Frequently Asked Questions (FAQ)

If the client does not have Medi-Cal, either primary or secondary, they should NOT be entered in IRIS.

If the client does not have Medi-Cal, either primary or secondary, they should NOT be entered in IRIS, this includes unfunded clients.

The Billing Team does not provide guidance on Third Party billing.  It is the provider’s responsibility to bill all third-party insurance outside of IRIS.

It is up to the contract providers to enroll with Medicare and bill Medicare within their own system when Medi-Cal requires it for coordination of benefits (see Service Tables -MedCCC—Library). If Medicare does not get billed, then Medi-Cal will not be billed. The services should not be entered in IRIS without a Medicare denial or payment.

No, a new FIN does not need to be created. A new claim can be generated from the same FIN. Email the Billing Team with the new claim number so that they can ensure HCA/IT/EDI submits the claim with an original claim indicator.

The client should contact Social Services Agency to have the OHC status updated.

Providers should inform the client that they may choose to apply the charges to the family SOC.  Do not charge the client if they choose not to apply the charges to the family SOC.

An original claim is the initial submission.  Origin claims must be submitted within 12 months of the month of service.

Replacement claims are claims that correct previously submitted claims.  A claim may be submitted to replace an approved claim or a denied claim no later than 15 months after the month of service.

a.    Reference Specialty Mental Health Billing Manual Specialty Mental Health Services Billing Manual SFY 2025-26 ; (Section 5.5.0 Duplicate Services) A claim for an outpatient service is considered a duplicate if all of the following data elements are the same as another service line within a claim that was approved in history:
     i.    The member’s CIN
     ii.    Rendering provider NPI
     iii.    Procedure code(s)
     iv.    Date of service

b.    With the exception of Sign Language or Oral Interpretive Services (T1013), Peer Support Services, Group Services (H0025) or mobile services (H2011 – POS 15).
c.    If the provider renders two of the same services to the same member on the same day in two or more separate encounters, all encounters must be claimed as one service to ensure the additional encounters are not denied as duplicate services.

a.    Contract providers have been instructed not to use Special Guarantors. If exceptions are made, they will be rare. The direction will come from the contract monitor or program manager.  
b.    To replace the Special Guarantor, you may use a parent/guardian or self in registration.  
c.    There are no additional funds by using the Special Guarantor.

Contract providers should work on both at the same time. They should work on the prior fiscal year so that there is no timely filing limitation and no risk of not being reimbursed.

The Billing Team does not provide guidance on third party billing.  It is the responsibility to bill all third-party insurance outside of IRIS.