DHCS APL 22-012 – Governor’s Executive Order N-01-19, Transitioning Medi-Cal Pharmacy Benefits from Managed Care to Medi-Cal Rx
Provider claim appeals are a method to resolve claim payment problems (e.g., resubmission, non-payment, underpayment, overpayment, etc.). Post-transition on January 1, 2022, the DHCS Medi-Cal Rx Provider Claim Appeals policy aligns with and builds upon existing Medi-Cal FFS processes and protocols for the Medi-Cal program. Providers will complete the Medi-Cal Rx Provider Appeal form and submit the completed form to:
Medi-Cal Rx CSC, Provider Claims Appeals Unit
P.O. Box 610
Rancho Cordova, CA, 95741-0610
Medi-Cal Rx will send a letter of explanation in response to each appeal. Providers who are dissatisfied with the decision may submit subsequent appeals, as stated in the Medi-Cal Rx Provider Manual. Medi-Cal providers also retain their right to seek judicial review of an appeal determination, as authorized under state law.
Providers can appeal Medi-Cal Rx PA denials, delays and modifications. Providers will submit appeals of PA adjudication results, clearly identified as appeals, to:
Medi-Cal Rx CSC, Provider Claims Appeals Unit
P.O. Box 610
Rancho Cordova, CA, 95741-0610
