Medi-Cal provider claim appeal to the fiscal intermediary
Medi-Cal provider claim-payment dispute using Appeal Form 90-1 and the fiscal intermediary claim appeal process. Do not appeal a claim still in suspense. Not a TAR denial/modification appeal, managed-care member appeal, Medicare appeal or a court filing.
Filing window: Written appeal within 90 days of the action or inaction precipitating the complaint. The specific action/inaction must be identified from the actual claim correspondence; no universal notice-receipt trigger or personal due date is inferred.. No personalized deadline is calculated.
Payer: California Medi-Cal fee-for-service administrative process; verify actual notice and program. State scope: California Medi-Cal; verify actual provider/program/TAR or claim scope, not residence alone.
Postal address: Attn: Appeals Unit; California MMIS Fiscal Intermediary; P.O. Box 15300; Sacramento, CA 95851-1300. Use the actual notice and the process-specific official submission instructions.
Submit the original signed Appeal Form 90-1 and supporting attachments. FI acknowledgment/decision periods are separate from this provider filing window. The source has differing Box10 requirement wording on pages 6–7; no unconditional form validation is asserted. Claim/reason and receipt evidence must be checked separately.
Official source — Appeal Form Completion — physical pages1,3–4,7–8; mixed per-page revisions2022–2025 · checked 2026-10-29
Document/page revision date is not a demonstrated universal effective date; checked current official downloadable source, not historical reconstruction