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Submit a claim with the adjusted SOC amount in the Patient s Share of Cost field and attach this MC 1054. And attach this MC 1054 form. Once the CIF is approved and payment is received you are required to reimburse the beneficiary any share of cost paid for the services or eliminate/adjust the outstanding share of cost obligated for the services billed. MC 1054 06/07. Submit a Claims Inquiry Form CIF with this MC 1054 attached. Note Do not submit.

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To file a claim, you must submit a Medi-Cal Claim Form for Beneficiary Reimbursement. The claim form must be filled out in blue or black ink; • The claim form must have an original signature (no copies will be accepted); The Claim Form must include: • A photo copy of your Medi-Cal Beneficiary Identification Card (BIC).

The Claims Inquiry Form (CIF) is used to request an adjustment for either an underpaid or overpaid claim, request a Share of Cost (SOC) reimbursement or request reconsideration of a denied claim. The CIF can also be used as a tracer.

​ Helpful Hints & Resources Lost or stolen Medi-Cal Beneficiary Identification Cards (BIC): If you have just lost your BIC card, contact your local county worker for a replacement. ... The California Medical Board: (800) 430-4263. Medi-Cal Managed Care Ombudsman: (888) 452-8609. Medi-Cal Billing: (800) 541-5555.

Haven't received your member medical ID card yet? Or do you need to go to a doctor's appointment before you get it? There's no need to worry – you can always print a temporary ID card. It'll work just as well as the real thing.

For Medi-Cal, you must report it within 10 days. To report changes, call Covered California at (800) 300-1506 or sign in to your online account. You can also find a Licensed Insurance Agent, Certified Enrollment Counselor or county eligibility worker who can provide free assistance in your area.

You will soon get a Medi-Cal identification card called a Benefits Identification Card, or BIC. It is white with blue writing, and it has a picture of the seal of the State of California. It will also have your name on it. This card will be sent to you in a separate letter.

Click the print icon in the upper left hand corner of the PDF to print. You can print the ID card using your own printer and then use it at your next doctor's appointment.

Online: Apply online at .CoveredCA.com . Applications are securely transferred directly to your local county social services office, since Medi-Cal is provided at the county level.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232