Get the free Medi-Cal Rx Provider Claim Inquiry Form (CIF)

State of California Health and Human Services AgencyDepartment of Health Care ServicesProvider Claim Inquiry Form (CIF) Instructions: The Provider Claim Inquiry Form (CIF) is used to resolve claim

How to fill out medi-cal rx provider claim

How to fill out medi-cal rx provider claim

1. To fill out the Medi-Cal Rx provider claim form, follow these steps:
2. Start by entering the patient's name and identification number on the top section of the form.
3. Provide the date of service and the corresponding service code for each medication or service being claimed.
4. Specify the quantity and dosage of each medication or service.
5. Enter the total charge for each medication or service in the appropriate column.
6. Include any applicable modifiers or special codes, if necessary.
7. Calculate the subtotal for each line item by multiplying the quantity by the charge.
8. Add up all the subtotals to obtain the total claim amount.
9. Provide any additional required information or documentation, such as prior authorization numbers or supporting medical records.
10. Sign and date the form, certifying the accuracy of the information provided.
11. Keep a copy of the completed form for your records and submit the original claim to the appropriate Medi-Cal Rx claims processing address.

Who needs medi-cal rx provider claim?

1. Medi-Cal Rx provider claim is required by healthcare providers who offer services covered by the Medi-Cal program.
2. This form is specifically used by providers to request reimbursement from Medi-Cal for medications or services provided to eligible Medi-Cal beneficiaries.

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What is medi-cal rx provider claim?

Medi-Cal Rx provider claim is a form used to request reimbursement for pharmacy services provided to Medi-Cal beneficiaries.

Who is required to file medi-cal rx provider claim?

Pharmacies and healthcare providers who dispense medications to Medi-Cal beneficiaries are required to file Medi-Cal Rx provider claims.

How to fill out medi-cal rx provider claim?

Medi-Cal Rx provider claims can be filled out electronically or using paper forms provided by the state Medicaid program. Providers must include specific patient and service information on the claim form.

What is the purpose of medi-cal rx provider claim?

The purpose of Medi-Cal Rx provider claim is to ensure that pharmacies and healthcare providers are reimbursed for prescription medications provided to Medi-Cal beneficiaries.

What information must be reported on medi-cal rx provider claim?

Information such as patient name, Medi-Cal ID number, date of service, prescription details, and provider information must be reported on the Medi-Cal Rx provider claim.