The CIF is used to resolve claim payments or denials as identified on the RAD. There are four main reasons to submit a CIF:
Trace a claim.
Request reconsideration of a denied claim.
Adjust an underpayment or overpayment of a claim.
Request Share of Cost (SOC) reimbursement.
CIFs need to be submitted within six months from the date on the RAD and mailed in black and white envelopes available from Medi-Cal. Providers should send CIFs to the following address:
HP Enterprise Services
P.O. Box 15300
Sacramento, CA 95851-1300
Medi-Cal will send a Claims Inquiry Acknowledgment to the provider within 15 days of receipt of the CIF.
Exceptions for submitting a CIF
Exception
Action
Incorrect Provider Number
Rebill with corrections if timeliness permits, otherwise appeal.
Inpatient claims (if claim lines need to be added or deleted)
Rebill with corrections if timeliness permits, otherwise appeal.
RAD Codes: 0002, 010, 0072, 0095, 0314, 0326
Appeal – A review by a person in the appeals unit is the only way of resolving denials if the claim has a unique circumstance needing human intervention.
CIF Attachments
The following attachments are required for all CIFs as they apply to the claim, except those used as tracers or those requesting Share of Cost (SOC) reimbursements:
TAR/SAR indicating authorization
“By Report” documentation
Completed Sterilization Consent Form (PM 330)
Explanation of Medicare Benefits (EOMB)/Medicare Remittance Notice (MRN)/Medicare National Standard Intermediary Remittance Advice (MNSIRA)
Explanation of Benefits (EOB) from Other Health Coverage (OHC)
Drugs and supplies itemization list, manufacturer’s invoice or description, including the name of the medication, dosages, strength and unit price
Supplier’s invoice, indicating wholesale price and the item billed
Manufacturer’s name, catalog (model) number and manufacturer’s catalog page, showing suggested retail price
Copy of Point of Service (POS) device printout or Internet eligibility response attached to the claim on an 8.5 x 11-inch sheet of white paper
Note: All supporting documentation must be legible.
Rollover the highlighted fields with your mouse to learn about CIF form completion.
Provider Name/Address
Provider Name/AddressEnter provider name and address in Box 3.
Provider Name/AddressEnter provider name and address in Box 3.
Provider NumberEnter the provider number or National Provider Identifier (NPI) in Box 4.
Claim TypeEnter an “X” to indicate the claim type in Box 5.
Note: Only one box may be checked
DeleteEnter an “X” in Box 6 to delete the entire line. When Box 6 is marked the information on the line will be “ignored” by the system and will continue to process the other claim lines. Enter the correct billing information on another line.
Patient’s Name or Medical Record No.Enter up to the first 10 letters of the patient’s last name or the first 10 characters of the patient’s Medical record number in Box 7.
Patient’s Medi-Cal I.D. No.Enter the recipient ID number that appears on the (RAD) showing adjudication of that claim in Box 8.
Claim Control No.Enter the 13-digit CCN assigned by the DHCS Fiscal Intermediary (FI) to the claim line in question in the first part of Box 9 and indicate claim line in the second part of Box 9.
Attachment/Underpayment/Overpayment Enter an “X” in Box 10 to indicate attachments for a denied claim. Note: all CIF’s should have attachments with the exception for Tracers.
Enter an “X” in Box 11 for Underpayment. Note: Do not mark Box 11 if the claim was denied.
Enter an “X” in Box 12 for an Overpayment. Note: Do not mark Box 12 if the claim was denied
Date of ServiceEnter the Date of Service (DOS) in the MMDDYY format in Box 13. If “block billing” enter the Thru date.
NDC/UPN or Procedure CodeIf applicable, enter the appropriate procedure code, modifier, drug or supply code in Box 14.
Amount BilledEnter the amount originally billed in Box 15.
RemarksIn the Remarks area be sure to answer the 3 questions:
1. What is wrong with the claim?
2. What corrections did you make?
3. What do you want the DHCS Fiscal Intermediary (FI) to do?
Signature and DateThe Provider or Authorized Representative signature and date is required on the CIF.
No more than four claim inquiries per CIF form. Denied, underpaid and overpaid claim inquiries may be combined on one CIF. These types of inquiries each follow unique completion instructions and requirements for attaching documentation.
CIFs for Share of Cost (SOC) reimbursement, inpatient claims, pharmacy compound claims, Medicare/Medi-Cal crossover claims and tracers should be submitted separately.
Using CIFs as tracers does not keep you timely.
Reminders
All Inquiries
Adjustments
Crossover, Inpatient and Pharmacy Compounds
Denial
SOC
Tracer
Always enter an “X” in the box to indicate the claim type.
X
Enter no more than four claim inquiries per form. Note: This does not apply to crossover and inpatient claims.
X
Fill out each line completely. Do not use ditto marks (“) nor draw an arrow to indicate repetitive information.
X
All information must be exactly the same as that on the RAD. For example, an incorrect ID number on the RAD should be copied exactly on the CIF.
X
Only one claim line per CIF.
X
Be sure the recipient ID number and Claim Control Number on the CIF exactly match the numbers on the RAD.
X
RAD not required.
X
X
Enter the recipient’s original ID (the number issued prior to being enrolled in a no-SOC program).
X
X
Do not use the Remarks area for additional inquiries.
X
State clearly and precisely what is being requested in the Remarks area.
X
Always indicate the denial or adjustment reason code in the Remarks area.
X
X
Secure documentation to the upper right-hand corner of the CIF.
X
Do not attach any documentation.
X
Only original CIFs are accepted. Photocopies will be returned.
CPT Codes, Descriptors, and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved to AMA.
The revenue codes and UB-04 codes are the IP of the American Hospital Association. All Rights Reserved to AMA.
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