Important Billing Announcements

Dear Contract Providers,

Please note that the Self-Pay (SP) health plan option has been deactivated for Contract Providers. This update aligns with the policy and processes communicated during the CalAIM trainings.

IRIS has not been, and continues not to be, authorized for use by Contract Providers for SP client billings. Therefore, this change is consistent with established procedures and expected outcomes.

Thank you for your attention to this update.

• The AOB/ATD field in IRIS has been updated so the only available selection is “Yes.”
• An AOB/ATD must be obtained from the client when appropriate. If one is not obtained, these services should not be entered into IRIS.
• Services with Medicare or third-party insurance as primary, without Medi-Cal, should not be entered into IRIS.

Reminder: Medi-Cal is always the payer of last resort.

• The Medi-Cal CIN field is now a required field in IRIS.
• Eligibility must be checked at every visit/date of service, as coverage may change.
• Ensure the CIN entered in IRIS matches exactly what is verified, errors will result in denials.

We have observed instances where services that should not be entered into IRIS are still being entered. Please note:

1. You must bill the primary insurance and obtain either a payment or denial before entering services into IRIS for Medi-Cal billing.
2. If you are awaiting a response from the primary payer, do not enter these charges into IRIS until you receive the payment or denial.
3. Any charges awaiting a response from other health insurance in combination with Medi-Cal entered and not updated with payment or denial information within seven (7) days will be removed from the system.
4. All third-party billing requirements must be met, and providers must maintain documentation of correspondence for potential oversight reviews.

Please ensure that billing queues are worked at least once daily. The Rejected 837 billing queue for Date of Service (DOS) July 1, 2025, and current includes the rejection reason to help correct the rejection. Rejection reasons can be found in the Revenue Cycle Application (RCA) on the Timeline tab. Once all corrections are made, these services will be billed to Medi-Cal.