Presumptive Eligibility: Best Practices
| Date: | May 14, 2025 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan Providers |
| Type: | Regulatory |
| Subject: | Presumptive Eligibility: Best Practices |
| Business: | Medi-Cal Managed Care |
Presumptive Eligibility (PE) determinations rely solely on the applicant’s self-attestation of facts with no other form of proof required. While Qualified Providers (QPs) may not question or request verification of attested information, the Department of Health Care Services (DHCS) has provided the below best practices that can minimize instances of duplicate records requiring remediation, reduce QP follow up, and limit billing impacts.
Paper PE Worksheet
The paper PE worksheet may be completed by applicants and referenced by QPs when completing the electronic PE application. The worksheet is optional, and questions may also be asked verbally.
When issuing the paper PE worksheet, provide applicants with the following instructions:
- Complete using their full legal name. They should not use nicknames (ex. Billy instead of William) or partial names (for example: Jones instead of Jones-Smith).
- Date of birth follows MM/DD/YYYY format.
- Social Security Number and Client Identification Number (CIN) or Benefits Identification Card (BIC) ID are optional but should be provided when known.
Questions regarding this topic may be emailed to: ChildrenPE@dhcs.ca.gov, DHCSHospitalPE@dhcs.ca.gov, or PE@dhcs.ca.gov.
Please visit the link below and select number 4 under Contents section for more information:
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org
