Frequently Asked Questions & Common Denials

What is the status of my claim?

Our Claims Service Representatives are always available to assist our Providers with the status of a claim, however please allow 45 days for the processing of all claims. If a claim has not appeared on an EOP within this time, claim status may also be verified through our website, submitting a mail inquiry on the CenCal Health Claims Inquiry Verification Form, e-mailing the Claims Department or by telephoning a CenCal Health Claims Service Representative at (805) 562-1083.

Does this specific procedure code require a TAR?

This can be verified by either referring to the State Medi-Cal Manual TAR and Non-Benefit List, contacting your Claims Service Representative at (805) 562-1083, or click the following link to look up CenCal Health’s HCPCS/CPT Procedure Code – Prior Authorization Requirement Search Tool.

My claim is denied due to NCCI edits. What is my recourse?

If your claim is denied with explain code MT, MW, MY or MZ, check both the procedure to procedure (PTP) edits in the NCCI Table and also the CPT coding rules and guidelines before re-billing.

The NCCI Tables may be accessed at the link below:

PTP Coding Edits – Centers for Medicare & Medicaid Services

Why is the paid amount on my claim $0.00?

If the service is a capitated or encounter service, or if the primary insurance payment exceeds CenCal Health’s allowable, the “paid amount” will be $0. In addition, there are some services that are not Medi-Cal or CenCal Health benefits and therefore not payable that may appear on the EOP as “0” paid amount.

Can we scan the primary EOP with our claim on the website?

Not currently. For claims that are not electronically crossing over to CenCal Health, please submit a paper claim with a copy of the Explanation of Payment from the primary payer. Paper claims should be submitted to:

CenCal Health
P.O. Box 948
Goleta, CA 93116-0948

Common Denials
For a list of our most common denials and tips on how to make corrections to those denials see attached link Most Common Denials. For questions about denials not listed on this attachment, please contact your Claims Service Representative for further assistance.