Claims and Eligibility

Claims Process

Claims Process Determined by Each Health Network

CalOptima Direct and each contracted CalOptima 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 claim 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 Provider Manual .   

Contact Us
  • Providers and other health care professionals with questions regarding Medi-Cal, OneCare Connect, OneCare or PACE can call the Provider Relations department at 714-246-8600 or email: providerservices@caloptima.org

Electronic Data Interchange (EDI)
Provider Disputes
  • Dispute Process
    Review the payment dispute process for Medi-Cal and OneCare contracted providers

Prior Authorizations

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