The California Medicaid fee schedule, published by the Department of Health Care Services (DHCS), lists the maximum Fee-for-Service (FFS) reimbursement for every covered medical, surgical, and diagnostic procedure code. You can search it directly at the DHCS provider rates portal, mcweb.apps.prd.cammis.medi-cal.ca.gov/rates.1Medi-Cal Providers. Medi-Cal Rates The rate shown next to a code is the ceiling the state will pay under FFS. It is not always the amount that lands in your account, because several adjustments and edits sit between the published rate and the final payment.
Looking Up a Rate
The portal offers two ways in. You can browse the full schedule through a dropdown that divides it into roughly 20 pages, or search directly by procedure code.1Medi-Cal Providers. Medi-Cal Rates Searching by code is faster if you already know what you’re billing.
The results table has several columns worth understanding before you rely on the number:
- Basic Rate is the standard FFS reimbursement for the procedure.
- Child Rate applies when the patient is under 21.
- ER Rate applies when the service is delivered in an emergency room.
- Unit Value and Conversion Indicator are used when a service is priced by a unit value multiplied by a conversion factor rather than a flat dollar amount. Anesthesia is the most common example.
- Prof % is the professional-component percentage for services that split into professional and technical components, such as radiology and pathology.
DHCS also publishes a separate Notes to Rates page that explains each column and documents caveats about how the published rates translate to actual payment.2Medi-Cal Providers. Notes to Rates From the main rates page you can also open adjusted rate tables for clinical laboratory, radiology, durable medical equipment, audiology, and physician-administered drugs.1Medi-Cal Providers. Medi-Cal Rates
Which Codes the Schedule Uses
Rates are tied to standardized procedure codes. Current Procedural Terminology (CPT) codes describe medical and surgical procedures. Healthcare Common Procedure Coding System (HCPCS) codes cover supplies, equipment, and services that CPT does not address. When you search the portal, you enter one of these.
ICD-10 diagnosis codes do not appear on the schedule, but they still decide whether you get paid. The diagnosis code establishes medical necessity for the procedure billed. If the ICD-10 code on the claim doesn’t support the CPT or HCPCS code, the claim gets denied regardless of what the rate table says.
NCCI Edits and Medically Unlikely Edits
Medi-Cal applies National Correct Coding Initiative (NCCI) edits to every FFS claim. These edits pair procedure codes that should not be billed together for the same patient on the same day. The Column One code is eligible for payment; the Column Two code is denied unless a clinically appropriate modifier is attached.3Medi-Cal Providers. National Correct Coding Initiative (NCCI)
The second type of edit is the Medically Unlikely Edit (MUE), which caps the number of units payable for a single code. Billing five units of a procedure limited to one triggers a denial for the excess.4CMS. Medicaid NCCI 2026 Coding Policy Manual Neither edit is visible in the rate lookup. Checking the NCCI files before submitting high-dollar claims prevents avoidable denials.
Adjustments That Change the Actual Payment
The published rate is a starting point. Several adjustments can push what you actually receive higher or lower, and most of them are not shown in the online table.
Hospital Outpatient Augmentation
Hospital outpatient departments receive an additional 43.44 percent on top of the base rate that was in effect on June 30, 2001. The augmentation grew out of a series of federal and state court judgments and has been at its current percentage since July 1, 2004.2Medi-Cal Providers. Notes to Rates It is calculated on the historical base rate rather than the current published rate, which is why the online lookup does not reflect it.
FQHCs and Rural Health Clinics
Federally Qualified Health Centers and Rural Health Clinics do not use the standard fee schedule. These facilities receive a per-visit rate based on their actual costs under a Prospective Payment System. If you work at an FQHC or RHC, the rates portal is reference material only; it will not tell you what your facility is paid.
Targeted Rate Increases
Starting January 1, 2024, DHCS implemented substantial rate increases for primary care, obstetric, and non-specialty mental health services under Assembly Bill 118. These Targeted Rate Increases set reimbursement at the greater of two benchmarks: 87.5 percent of the lowest maximum allowance Medicare establishes for the same service, or the prior Medi-Cal rate after eliminating the AB 97 provider payment reductions and folding in Proposition 56 supplemental payments.5California Legislative Information. California Code WIC 14105.201 DHCS described the result as the largest across-the-board Medi-Cal rate increase in decades for the targeted service categories.6DHCS – CA.gov. Medi-Cal Targeted Provider Rate Increases and Investments
The TRI amounts are now built into the published rates for affected codes. If you billed primary care or OB services before 2024 and see a jump in the current numbers, this is the reason.
What the Medical Fee Schedule Does Not Cover
Two large categories of Medi-Cal reimbursement sit outside the medical rates portal.
Dental services run through a separate DHCS FFS program with its own fee schedule and billing rules. In all but two California counties, dental providers bill the state directly rather than through a managed care plan. The dental fee schedule is published on the DHCS dental services page, not the main rates portal.
Outpatient pharmacy reimbursement runs through Medi-Cal Rx, the state’s pharmacy benefit program. Drug ingredient costs are based on the National Average Drug Acquisition Cost (NADAC), a benchmark CMS publishes weekly. When no NADAC price exists for a drug, Medi-Cal uses the Wholesale Acquisition Cost with no markup.7DHCS – CA.gov. Medi-Cal Rx Pharmacy Fee-For-Service Covered Outpatient Drugs FAQs Pharmacy providers should not use the medical fee schedule for drug reimbursement.
When Rates Change
Rate updates become effective on the 15th of each month, and the new data posts to the site on the 16th.1Medi-Cal Providers. Medi-Cal Rates If you check a rate on the 10th for a service scheduled on the 20th, the number may shift before your claim processes. DHCS issues provider bulletins and regulatory notices ahead of significant changes, including updates driven by new coding standards and legislative mandates such as the TRI adjustments.6DHCS – CA.gov. Medi-Cal Targeted Provider Rate Increases and Investments
Some changes apply retroactively, and claims already submitted can be reprocessed at the new rate. DHCS typically notifies affected providers through its bulletin system when that happens. Checking the portal around the 16th of each month is the simplest way to stay current.
When the Payment Does Not Match the Schedule
If a payment comes in lower than the published rate, the discrepancy usually traces to an adjustment the online table does not display. Compare the Explanation of Benefits line by line against the published rate and check whether an NCCI edit pair or an MUE cap affected the claim. For hospital outpatient services, apply the augmentation to the historical base rate rather than the current published rate. Many apparent underpayments turn out to be correct once those adjustments are accounted for.
For managed care claims, the fee schedule is a reference point rather than the payment rule; plans negotiate their own rates. Disputes on those claims start with the plan’s provider dispute resolution process, detailed in each plan’s provider manual. If the plan’s response is unsatisfactory and the plan is licensed under Knox-Keene, providers can file a complaint with the Department of Managed Health Care.8Medi-Cal Providers. Provider Dispute Resolutions with Managed Care Plans