Medical billing for California practices

Delegated risk and IPA claims

When a plan delegates claims payment to an IPA or medical group, the claim belongs to the delegated entity and the plan will deny it as not its responsibility. The reverse is equally common. We identify the responsible payer from the patient's assignment, which removes a category of denial that otherwise repeats monthly. When a delegated group pays short or not at all, the Knox-Keene provider dispute process applies: the dispute goes to the plan or its delegate in writing, and the payer has to acknowledge it and resolve it within a fixed number of working days. We file those disputes as dated items and escalate to the Department of Managed Health Care when the window passes.

Medi-Cal enrollment through PAVE, plan credentialing and licensing

Medi-Cal enrollment runs through PAVE, the DHCS Provider Application and Validation for Enrollment portal. By statute DHCS has up to 90 days to act on a physician application and up to 180 for most other provider types, and a package returned for corrections has to come back within 60 days. Managed care plans may let a provider start seeing members while the PAVE application is pending, but DHCS caps that at 120 days: if the application is still not approved by then, the plan has to remove the provider from its network until it is. Since mid-2026 a prescriber also has to hold an individual Medi-Cal enrollment under a Type 1 NPI before treatment authorization requests for physician-administered drugs will process, so group enrollment alone no longer covers a prescribing physician. Medicare Part B in California is administered by Noridian as the Jurisdiction E contractor through PECOS. Commercial plans and IPAs credential from CAQH ProView, and each delegated group credentials on its own cycle. The Medical Board of California license renews every two years with a CME attestation. We hold every one of those dates on a per-provider calendar and file revalidations early, because a lapsed record in any one of them stops payment without a warning anyone reads in time.

Medi-Cal managed care by county under CalAIM

Which plan a Medi-Cal member holds depends on the county. Los Angeles runs through L.A. Care and Health Net, Riverside and San Bernardino through Inland Empire Health Plan, Orange County through CalOptima, and a run of northern counties through Partnership HealthPlan, while the 2024 contracts placed Anthem, Molina, Health Net and Blue Shield Promise in specific counties and gave Kaiser a direct contract of its own. Fee-for-service Medi-Cal claims must be received within six months following the month of service, and each plan writes its own limit into the provider agreement. We map each location to its county plan and delegated groups, confirm the member's plan before the visit, and track the filing limit that applies to that payer rather than a single statewide number.

Prior authorization and the thirty-day payment clock

California commercial plans and Medi-Cal managed care both authorize heavily for imaging, therapy and specialty referrals. Authorizations are tracked to approval, attached to the claim and watched for expiry, because an authorization that lapsed before the date of service denies exactly like no authorization at all. On the payment side, AB 3275 took effect on January 1, 2026: health plans regulated by the DMHC and insurers regulated by the Department of Insurance now have 30 calendar days to pay, contest or deny a claim, with interest owed automatically on late payments. Clean claims that pass day 30 move into a late-payment file rather than routine follow-up. Out-of-network disputes are split the same way, with AB 72 governing state-regulated plans and the federal No Surprises Act governing self-funded employer coverage.

Workers' compensation billing under the California fee schedule

California workers' compensation is paid under the Official Medical Fee Schedule set by the state Division of Workers' Compensation, and the process is more formal than in most states. Treatment beyond the first visit generally needs a Request for Authorization that goes through the claims administrator's utilization review, bills are answered with an Explanation of Review rather than a standard remittance, and a disputed payment moves through second bill review and then Independent Bill Review on fixed deadlines rather than through an ordinary appeal letter. Each step has a form and a window. We bill workers' compensation as its own category, track the authorization and review deadlines separately from commercial claims, and escalate a short payment through the review path before the right to dispute it lapses.

Medical billing for Los Angeles, Bay Area and Inland Empire groups

A group with offices in Los Angeles, the Inland Empire and the Bay Area is billing three Medi-Cal markets, three sets of delegated groups and often three sets of commercial contracts, so a patient who moves between offices can change payers without changing coverage. Capitation adds a second discipline: capitated primary care still requires encounter submissions, because attribution and risk adjustment depend on them, while carve-out services under the same contract are billed fee-for-service. We configure each location as its own payer market, separate capitated encounters from billable claims, and report collections per site so a contracting gap at one office is visible instead of averaging out. If you want to see the work first, the free billing audit covers one month of remittances and your aging.

Medi-Cal

Medi-Cal managed care is organized by county, and the 2024 plan contracts moved members between plans in more than twenty counties. A practice that opens a second location in another county is, for billing purposes, entering a new payer market with a different plan, a different delegated group and often a different filing limit.