Covered California

When submitting a claim for a covered service, please submit a written request with the following information:

• Date of service
• Provider/office name
• Diagnosis code
• CPT/HCPCS/REV code
• Provider NPI
• Amount billed
• Any applicable medical records
  
  

For your convenience, claim forms can be found here:

• CMS-1500
• UB-04