj cov ntaub ntawv tshiab los qhia lossis cov ntaub ntawv los muab cov ntaub ntawv uas twb muaj lawm. Rau lub hom phiaj kev nyab xeeb, peb tsis lees txais cov xov xwm digital.​​