Cardiology billing in California
Cardiology medical billing services in California
Cardialogy Billing handles the claims, authorizations and follow-up for California cardiology groups, from Medi-Cal plans and capitated IPAs to Medicare Part B and commercial HMOs.
How California works
What shapes a California cardiology claim
Cardiology practices in California operate within a payer environment that requires attention to state programs, Medicare rules, authorizations, provider enrollment, and specialty coding.
Medi-Cal delivery systems
Two-plan, COHS, geographic managed care and regional counties each route claims differently, so we confirm the county model first.
Delegated risk groups
Many HMO members are assigned to a medical group or IPA that carries the risk, so the claim may belong with the group instead of the plan.
Medicare Part B
California sits in Noridian's Jurisdiction E, shared with Hawaii and Nevada, and we file and appeal through the Noridian portal.
ORP enrollment
Physicians who order or refer for Medi-Cal patients need their own Medi-Cal enrollment under an individual NPI. Medicare enrollment alone does not satisfy it.
Why California claims behave differently
A California cardiology claim has to find the right payer first
California's payer environment can vary significantly between Medi-Cal managed-care arrangements, fee-for-service, Medicare, commercial plans and out-of-area Blue plans.
Our workflows are designed around eligibility, authorization, coding, provider enrollment, claim routing, denial management and A/R follow-up.
- County model for Medi-Cal plans
- IPA and medical group assignment
- Medi-Cal share of cost
- Referral and authorization records
- Noridian Part B rules
- Medicare Advantage plan policies
- Medi-Medi secondary claims
- Modifiers on same-day diagnostics
Payer workflows
Where California cardiology claims actually go
Each payer asks for something different at the front end, and something different again when a claim comes back unpaid.
MC-Medi-Cal managed care
We identify the health plan and the contracted group, then follow that plan's own authorization list and claim address.
FFS-Medi-Cal fee-for-service
Treatment authorization requests, eligibility checks and the six-month billing limit all apply, so we track these claims from the month of service.
JE-Medicare Part B (Noridian)
We submit professional claims, work edits through the portal and file redeterminations inside the 120-day window.
MA-Medicare Advantage
Plan rules sit on top of Medicare rules. We check each plan's authorization requirements for imaging and procedures.
HMO -Commercial HMOs
Blue Shield of California, Anthem Blue Cross, Health Net and others often delegate claims to groups. We confirm who pays before the claim goes out.
OON-Out-of-network at in-network hospitals
State-regulated plans owe the greater of their average contracted rate or 125% of Medicare. We bill to that floor and use the dispute process on short pays.
Enrollment and payer rules
Keeping provider records clean across payers
Claims get denied for reasons that have nothing to do with the service. A mismatched NPI, a lapsed revalidation or a missing ORP record is enough.
ORP enrollment and denied claims
When a Medi-Cal claim lists an ordering or referring NPI that is not actively enrolled with DHCS, the claim can be denied. DHCS is rolling out enforcement in phases by service and provider type, so we check each physician's status now and file ORP-only applications through PAVE where needed.
Where revenue slips
Where California cardiology practices lose revenue
Group-level routing
A claim sent to the plan instead of the IPA sits unpaid for weeks.
Share of cost
Some Medi-Cal patients pay a monthly share of cost before coverage pays, and it has to be reported correctly.
Authorization gaps
Some advanced cardiac imaging and other procedures require prior approval, and each plan or benefit manager has their own list.
Same-day modifiers
There needs to be modifier logic to support an E/M with an ECG or echo the same day.
Split billing of tests
This is dependent on the place of service and who owns the equipment.
Medical necessity
Diagnosis codes have to match the payer’s coverage rules for an echo or stress testing, for example.
Filing limits
Medi-Cal requires claims be filed within 6 months of the month of service, and Medicare requires them be filed within 12 months of the date of service.
Aging balances
There is a follow-up date for short pays and unresolved claims, and a claim owner.
What we handle
Our cardiology billing services in California
We take a claim from the first eligibility check to the final payment posting, and we work the exceptions along the way.
Eligibility and plan checks
We confirm active coverage, Medi-Cal aid code and share of cost, managed care plan, IPA assignment and dual status before the patient is seen.
Cardiology coding
Coders review CPT and ICD-10-CM codes, modifiers, units and place of service against the procedure note.
Authorization handling
We find which plan, group or benefit manager approves the service, request it, and attach the number to the claim.
Charge entry
Every documented service becomes a charge, including add-on codes and same-day tests that often go unbilled.
Pre-submission claim edits
Claims run through payer and NCCI edits for demographics, codes, modifiers and authorization numbers before they go out.
Electronic submission
Claims go to Noridian, Medi-Cal, commercial plans or the capitated group under the correct payer ID.
Payment posting
We post ERAs and Medi-Cal RADs line by line, compare payments with contracted rates and flag short pays.
Denial management
Each denial gets a reason, a fix and the right route: corrected claim, Medi-Cal CIF, Medicare redetermination or plan appeal.
A/R follow-up
We chase unpaid claims by payer and cite California's 30-day payment deadline and interest rules when plans run late.
Enrollment and credentialing
We prepare and track Medi-Cal PAVE, Medicare and commercial applications, and keep revalidation dates on one calendar.
Procedures we bill
Cardiology procedures we code and bill
From an in-office ECG to a structural heart case, each service carries its own coding rules and payer edits.
1-Noninvasive testing:
- ECG
- Echocardiography
- Stress testing
- Holter monitoring
- Event monitors
2-Cardiac imaging:
- Nuclear cardiology
- Cardiac CT
- Cardiac MRI
- Radiopharmaceuticals
3-Rhythm management:
- Pacemakers
- ICDs
- Device checks
- Ablation
- Remote monitoring
4-Interventional care:
- Cardiac catheterization
- PCI with stenting
- TAVR
- Peripheral interventions
5-Clinical care:
- Office E/M visits
- Inpatient rounding
- Transitional care
- Cardiac rehab
6-Coding review:
- ICD-10-CM
- Modifier logic
- NCCI edits
- Medical necessity
- Technical and professional splits
Specialties
Cardiology specialties we bill for in California
Our process
How a California claim moves through our team
Each stage has a named owner, so a stalled claim always has an obvious place to look.
In-house or outsourced
Why California cardiology groups hand off billing
A California billing office tracks Medi-Cal plans, IPAs, Noridian and commercial HMOs at the same time. That workload is what practices usually hand off first.
Billing in-house
- Tracking plan and IPA changes by hand
- Training staff on cardiology coding
- Chasing authorizations by phone
- Keeping enrollment records current
- Working denials between other tasks
- Following up on aging balances
Working with Cardialogy Billing
- Cardiology-focused coders and billers
- Group and plan routing checked on each claim
- Coding reviewed against procedure notes
- Denials worked with a reason and a deadline
- Enrollment dates kept on a shared calendar
- Aging claims worked by payer and age
Statewide remote billing
Billing support for cardiology groups across California
We offer remote cardiology revenue cycle support for practices across California. This includes independent practices, multi-provider groups and specialty organizations.
We've designed our remote infrastructure to coordinate with the practice management and EHR workflows of various specialties and retain the requirements of California payers.
Why specialty matters
One cardiovascular encounter can involve multiple billable components, payer rules and documentation requirements
What makes cardiology billing hard to get right
Cardiology billing involves various components of diagnostic testing and professional and technical components, as well as evaluation and management services and various types of procedure-specific coding. There are also differing requirements among payers.
This requires knowledge of not only various codes, but also consideration of the documentation, including CPT and HCPCS codes, modifiers, units and place-of-service, as well as the complete reporting of ICD-10-CM diagnostic codes.
Our billing workflows are designed to help practices identify and resolve billing issues before claims are submitted and to track and resolve unresolved claims throughout the revenue cycle.
Questions we hear
Questions about cardiology billing in California
1. What does Cardialogy Billing do for a California cardiology practice?
We run the billing cycle from eligibility checks through payment posting and A/R. That includes cardiology coding, authorizations, electronic claims, Medi-Cal and Medicare follow-up, denials and monthly reporting.
2. How do Medi-Cal managed care plans change cardiology billing?
Counties use different models, such as two-plan, COHS and geographic managed care, and each has its own plans and contracted groups. We confirm the plan and group at scheduling so the claim goes to the right address.
3. What is the difference between Medi-Cal FFS and managed-care billing?
Yes. Fee-for-service claims go to the Medi-Cal fiscal intermediary, use treatment authorization requests where required, and must arrive within six months of the month of service. Managed care claims follow each plan's own rules.
4. What happens when a Medi-Cal claim is denied?
The Remittance Advice Details shows the reason. Depending on it, we rebill, send a Claims Inquiry Form within six months of the RAD date, or file an appeal within 90 days.
5. What is the ORP enrollment requirement for Medi-Cal?
Physicians who order, refer or prescribe for Medi-Cal patients must be enrolled in Medi-Cal under an individual (Type 1) NPI. Medicare enrollment does not meet it, and DHCS is phasing in enforcement. We check each provider and file ORP-only applications in PAVE when needed.
6. Who processes Medicare claims in California?
Noridian Healthcare Solutions processes California Medicare Part B claims, along with Hawaii, Nevada, and other Pacific territories. Redeterminations are due within 120 days of the initial determination.
7. How long do California health plans have to pay a complete claim?
HMOs and Medi-Cal managed care plans pay or dispute complete claims within 30 calendar days. Failure to do so results in 15% interest per year on the amount due.
8. Does prior authorization apply to cardiology services in California?
Yes and no. It depends on the service and payer. Currently, prior authorization is not required for most cardiac device procedures and some structural heart procedures; however, that can change based on the payer. We must check for ourselves for each service.
9. How do you handle patients who have both Medicare and Medi-Cal?
We always bill Medicare first and Medi-Cal second and then reconcile the two payments. Often, Medi-Cal second payment is zero.
10. Can you work denials and old A/R for the group?
Yes. We work A/R by payer first and handle denials. We research each and every one, including, if applicable, filing a timely appeal. Claims are prioritized based on the Medicare and Medi-Cal filing deadline, and the one closest to the deadline is processed first.
Cardiology billing in California
Bring your California cardiology billing to a specialist team
Send us an aging report and a set of recent denials, and we will show where claims are stalling, whether in routing, authorization, coding or enrollment.