Report a New Case and Case Updates – Online Forms
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 txhua tus tswv cuab Medi-Cal uas koom nrog hauv qhov xwm txheej raug mob ntawm tus kheej. Yog xa ntau daim ntawv tuaj yuav ua rau kev ua tiav qeeb. Daim ntawv ceeb toom tshiab txog rooj plaub yuav tsum muaj cov hauv qab no kom ua tau raws li cov kev cai tshaj tawm raws li W&I Code ntu 14124.73(c):
- Date of the Medi-Cal member’s injury.
- Tus lej Medi-Cal ID ntawm tus tswv cuab raws li teev nyob rau ntawm lawv daim npav qhia txog cov txiaj ntsig (BIC), lossis tus lej Social Security.
- Contact information of the liable third party or insurer.
- Cov ntaub ntawv tiv tauj ntawm tus thawj coj kev thov nyiaj pov hwm, suav nrog lawv tus lej thov.
- Cov ntaub ntawv tiv tauj ntawm ib tus kws lij choj tiv thaiv uas sawv cev rau tus neeg thib peb lossis tus neeg pov hwm uas muaj 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.
Tus kheej raug mob (PI)
PI – Step 1
Qhia Txog Tus Kab Mob Tshiab (Daim Ntawv Qhia Txog Kev Raug Mob Tus Kheej)
PI – Step 2
Muab Cov Ntaub Ntawv Hloov Kho lossis Cov Ntaub Ntawv (Tag nrho Lwm Cov Kev Ceeb Toom)
PI – Step 3
Them Medi-Cal Lien Online
Lwm yam
Thov qhov xwm txheej ntawm qhov Qhib Case
Kev them nyiaj rau cov neeg ua haujlwm (WC)
WC – Step 1
Xa daim ntawv ceeb toom thov tshiab lossis cov ntaub ntawv rau qhov kev thov uas twb muaj lawm
Please Note: a response will be provided only if DHCS is asserting a Medi-Cal lien.
WC – Step 2
Pay online
Lwm yam Forms
Tswj Kev Kho Mob
Managed Care Single Member Submission
Managed Care Multi-Member Form