Understanding Backbilling in Medi-Cal: What You Can (and Can’t) Do

Understanding Backbilling in Medi-Cal: What You Can (and Can’t) Do

Backbilling—also called retroactive billing—is a lifeline for providers who saw Medi-Cal patients before being fully credentialed. But the rules are tight, and mistakes can lead to claim denials. Here’s what you need to know.

✅ What Is Backbilling?Backbilling means submitting claims for services rendered before your Medi-Cal application was approved, as long as certain conditions are met.

✅ When Backbilling Is Allowed:

1. You saw a Medi-Cal patient while fully licensed.

2. You submitted your Medi-Cal application within 30 days of the first visit.

3. The patient was eligible for Medi-Cal at the time of service.

4. Your application is eventually approved.

❌ When Backbilling Is Not Allowed:

• If your first application was denied, even if you later get approved.

• If you apply more than 30 days after the first service.

• If you weren’t licensed at the time of service.

⏰ Timeframes to Remember:

• 30-day rule: Apply within 30 days of first service.

• 12-month rule: Once approved, you have 12 months from the date of service to submit claims.

🔧 How to Submit a Retroactive Claim:

• Wait for your approval and effective date.

• Bill via CMS-1500 or standard method.

• Include a cover letter noting the retroactive nature.

🚫 Don't Try to Backbill for:

• Medication refills alone.

• Visits that didn’t happen.

Pro Tip: Even if you saw someone before you were approved, you can bill a 90792 psychiatric evaluation once per year if you do a full intake session.