Claims Inquiry Form - when and where to submit

Medical CA Claims Inquiry Form (CIF)

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.

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