A person in a brown shirt working on a laptop at a modern workspace, with a smartphone and a pen holder nearby.

Claims and Eligibility

CalOptima Health providers can use these tools to verify eligibility and benefits, check on the status of a claim, or request treatment authorizations.

Provider Portal

The CalOptima Health Provider Portal is a secure online website where you have 24-hour access to verify member eligibility, check claims history, check authorization status, submit referrals and more.

Getting Started Guides

Loading component...

A woman in a white blouse sits at a desk talking on the phone while working on a laptop in a modern office setting.

How to Verify Eligibility

Find resources to verify CalOptima Health member eligibility.

Automated Eligibility Verification System (AEVS)

Call 800-456-2387 (Medi-Cal only).

Point of service (POS) help desk

Call 800-541-5555 (Medi-Cal only).

CalOptima Health Eligibility and Benefits Reference Guide

A person's hand interacts with a laptop, displaying digital folder icons and data transfer arrows on a blue background.

Electronic Data Interchange (EDI)

Learn more about the transmission of claims data, benefit eligibility and claim status inquiry.

Electronic Data Interchange and Interoperability Resources

A healthcare professional in scrubs works intently on a laptop at a sunlit desk, with a stethoscope around their neck.

Provider Claim Registration Forms

Forms for noncontracted providers to register with CalOptima Health for claims submission or to update their information.

If you are a contracted provider or inquiring about becoming contracted, please email the Provider Relations department at providerservicesinbox@caloptima.org or visit How to Contract with CalOptima Health.

Provider Registration for Claims Submission Form

Provider Demographic Change Form

W9 Form

Notification of Federal Tax ID Change Form

Returned or resubmitted claims for processing will be considered a newly submitted claim.

Loading component...

Prior Authorizations

Find the current list of procedure codes that require prior authorization and Authorization Request Forms (ARFs).

Prior Authorizations

A nurse in blue scrubs is consulting with a seated patient while another staff member observes in a bright, modern medical office.

Post-Stabilization Services

How to admit members into contracted and noncontracted hospitals for inpatient post-stabilization services.

Post-Stabilization Services

A healthcare professional in a blue scrubs shirt works on a laptop at a desk, with a smartphone and plants in the background.

Provider Complaint Process

How to file disputes for claims payments for claims where CalOptima Health has financial responsibility.

Provider Complaint Process

Loading component...

Claims Process Determined by Each Health Network

CalOptima Health Direct and each contracted CalOptima Health health network has its own process for receiving, processing and paying claims. Providers must verify member eligibility and identify the member’s assigned health network prior to submitting a claim for the member. To ensure accurate and timely payment, providers must submit the claim according to the assigned health network’s claims processing guidelines.

For a listing of health network claims processing guidelines, including information for submitting paper and electronic claims, see Section H of the CalOptima Health Provider Manual.