Medi-Cal provider claim appeal to the fiscal intermediary

For provider billing teams researching a claim-payment dispute and the Appeal Form 90-1 process.

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.

Check the action or inaction being challenged

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.

The manual says not to appeal a claim still in suspense. Identify the actual disputed claim action and retain the supporting dated correspondence. A TAR authorization denial or modification follows a separate appeal process.

Preserve submission and follow-up evidence

Supporting documents should be legible. The manual discusses the claim, Remittance Advice Details and applicable dated fiscal intermediary correspondence. A Claims Inquiry Form alone, without its accompanying acknowledgment, does not prove timely follow-up. Supplemental Claims Payment Information facsimiles are not accepted as timeliness documentation.

An appeal should concern one recipient. The provider or an authorized representative signs the form; unsigned appeals are returned. Common-reason Box 14 can replace Box 13 when applicable. The manual has different wording about whether Box 10 is required for a non-adjudicated claim, so confirm that situation against the current instructions.

Where to send the appeal

Attn: Appeals Unit; California MMIS Fiscal Intermediary; P.O. Box 15300; Sacramento, CA 95851-1300

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.

The manual separately describes acknowledgment within 15 days of receipt, a decision within 45 days of receipt, and an additional 30-day professional-review referral when needed. Those are fiscal intermediary response stages and do not extend the provider filing window.

Official Medi-Cal manual — 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

A denied or modified TAR? Check the separate non-vision TAR appeal · Provider claim appeal directory record · Other provider appeal routes