California • Medicare Advantage, High-Deductible Health Plan (HDHP), EPO
This prefix includes Medicare Advantage coverage. MA plans follow CMS guidelines for timely filing (365 days from date of service), which may differ from the commercial plan's deadline. The payer ID for Medicare Advantage claims may differ from the standard commercial payer ID. Verify before submitting.
Under this HDHP prefix, the member's plan has a higher deductible than traditional coverage. This affects patient cost-sharing but does not change how claims are submitted or processed. Use the same payer ID, claims address, and filing procedures listed above. Verify the member's remaining deductible before estimating patient responsibility.
EPO coverage under this prefix means the member must use network providers but does not need referrals for specialist visits. This plan type is becoming more common as it offers lower premiums than PPO plans while providing more flexibility than HMOs. Verify network status before providing services.
Nonprofit health plan providing 6 million Californians with affordable healthcare coverage including HMO, PPO, dental, and vision plans for individuals, families, and employers.