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Medi-Medi Plans, Dual Eligible Special Needs Plans aligned with a Medi-Cal managed care plan from the same parent organization, opened for enrollment in 29 additional counties in 2026, bringing the total to 41 counties where a dual-eligible patient can choose one. For a practice with meaningful dual-eligible volume, this is a live, expanding structural change to how Medicare and Medicaid benefits get coordinated, not a settled, static system.
AB 72, in effect since 2017, bars non-contracting individual health professionals from balance-billing patients for non-emergency services delivered at an in-network facility, unless the provider gives 72-hour advance written notice and gets written consent. Disputes over whether the payer paid the correct rate go through the Department of Managed Health Care's own Independent Dispute Resolution Process, a state-run system that operates separately from, and in some circumstances preempts, the federal No Surprises Act.
Health plans regulated under the Knox-Keene Health Care Service Plan Act must acknowledge receipt of a claim within 15 working days and pay or deny a complete electronic claim within 30 working days. A billing team used to a state without this kind of enforceable timeline often doesn't track these deadlines closely enough to flag a plan that's running past them.
Kaiser Permanente operates as both payer and provider across much of the state, Sutter Health and CommonSpirit Health (Dignity Health) dominate Northern and Central California, and Providence and the University of California health system carry significant weight elsewhere. Which system a patient's practice refers into changes the contract terms, and for Kaiser members, it can change whether the visit gets billed as a claim at all rather than handled entirely inside Kaiser's own network.
Claims submission built around your specific California county's Medi-Cal managed care structure, not a single statewide assumption.
Learn MoreFull-cycle RCM that tracks AB 72 dispute eligibility and Knox-Keene payment deadlines as distinct, trackable compliance clocks.
Learn MoreProvider enrollment across Anthem, Blue Shield of California, Health Net, and the major hospital-affiliated networks your referrals come from.
Learn MoreA free audit that checks specifically for missed AB 72 notice requirements and Knox-Keene 30-day payment deadline violations.
Learn MoreFront-desk and administrative support that scales with a growing California practice without new office overhead.
Learn MoreBenchmarks your claims data against current California payer-specific denial patterns, including county-level Medi-Cal variation.
Learn MoreLocal visibility support built for a market where patients are choosing between practices across dense, competitive metro regions.
Learn MoreAggressive denial management and appeals targeting aged A/R and stalled Knox-Keene payments across California payers.
Learn More| California Regulation | The Generic Billing Trap | The MD Revenue Group Approach |
|---|---|---|
| AB 72 Surprise Billing Law | Billing out-of-network claims without the required 72-hour notice, instantly losing all balance-billing rights. | We build out-of-network claims around the 72-hour notice and route disputes through the DMHC Independent Dispute Resolution Process. |
| Knox-Keene 30-Day Deadline | Using a standard "follow up at 60 days" workflow, missing the statutory deadline for electronic claim payment. | We track the 30-working-day payment clock specifically and cite the Knox-Keene Act directly to escalate slow-paying plans. |
| Medi-Cal County Variation | Treating Medi-Cal as one statewide system, resulting in routing denials when billing across county lines. | We match claims specifically to the managed care and Medi-Medi plan rosters active in your exact county. |
| Kaiser Closed Network | Attempting to bill Kaiser referrals like a standard third-party commercial payer, creating endless denial loops. | We separate Kaiser workflows entirely to track which visits generate claims versus which stay inside Kaiser's closed network. |
We pull a sample of recent claims and check for AB 72, Knox-Keene, and county-level Medi-Cal gaps.
We configure payer-specific submission paths for your county, specialties, and referral patterns.
We handle claims, denials, and appeals with California-specific compliance built in from day one.
Monthly reporting shows clean claim rates, A/R days, and payer-specific denial trends.
Our local Medi-Cal payer specialists identified a systematic AB 72 notice error and leveraged Knox-Keene deadlines to force payment on claims previously written off as uncollectible.
See What We Can Recover For YouCalAIM continues its multi-year overhaul of Medi-Cal, shifting the focus to value-based care delivery. Flagship benefits like Enhanced Care Management (ECM) and Community Supports (CS) are now active across most California counties. However, billing for these services requires strict adherence to county-specific rules and modifiers.
The Division of Workers’ Compensation (DWC) updates the Official Medical Fee Schedule (OMFS) regularly to align with Medicare. A major physician fee schedule update modified Relative Value Units (RVUs) and adjusted conversion factors for California inflation.
The Provider Application and Validation for Enrollment (PAVE) system remains backlogged. A single missing attachment or incorrect taxonomy code on a PAVE application can delay your Medi-Cal billing privileges for months. Providers are experiencing massive workflow delays simply trying to get registered, which directly impacts initial cash flow.
California falls under MAC Jurisdiction E, run by Noridian. The Local Coverage Determinations (LCD) issued by Noridian dictate exactly which diagnoses justify specific treatments for Medicare patients in this state. These clinical coverage rules change frequently and require precise ICD-10 cross-walk mapping.
We check specifically for missed AB 72 notice requirements and Knox-Keene 30-day payment deadline violations.
