Claims And Eligibility

Image - Design Element
Decorative Image


If you have questions or need assistance, call our Provider Relations Department at:


Monday through Friday from 8 a.m. to 4 p.m. Pacific Time

Claim Billing Update: Local Modifier ZS Discontinued – Effective August 1, 2015

CalOptima and the Department of Health Care Services (DHCS) have discontinued the use of local modifier ZS for dates of service on or after August 1, 2015.

Modifier ZS previously designated both the professional (26) and technical components (TC) of a split-billable procedure on a claim. When billing for both the professional and technical components, a modifier is not required nor allowed. This change continues CalOptima’s compliance with HIPAA requirements and is aligned with the Centers for Medicare & Medicaid Services (CMS) guidelines.

Providers who continue to submit claims for split-billable procedures using local modifier ZS for dates of service on or after August 1, 2015 will receive a claim denial.

Medicare Part-A Members Assigned PCP

The Department of Health Care Services (DHCS) recently required all Medi-Cal health plans to assign a primary care provider (PCP) to partial benefit dual eligible members receiving primary or specialty care through a Medi-Cal managed care plan. As a result, effective February 1, 2016, CalOptima will assign PCPs to nearly 400 Medicare Part-A dual members who currently receive their primary and specialty care through CalOptima.

What does this mean for existing Medicare Part-A
CalOptima members?

PCPs will be assigned to members 30 days prior to the effective date. Members will be notified of their option to change PCPs if desired. A 12-month utilization and prescribing history will be used to assist CalOptima in the initial PCP assignment process.

  • If there are multiple CalOptima PCPs, the assignment is based on the highest number of encounters for the member, followed by the recent date of service within a 12-month period.

  • If there is no recent PCP information, or the provider is not contracted as a PCP with CalOptima, the PCP assignment will be based on member geographic location and language.

  • If there are multiple matched PCPs within the member geographic location and language, the assignment will be based on rotation of available matched PCPs.

What does this mean for new Medicare Part-A
CalOptima members?

For newly eligible Medicare Part-A dual members, CalOptima will make use of the existing PCP assignment process utilized for CalOptima Community Network members based on:

  • Geographic location of the participating PCP’s office in relation to the member’s residence

  • Match of the member’s age and language requirements to the participating PCP availability

  • If more than one PCP meets the assignment criteria, a PCP is assigned based on a rotation to allow balanced distribution

For more information contact the Provider Relations department at 714-246-8600.

CalOptima Link

How to Reach Us

If you are a provider or other health care professional and have a question regarding the Medi-Cal, OneCare (HMO SNP), OneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan), or PACE programs, please call our Provider Relations Department at 1-714-246-8600.

Text Size