Procedure Reimbursement Rates
Program: Medi-Cal Healthy Families Healthy Kids IHSS AIM
County: Santa Cruz Monterey Merced
(Please choose only one program and one county per each request form.)
To: Central California Alliance for Health – Provider Services Date:
FAX: (831) 430-5857
From: Provider Billing #:
Phone #: Rates Requested:
Fax #: Contracted Non-Contracted
Internal Use Only: Provider Type: Specialty: Date Recd:
Facility or Professional Procedure Code Modifier(s) Place of Service Contracted Rate Non-Contracted Rate
Rates given are for current pricing. (As of date listed on request form.)
If you would like pricing for another time period please indicate the date of service you are requesting pricing for in the note section.
All pricing requests will be responded to within 3 working days.
CREATING HEALTHCARE SOLUTIONS
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