Medical CA Claims Inquiry Form (CIF) filling tips
Provider Name/Address : Enter provider name and address in BOX 3.
Claim Type : Enter an “X” to indicate the claim type in Box 5.
Note : Only one box may be checked.
Patient Name or Medical Record No. : Enter up to the first 10 letters of the patient’s last name or the first 10 characters of the patient’s Medical record number in Box 7.
NDC/UPN or Priocedure Code : If applicable, enter the appropriate procedure code, modifier, drug or supply code in Box 14.
Remarks : In the REmarks area be sure to answer the 3 questions :
1. What is wrong with claim?
2. What corrections did you make?
3. What do you want to the DHCS Fiscal Intermediary (FI) to do?
Signature and Date: The Provider or Authorized Representative signature and date is required on the CIF.
- No more than four claim inquiries per CIF form. Denied, underpaid and overpaid claim inquiries may be combined on one CIF. These types of inquiries each follow unique completion instructions and requirements for attaching documentation.
- CIFs for Share of Cost (SOC) reimbursement, inpatient claims, pharmacy compound claims, Medicare/Medi-Cal crossover claims and tracers should be submitted separately.
- Using CIFs as tracers does not keep you timely.
