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2013 Federal Poverty Level Income Guidelines (PDF) | Effective April 1, 2013
Family PACT Retroactive Eligibility Certification and Claim Processes
Retroactive eligibility is available for newly-enrolled Family PACT clients who were eligible for Family PACT up to three months before enrolling in the program.
Once a new client has been certified as eligible for Family PACT, Family PACT providers shall ask the client if she or he received a Family PACT-covered service in the last three months. This includes office visits and health education, birth control methods, formulary, laboratory and radiology. If the client responds affirmatively, the Family PACT provider will give the client retroactive eligibility information and a Retroactive Eligibility Certification (REC) form (CDPH 4001) for completion. The Family PACT provider accepts responsibility for appropriate on-site determination of retroactive eligibility according to program guidelines and administrative practices. Providers must include their NPI on the form for verification purposes.
The Family PACT provider gives the client the completed CDPH 4001 form for client claim processing and keeps a copy of the completed CDPH 4001 for their records.
Sample CEC Forms**The Sample CEC forms have moved to the Provider Resource page under Forms.**
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