Hospital and Insurance Billing
If a Medi-Cal patient presents a Benefits Identification Card and a Health Initiative Identification Card, the patient should not be billed for services except in certain situations.
A Medi-Cal patient will be responsible for payment of hospital bills under the following circumstances:
- If the patient asks for and receives services that are not covered by Medi-Cal, such as cosmetic surgery
- If the patient fails to notify the provider of their Medi-Cal coverage
- If the patient has other insurance and Medi-Cal coverage and does not adhere to the Medi-Cal guidelines
- If the patient owes a Medi-Cal allowable co-payment (Share of Cost)
When Prior Authorization is Required
Some services will require prior authorization. The Primary Care Physician is responsible for knowing which services need to be authorized in advance by the plan. Services that must be authorized in advance include:
- Non-emergency hospitalization
- Care at skilled or intermediate nursing facilities
- Certain outpatient laboratory and diagnostic imaging procedures
- Certain medications
- Certain medical equipment like wheelchairs
If a patient’s service or medication requires prior authorization, the physician will send a form called a Treatment Authorization Request (TAR) to the health plan (CenCal Health). The TAR will then be reviewed by CenCal’s staff. The physician will be notified when the request has been approved or denied.
Santa Barbara Health Authority: www.cencalhealth.org