Medical Authorizations & Claims

Authorization Process

All requests for CCS diagnostic and treatment services must be submitted using a Service Authorization Request (SAR) form except Orthodontic and Dental services (All necessary authorizations will be Denti-Cal’s responsibility). Only active Medi-Cal Providers may receive authorization to provide CCS program services. Services may be authorized for varying lengths of time during the CCS client’s eligibility period.

Some helpful tips when submitting a SAR:

  • Providers must request CCS services using a SAR form.
    Note: Providers should verify CCS eligibility before submitting a SAR.
  • Providers are required to submit documentation to substantiate medical necessity at the time the SAR is submitted. Send the completed SAR form with supporting documentation to the appropriate CCS county or Regional Office via fax or mail. Examples of required supporting documentations include prescriptions, clinic visit reports, physical therapy evaluation reports, etc. A SAR without supporting documentation will be deferred back to the provider for additional information.
  • Each SAR submitted to CCS is reviewed for medical necessity.
    • If the SAR is approved, a copy of the authorization letter will be sent to the provider and the family via fax or mail.
    • If the SAR is denied, a copy of the Notice of Action (NOA) or denial letter with the reason for denial of service will be sent to the client, parent or legal guardian with a courtesy copy to the provider via mail. 
    • If the SAR is incomplete and lacks supporting documentation to substantiate medical necessity, CCS will request the provider to submit additional information. There will be no further action on the SAR until CCS receives requested information. 

 

How to Avoid Denials for CCS Services

The CCS program requires prior authorization for services. This means that a Service Authorization Request (SAR) must be submitted to the CCS State office for approval for all diagnostic and treatments services, except for emergencies. Authorization request for emergency services must be submitted to CCS by the close of the next business day following the date of service.

 

Claims Processing

Claims for services that have been authorized by CCS are to be submitted directly to Electronic Data Systems (EDS) unless the client resides in Napa, San Mateo, Santa Barbara, Solano, Marin or Yolo counties. Clients residing in these counties are served by a County Organized Health System (COHS) that has been contracted by the department to serve these counties as the Medi-Cal Fiscal Intermediary. The following are some helpful reminders when submitting claims.

  • Submit claims for services that were approved or authorized by the CCS. Claims for services without CCS approval or prior authorization may be denied.
  • Submit claims for services rendered to a client confirmed eligible to receive CCS benefits. Claims for services rendered to clients who are not CCS or are no longer eligible to receive CCS benefits will be denied.
  • Submit claims to Xerox or the COHS in a timely manner.
  • Submit claims for services rendered to clients with other health insurance coverage with the Explanation of Benefits (EOB) attached to the claims.
  • Submit all claims for services rendered to clients in the following counties:
    • Napa, Solano, Marin or Yolo:
      Partnership Health Plan of California
      P.O. Box 1368
      Suisun, CA 94585
    • San Mateo:
      ALL CCS and HF CLAIMS STRAIGHT TO EDS
      ALL MEDI-CAL CLAIMS TO SAN MATEO COUNTY CCS
      California Children's Services
      2000 Alameda de las Pulgas       
      Suite 230
      San Mateo, CA 94403
    • Santa Barbara:
      CENCAL Health
      P.O. Box 1818
      Belflower, CA 90707-1818

 

Billing Questions

If you have billing questions, please contact Xerox at (800) 541-5555 (outside of California, please call 916-636-1980). You can also visit the Medi-Cal website for billing procedures and updates.

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Last modified date: 3/22/2019 9:25 AM