Timely filing · California Medicaid
Medi-Cal timely filing limit
Short answer
The Medi-Cal timely filing limit is six months following the month in which the service was rendered, the six-month billing limit set by Welfare and Institutions Code Section 14115 and 22 CCR Section 51008. A claim that arrives later without an allowed exception still pays, but at a reduced rate: 75 percent of the payable amount in months 7 to 9 and 50 percent in months 10 to 12. After month 12 it pays nothing.
Section 14115 lists four exceptions that allow later billing, each reported on the claim with a delay reason code and backed by documentation. Medi-Cal managed care plans apply the same six-month rule through their own claims policies. Compare other payers in the timely filing limits table.
Last reviewed by the Remitwright billing team. Editorial policy
The windows
- Initial claim
- Six months following the month of service, with payment cut to 75 percent in months 7 to 9, 50 percent in months 10 to 12 and nothing after month 121
- Counted from
- The month in which the service was rendered, not the date of service: the claim has to be received within the six months that follow that month. 22 CCR Section 51008 measures receipt at the Medi-Cal fiscal intermediary; a managed care plan measures it at the plan.
- Appeal
- Set by each Medi-Cal managed care plan: 365 days from the plan's action for a provider dispute at San Francisco Health Plan, six months from the initial EOP at CenCal Health
- Verified
- , against the payer document in the sources
Your participation agreement can set a different window. Where the contract and the manual disagree, the contract applies.
Exceptions the payer allows
The patient did not say they were on Medi-Cal
When the patient failed to identify as a Medi-Cal beneficiary within four months after the month of service, Section 14115 excuses the late bill. Keep whatever shows when you first learned of the coverage, because the delay reason has to be documented.
A liable third party was billed first
If you billed a third party that was liable for the service, you have one year after the month of service to submit the bill to Medi-Cal.
A legal proceeding against a third party
When a legal proceeding has started in which you are trying to collect from a third party, the window is also one year after the month in which the service was rendered.
A delay outside your control
The Director of Health Care Services can accept a late bill when the delay was caused by circumstances beyond the provider's control; 22 CCR Section 51008.5 lets the Department authorize the claim after reviewing substantiating documentation. Employee negligence, unfamiliarity with Medi-Cal rules, illness or absence of billing staff, and postal or courier delays do not qualify.
Medicare or other health coverage paid first (San Francisco Health Plan)
San Francisco Health Plan's policy requires Medicare or the other coverage to be billed within one year of the month of service, and the Medi-Cal claim, with that carrier's EOB, remittance advice or denial letter, to reach the plan within 60 days of the other carrier's payment or denial.
What counts as proof of timely filing
- The delay reason code in box 37A of the UB-04 or box 24C of the CMS-1500, with remarks or attachments that justify the late submission
- The substantiating documentation for the delay reason, which the Department reviews before it authorizes a late claim under 22 CCR Section 51008.5
- For a claim held for Medicare or other health coverage, that carrier's EOB, remittance advice or denial letter
Notes for billers
- The reductions are applied automatically. San Francisco Health Plan's claims system cuts or denies a late claim that carries no allowed exception, and a provider billing in months 7 to 12 without one enters 11 in box 24C of the CMS-1500 or in boxes 18 to 24 of the UB-04.
- Plans apply the rule with their own counting. San Francisco Health Plan denies claims submitted more than one year from the month after the date of service or the primary payer's paid date, while CenCal Health's hospital section counts its full-payment window as 180 days from the date of service.
- Federal Medicaid rules set the outer limit: 42 CFR 447.45 requires every state Medicaid agency to require claims within 12 months of the date of service, and it treats the agency's date stamp as the date of receipt.
- A claim reduced or denied for late filing is reconsidered through the plan's provider dispute process. San Francisco Health Plan follows the Title 28, Section 1300.71 timeframes; CenCal Health takes a dispute within six months of the initial EOP and an appeal of that dispute within 90 days.
FAQ
Questions about Medi-Cal deadlines
What is the Medi-Cal timely filing limit?
Can I bill Medi-Cal after six months?
Where does the delay reason code go on a Medi-Cal claim?
Do Medi-Cal managed care plans use the same limit?
How long do I have to dispute a reduced or denied Medi-Cal plan claim?
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