Commercial Billing
Through commercial billing support, counties can bill a client's other health coverage correctly the first time, without staff having to track payer-specific rules by hand.
Why this matters
Commercial payers use their own claim formats, coordination-of-benefits rules and documentation requirements, distinct from Medi-Cal; incorrect sequencing or formatting is a common source of denials and delayed reimbursement. Handling this correctly protects revenue the county is entitled to and keeps the county's billing compliant with coordination-of-benefits requirements.
What this is
Once a commercial or Medicare claim is processed, the resulting remittance is reconciled against what was billed. For Medicare, CalMHIN retrieves the 835 electronic remittance directly from the fiscal intermediary and posts it into the EHR; for other health coverage, the county reviews and processes the remittance directly, since commercial payers vary widely in how they issue and format remittance data. Denials are tracked and addressed the same way as any other claim: identifying the reason for denial, correcting the underlying issue, and re-submitting the claim until it reaches a resolution.
Who benefits
- County billing staff responsible for identifying and billing a client's non-Medi-Cal coverage get standardized claim generation for commercial and Medicare payers instead of manually tracking each payer's format.
- Finance staff reconciling commercial and Medicare remittances against the county's accounts receivable get Medicare remittance retrieved and posted automatically, narrowing the manual reconciliation work to other health coverage specifically.
Capabilities
What commercial billing support does
Other health coverage identification
Flags clients with commercial insurance or other coverage so those claims are billed in the correct order, ahead of Medi-Cal as payer of last resort.
Payer-specific claim generation
Produces CMS 1500 forms for other health coverage and 837 claims for Medicare, formatted to each payer's specific submission requirements.
Medicare remittance processing
Retrieves 835 electronic remittance data directly from the Medicare fiscal intermediary and posts it into the EHR.
Denial tracking and resubmission
Identifies the reason for a denied commercial or Medicare claim, corrects the issue, and resubmits until the claim is resolved.
Coordination with Medi-Cal billing
Sequences commercial and Medicare billing ahead of Medi-Cal claims for the same service, supporting correct coordination-of-benefits order and reducing duplicate or conflicting claims.