« BACK TO HUB
FIELD MANUAL // CONLAN PROTOCOL

DHCS 4521 GUIDE

"Medi-Cal Reimbursement (Conlan) Filing Instructions."

REIMBURSEMENT PROTOCOL

The DHCS 4521 (Conlan Claim) is the legal mechanism for requesting a refund when you paid out-of-pocket for services Medi-Cal should have covered. Claims are processed by the DHCS Beneficiary Service Center (BSC).

CONTACT & ELIGIBILITY
CONTACT DATA
SUPPORT

Beneficiary Service Center

BSC VOICE: (916) 403-2007 TDD/TTY: (916) 635-6491

Call for status updates or to request a physical form packet.

ELIGIBILITY
CRITERIA

Can I File This Claim?

  • [✓] You paid during your 3-month retroactive period.
  • [✓] You paid while waiting for a decision (Evaluation Period).
  • [✓] Post-Approval: You were charged an incorrect Share of Cost or co-payment.
SUBMISSION PROTOCOL
STATE PROTOCOL

Forensic Submission Strategy

"Prevent administrative 'loss' and establish a verifiable timeline."

1. WET INK RULE
Use blue or black ink only. Submit the original form with your original signature — Photocopies, scans, or digital signatures will be rejected by DHCS.
2. 100% CERTIFIED
USPS Certified Mail with Return Receipt — This gives you a tracking number and a physical signature confirming delivery. This is your primary weapon if DHCS misses their 120-day review window.
3. THE SHADOW ARCHIVE
NEVER send your only copy. Make a full photocopy or clear digital scan of every page of your signed packet, every receipt, and the envelope before you seal it.
RESOURCES
OFFICIAL

Form Repository

DOWNLOAD DHCS 4521 (CLAIM FORM) DOWNLOAD STD 204 (PAYEE RECORD) OFFICIAL CONLAN PORTAL

If the direct PDF links fail, use the Official Conlan Portal to access the digital version of the packet.

MANDATORY DATA
REQUISITES

Mandatory Documentation

REQUIRED FORMS:

  • [ ] DHCS 4521: The primary claim form.
  • [ ] STD 204: The separate Payee Data Record form.
  • [ ] BIC CARD: A clear copy of your Medi-Cal card.
  • [ ] ITEMIZED STATEMENT: Must show service dates and CPT codes.

PROOF OF PAYMENT (ONE OF):

  • [ ] Cancelled check (Front & Back)
  • [ ] Provider receipt showing "Paid"
  • [ ] Bank/Card statement showing the charge
  • [ ] Money Order copy
TIMELINE & ERRORS
TIMELINE

Submission Deadlines

DEADLINE
Claims must be received within 1 year of the date of service, OR within 90 days of receiving your BIC card—whichever is later.

ESTIMATED PROCESSING: Review takes up to 120 days. If the provider refuses to refund you within 30 days of approval, the State will involuntarily recoup the funds.

ERRORS

Common Rejection Triggers

  • Failing to check the "California Residency" box on the Payee form.
  • Submitting a bill without proof of actual payment.
  • Missing the Itemized Billing Statement (CPT codes).
  • No signature on the Beneficiary Agreement section.
  • Filing after the 1-year/90-day deadline.
SUBMISSION CHANNELS
SUBMISSION

Mailing Portals

Medical / Mental / IHSS
Beneficiary Service Center P.O. Box 138008 Sacramento, CA 95813-8008
Pharmacy (Medi-Cal Rx)
Medi-Cal Rx Claims Dept. P.O. Box 610 Rancho Cordova, CA 95741-0610

RX HELPLINE: 1-800-977-2273

DENTAL CLAIMS
Use a separate address. Call the BSC at (916) 403-2007 to verify the current dental mailing portal before sending documents.

© 2026 CALAUDIT | This hub is provided for informational purposes based on publicly available California statutes and regulations. It does not constitute legal advice. For legal counsel, consult a licensed California attorney. | PROPRIETARY WORK PRODUCT NOTICE: All original content, analysis, and commentary on this site represents the proprietary work product of the Operator. Unauthorized reproduction for legal, administrative, or commercial purposes is strictly prohibited without the express written permission of Nicolas Hernandez.

Authenticated via Debian 13 Forensic Rig