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.
Report a New Case (Step 1):
Submit one new case notification per injury as multiple submissions may result in delayed processing. The new case notification must include the following to satisfy reporting requirements pursuant to W&I Code section14124.73(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. Contact information of the liable third party or insurer.
4. Contact information of the claims administrator, including their claim number.
5. Contact information of any defense counsel representing the liable third party or insurer.
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.
Case Updates (Step 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.
- Provide a case update if you have new information to report or documentation to provide for an existing case. For security purposes, we do not accept digital media.