Please follow the Enrollment Instructions below to become an electronic submitter for California Medicaid, known as MediCal.
 

Required Documents

The following documents are required enrollment documents that must be completed, signed and returned to the Medi-Cal office prior to initiation of electronic claims submission or inquiry.

1. Medi-Cal Telecommunications Provider and Biller Application/Agreement

If the link above does not work properly, please go here:
http://files.medi-cal.ca.gov/pubsdoco/forms.asp
(You will find this under the Billing, Computer Media Claims (CMC) Section, form number DHCS 6153)

We can now process 276/277 requests (claim status). If this is a transaction you would like to utilize please make sure to enroll with the payer.

Medi-Cal Telecommunications Provider and Biller Application/Agreement

Section 1: Provider Information

• Enter your Business/Practice or Provider Name

• Enter your Medi-Cal number

• You may skip the DBA line

• Enter the last 4 Digits of Tax ID Number

• Enter your Business Address, Phone & Fax Numbers, and Business Email Address

• Enter the Name and Contact information for the main contact person for your office

• New applicants may leave the Submitter ID line blank

Section 1: Biller Information
If you are using a Billing Service, please enter the Billing Services information here

Section 1.1: CMC Submission Type

• Select "Internet"

Section 1.1: Real time Submission Type

• Select "Internet"

Section 1.1: Claim Type

• In the ANSI X 12 837 Version line write in: 5010A1

• Choose the type of claims you will be submitting listed under the ANSI X...line

• Leave the "ANSIX 12 276/277 Version" and "ANSIX 12 278 Version" areas blank

Section 9.0: Signature

• Please have the Provider complete the Provider Signature Section

• If you are using a Billing Service please have the Billing Service complete the Billing Service section as well.

Submitting your Forms

It is recommended that you keep a copy of all the forms you will be submitting for your records. Mail the enrollment forms reflecting original signatures to:

ACS
CMC Unit
P.O. Box 15508
Sacramento, CA 95852-1508

It is very important that you complete and return the entire enrollment packet as described above. Incomplete packets will not be processed and will be returned to the submitter.

Waiting for a Response

Once the complete provider enrollment packet has been received, the documents will be processed. Processing will take approximately two weeks from the date of receipt. (Remember that mailing time can take as much as five days.)

After processing, a confirmation will be faxed to you as notification to begin filing claims electronically. If neither confirmation nor a returned packet is received after two weeks, contact the Medi-Cal EDI Technology Support Center at 916-636-1980 option 1 for English, 1 for Provider, 1 for Technical Support then listen for "CMC".

Once you receive confirmation from Medi-Cal they will give you a number to call to set your password. Once you have your Submitter ID, Login ID, and Password you may start the Testing Process.

Testing

Once you have received your Submitter ID and Password from Medi-Cal, please call the ClaimShuttle Support Team and set an appointment for a Mailbox setup and Test Transmission to Medi-Cal.

Please have 25 test claims ready for testing. Test files should consist of a variety of claims that represent the type of claims you will be submitting once production status is achieved. Test claims will not be processed for payment but will be validated against production files; therefore, they must contain valid patient procedure, diagnosis, and provider information.