Orthopedics Billing in California

Yes. Medicaid runs as Medi-Cal, delivered largely through commercial managed care plans. So most California Medicaid claims are adjudicated by an insurer with its own filing window, its own authorization rules, and its own appeal path — not by the state. Nationally about 78% of Medicaid beneficiaries sit in comprehensive managed care, and five companies hold roughly half of that enrollment.

Noridian Healthcare Solutions (JE). That contractor adjudicates Medicare claims for California providers, publishes the local coverage determinations that bind you, and hears the first level of appeal. An argument that works with them works across every state they cover.

The specialty causes first: services inside a global period billed separately; missing or unsupported modifier on staged procedures; comp claims billed at commercial rates. On top of those, California Medicaid runs through commercial plans, so filing windows and authorization rules vary by plan rather than by program.

California is a tort state for auto injuries, so standard coordination of benefits applies rather than an auto carrier taking first position. The injury still has to be identified at registration, because liability coverage may be primary for the related care.

California prohibits fee splitting generally while authorizing percentage-based billing arrangements subject to conditions. Our pricing in California is set accordingly, and it is confirmed in writing before any work begins. That describes what we charge; your own position is a question for your counsel rather than for us.

Yes. All coding is performed by certified coders credentialed through the AAPC or AHIMA, working from the documentation you provide. Global surgical periods and modifier use, where a post-operative visit billed separately is a denial by design.