Long Term Care (LTC)

LTC25-1 claim form

AIDS Waiver ProgramCommunity-Based Adult Services (formerly ADHC)Expanded Access to Primary Care (EAPC)Home Health Agencies/Home and Community-Based ServicesLocal Educational Agency (LEA)Multipurpose Senior Services Program

OUTPATIENT

HOME & COMMUNITYUB-04 claim form

AIDS Waiver ProgramChronic Dialysis Clinics Clinics and Hospitals Federally Qualified Health Centers (FQHC) Heroin DetoxificationHospice Care ProgramIndian Health Services (IHS)Inpatient ServicesRehabilitation ClinicsRural Health Clinics (RHC)

INPATIENT/OUTPATIENT

INSTITUTIONALUB-04 claim form

Vision Care

VISION CARE

Pharmacy (PH) SuppliesPharmacy 30-1 and 30-4 claim forms

PHARMACY

MEDICAL SERVICES

General Medicine (GM)Obstetrics (OB)

AcupunctureAudiology and Hearing AidsChiropracticDurable Medical Equipment and Medical Supplies (DME)Medical TransportationOrthotics and ProstheticsPsychological ServicesTherapies

ALLIED HEALTH

PROFESSIONALCMS-1500 claim form

**

PM160 ‡ CMS-1500 UB-04 30-1/30-4MEDI-CAL SPECIALTY PROGRAMSComprehensive Perinatal Services Program (CPSP)**Every Woman Counts (EWC)** Presumptive Eligibility for Pregnant Women (PE4PW)**OTHER SPECIALTY PROGRAMSCalifornia Children’s Services (CCS)Child Health and Disability Prevention (CHDP)Family Planning, Access, Care and Treatment (Family PACT)**Genetically Handicapped Persons Program (GHPP)

SPECIALTY PROGRAMS

** Health Access Program (HAP) ‡ End Date 11/1/18

Child Health Disability Program (CHDP) PM 160 Claim FormCalifornia Children's Services (CCS)Genetically Handicapped Persons Program (GHPP )

SPECIALITY PROGRAMSXXXXX Claim Form

Navigating Medi-Cal and Specialty Health Programs

Use this chart to help you navigate the Medi-Cal LearningPortal (https://learn.medi-cal.ca.gov), understand theMedi-Cal or specialty provider manual you reference forpolicy and billing instructions (for example, the Allied Healthfor Therapies manual) and identify the claim form youuse when billing for services rendered.