CurrentHealth NetPolicy N/A

Medi‑Cal Targeted Provider Rate Increases (TRI)

Establishes minimum fee schedule and reimbursement requirements for Medi‑Cal managed care plans (MCPs) and eligible Network Providers for services covered by the TRI Fee Schedule and certain Legacy Fee Schedule family planning services, effective for dates of service on or after January 1, 2024.

Policy Summary

PayerHealth Net

PolicyMedi‑Cal Targeted Provider Rate Increases (TRI)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionMCPs must comply with the TRI minimum fee schedule for qualifying services and attest to compliance, providing documentation and methodologies to DHCS upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jan 1, 2024MCP compliance effective

Dec 31, 2024Full compliance deadline

≥87.5%TRI benchmark

Jan 1, 2025SDR verification begins

TRI Coverage and Payment Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

TRI coverage and payment criteria

Covered when ALL of the following inclusion rules and program requirements are met; exclusions and timing requirements also apply.

Operational notes: MCPs must ensure capitation accounting and capitation rates developed by DHCS reflect these increases where specified; nothing in this APL obligates MCPs to increase total reimbursement across all services beyond what is necessary to ensure eligible Network Providers receive at least TRI rates for qualifying services.

TRI Fee Schedule Codes and Rate Benchmark

TRI Fee Schedule procedure codesmixed

Procedure codes identified on Supplement 40 to Attachment 4.19-B (TRI Fee Schedule) and applicable HCPCS/CPT codes for Encounter reporting

TRI rate benchmark

TRI rate benchmarkNo less than 87.5% of the lowest California-specific Medicare locality rate (or equivalent benchmark where Medicare rate absent)

Inclusive adjustmentsBenchmark is inclusive of eliminating AB 97 provider payment reductions and incorporating applicable Proposition 56 physician supplemental payments into the TRI Fee Schedule

Equivalent benchmark when Medicare rate absentDHCS calculated an equivalent rate benchmark and increase for services without a Medicare-established rate

Required Attestations, Reporting, and Payment Procedures

Documentation Required

Attest to compliance and retain documentation

MCPs must attest that they have complied with the minimum fee schedule requirements and retain supporting documentation and methodologies; DHCS may request these materials and MCPs must provide them upon request.

MCPs must ensure eligible Network Providers receive no less than the applicable minimum fee schedule rates for qualifying services.
For capitated payments, MCPs must ensure reimbursement provides payment equal to, or projected to be equal to, the TRI Fee Schedule rate.
MCPs must attest to compliance and retain supporting analyses and methodologies for DHCS review.

Denial Risk

Timely payment standards and enforcement risks

MCPs must make payments in accordance with timely payment standards for Clean Claims and accepted Encounters and achieve full compliance (including retroactive adjustments where due) by December 31, 2024; failure to comply may result in interest penalties, corrective action, and other remedies.

Payments must follow timely payment standards for Clean Claims in the MCP Contract or accepted Encounters received within one year of the date of service.
MCPs that fail to meet compliance timelines may be subject to interest penalties, corrective action, and other remedies under state law and the MCP Contract.
MCPs must provide clear P&Ps to Network Providers on claims/Encounter submission and what constitutes a Clean Claim; timing requirements may be waived only by written agreement.

Documentation Required

Report qualifying services with specified HCPCS/CPT codes and respond to SDRs

MCPs must report qualifying services in Encounter Data using the specified HCPCS/CPT codes and follow TRI and DHCS reporting requirements; DHCS may request supplemental data (SDR) to verify compliance no sooner than January 1, 2025 for 2024 dates of service.

Report qualifying services using the specified HCPCS and CPT codes appropriate to the services and reported to DHCS in Encounter Data per APL 14-019.
Follow reporting requirements posted on the TRI and DHCS Directed Payments Program websites and respond to Supplemental Data Requests (SDRs) when requested.
DHCS may leverage SDR to collect data and verify full compliance for calendar year 2024 dates of service beginning no sooner than January 1, 2025.

Key Definitions and Fee Schedule References

TRI Fee Schedule (Supplement 40)

TRI Fee Schedule sourceTRI Fee Schedule rates established in Supplement 40 to Attachment 4.19-B of the California Medicaid State Plan

Applicable procedure categoriesProcedure codes include Mental Health Services, Primary/General Care services billed on CMS-1500, and Obstetric and NonSpecialty Mental Health Services

Provider types coveredPhysicians, Nurse Practitioners, Physician Assistants, Podiatrists, Certified Nurse Midwives, Licensed Midwives, Doula Providers, Psychologists, LPCC, LCSW, LMFT

Adjustments and exceptionsRates subject to specified adjustments (e.g., CCS eligibility, 20% outpatient facility reduction); TRI rates do not apply where Legacy Fee Schedule yields greater net reimbursement or to Assistant Surgeon services

Clean Claims and timely payment

Clean Claim definition referenceTimely payment standards for Clean Claims as defined in 42 CFR 447.45(b) and the MCP Contract apply to payments under this APL

Timely payment windowPayments for Clean Claims or accepted Encounters received within one year of date of service must follow MCP Contract timely payment standards

Provider P&PsMCPs must provide clear P&Ps to Network Providers describing what constitutes a Clean Claim or acceptable Encounter; nonadherence can affect payment timing