By Ricky Hudson,2014-07-06 12:38
9 views 0

     prov guide

    Provider Guidelines 1

This section contains information to guide medical practitioners who wish to participate as Medi-Cal



    How to Enroll Practitioners rendering services to Medi-Cal recipients must be

     approved as Medi-Cal providers by the Department of Health Care

    Services (DHCS) in order to bill Medi-Cal for services rendered. To

    enroll, practitioners may contact DHCS Provider Enrollment Division:

     Department of Health Care Services

     Provider Enrollment Division

    P.O. Box 997412

    Sacramento, CA 95899-7412

     Telephone: (916) 323-1945

    DHCS Provider DHCS Provider Enrollment Division assists providers as follows: Enrollment Division

    ; Accepts and verifies all applications for enrollment

    ; Enrolls each provider using his or her 10-digit National Provider

    Identifier (NPI)

    ; Maintains a Provider Master File of provider names and


    ; Updates the enrollment status of providers for Medi-Cal records

1 Provider Guidelines September 2008

prov guide



    Introduction Requirements for providers approved for participation in the Medi-Cal

    program include:

Federal Laws and Regulations, 1. Compliance with the Social Security Act (United States Code,

    W&I Code and CCR Title 42, Chapter 7); the Code of Federal Regulations, Title 42;

     the California Welfare and Institutions Code (W&I Code)

     Chapter 7 (commencing with Section 14000) and, in some

    cases, Chapter 8; and the regulations contained in the

    California Code of Regulations (CCR), Title 22, Division 3

    (commencing with Section 50000), as periodically amended.

Record Keeping 2. Agreement to keep necessary records. Refer to the Provider

    Regulations section of this manual for specifics.

    Non-Discrimination 3. Non-discrimination against any recipient on the basis of race,

    color, national or ethnic origin, sex, age, or physical or mental


1 Provider Guidelines September 2008

     prov guide



    Address Change A change of pay-to address, mailing address, telephone number or

    Forms for Providers status must be submitted on the Medi-Cal Supplemental Changes

    form (DHCS 6209). Providers may obtain this form by contacting the Telephone Service Center (TSC) at 1-800-541-5555.

    Providers who have changed their pay-to address, mailing address, status or any other related information must notify the DHCS Provider Enrollment Division (PED). See “How to Obtain Enrollment and

    Supplemental Changes Forms” on a following page.

    Note: Changing a business address requires a complete application

    package. However, beginning July 1, 2008, individual physician

    practices, relocating their business location within the same

    county, may submit the Medi-Cal Change of Location Form for

    Individual Physician Practices Relocating Within the Same County

    (DHCS 9096) in place of submitting a complete application

    package. See “Enrollment Applications” on a following page.

    See Inpatient, Outpatient and Long Term Care provider information below. Inpatient, Outpatient and Long Term Care Providers

    Inpatient, Outpatient and Long Term Care providers (institutional providers) must contact the local Licensing and Certification Division of DHCS to change their business addresses or other information. To change a pay-to address, institutional providers must send a signed, notarized Pay-To Address Change Notification (DHCS 6129) to the

    DHCS PED, at the address on a following page, to prevent unauthorized pay-to address changes. Institutional providers include:

    ; Alternative Birthing Centers

    ; Adult Day Health Care (ADHC)

    ; AIDS Waiver

    ; Chronic Dialysis Clinics

    ; Community Clinics

    ; Exempt from Licensure Clinics

    ; Federally Qualified Health Centers (FQHC)

    ; Heroin Detoxification

    ; Home Health Agencies (HHA)

    ; Hospices

    ; Hospitals

    ; L.A. Waiver

    ; Level A Nursing Facilities

    ; Level B Nursing Facilities

    ; Rehabilitation Clinics

    ; Rural Health Clinics (RHC)

    ; Subacute

    ; Surgical Clinics (non-physician owned)

    1 Provider Guidelines September 2008

    prov guide


    Clinical Laboratory Providers

    Clinical laboratory providers must contact Laboratory Field Services

    at (510) 620-3800 to report a change in business address or other

    information. Clinical laboratory providers reporting a change in their

    Medi-Cal pay-to address or mailing address must use the Medi-Cal

    Supplemental Changes (DHCS 6209) form.

    Pharmacy Providers

    Pharmacy providers reporting changes should consider whether the

    change requires the Board of Pharmacy to issue a new Retail

    Pharmacy Permit. The Board of Pharmacy can be contacted at

    (916) 445-5014. If the change requires the Board of Pharmacy to

    issue a new Retail Pharmacy Permit, the Pharmacy provider is

    required to complete a new Medi-Cal Pharmacy Provider Application

    (DHCS 6205), a Medi-Cal Provider Agreement (DHCS 6208) and a

    Medi-Cal Disclosure Statement (DHCS 6207). If a new Pharmacy

    Retail Permit is not required as a result of the change being reported,

    then the change may be reported on the Medi-Cal Supplemental

    Changes (DHCS 6209) form.

    Where to Submit Pay-to address, mailing address, telephone number or status changes

    Address/Status Changes submitted on the Medi-Cal Supplemental Changes (DHCS 6209) form

    should be mailed to:

    Department of Health Care Services

    Provider Enrollment Division

    MS 4704

    P.O. Box 997412

    Sacramento, CA 95899-7412

    1 Provider Guidelines January 2009

     prov guide



    Overview In response to fraud and abuse in the Medi-Cal program, DHCS

    has adopted regulations governing provider enrollment. These

    regulations require the submission of consistent information that can

    be used to verify the identity and qualifications of individuals and

    groups requesting Medi-Cal provider status, and establish

    requirements for the enrollment of most non-institutional providers

    who submit fee-for-service claims. Institutional and other providers

    licensed or certified by the Licensing and Certification Division and

    providers otherwise approved for participation in the Medi-Cal

    program by other State agencies, such as the Department of Aging or

    the Department of Alcohol and Drug Programs, are not impacted by

    these regulations.

    Medi-Cal Supplemental DHCS must have current provider information. This is the

    Changes Form responsibility of the provider who must report any changes in

    information to DHCS within 35 days of the change. Deactivation of

    the provider billing number will occur if DHCS is unable to contact a

    provider at the last known pay-to, business or mailing address. DHCS

    has developed the Medi-Cal Supplemental Changes (DHCS 6209)

    form that must be used to report the following changes,

    additions or actions:

    ; Pay-to address, mailing address or phone number changes.

    Providers may NOT use the Medi-Cal Supplemental Changes

    (DHCS 6209) form to change a business address.

    ; Medicare/other NPI

    ; Change in business activities (for Durable Medical Equipment

    providers and providers of incontinence medical supplies)

    ; Provider Identification Number (PIN) confirmation of current

    number or issuance of a new number

    ; Medical transportation driver/pilot or vehicle/aircraft information,

    hours of operation or geographic areas served

    ; Doing-Business-As (DBA) or Fictitious Business Name

    ; Clinical Laboratory Improvement Amendment (CLIA) certificate

    number and effective date

    ; Deactivation of provider number(s) or group provider number(s)

    ; New pharmacist-in-charge for Pharmacy providers

    ; Changes of less than 50 percent of the ownership or control

    interest in the provider or provider group (also requires a

    Medi-Cal Disclosure Statement, DHCS 6207)

    ; New Seller’s Permit, license or certificate.

    1 Provider Guidelines September 2008

prov guide


Institutional Providers Changes to the provider’s business address or other information must

    be reported to the local Licensing and Certification Division of DHCS.

    Also see “Address Change Forms for Providers” on a previous page.

Enrollment Applications See below for information about enrollment applications.

    Change of Ownership or Control Providers must submit a new enrollment application, including a Interest of 50 Percent or More Medi-Cal Disclosure Statement (DHCS 6207) and a Medi-Cal Provider

    Agreement (DHCS 6208), if the provider undergoes a change of 50

    percent or more in ownership or control interest.

    Reporting Additional Providers or provider groups that want to submit claims for services Business Locations rendered at an additional business address are required to submit

    an enrollment application, applicable to the provider type, a Medi-Cal

    Disclosure Statement (DHCS 6207) and a Medi-Cal Provider

    Agreement (DHCS 6208) are required for each additional business


    Application Deficiencies Applicants are allowed 60 days to resubmit their corrected application

    when DHCS returns it deficient.

    If an applicant fails to resubmit the application to DHCS within 60

    days, or fails to remediate the deficiencies identified by DHCS, the

    application shall be denied. Applicants denied for failure to resubmit

    in a timely manner or for failure to remediate may reapply at any time.

1 Provider Guidelines December 2008

     prov guide


    Adding Rendering Rendering providers in good standing may join existing provider Providers to a Provider Group groups. The group may begin billing for the services delivered by an

    already enrolled rendering provider, without the need for submitting a

    new application. Rendering providers need to apply to Medi-Cal only

    once. To initially enroll as a rendering provider, the applicant needs

    to submit a complete application package, consisting of the new

    Medi-Cal Rendering Provider Application/Disclosure Statement/

    Agreement for Physician/Allied Providers (DHCS 6216) and all

    required attachments.

How to Obtain Enrollment and Enrollment forms and the Medi-Cal Supplemental Changes

    Supplemental Changes Forms (DHCS 6209) form are available by contacting the Telephone Service

    Center (TSC) at 1-800-541-5555. Completion instructions are

    included with the forms. Enrollment forms also are available on the

    Medi-Cal Web site at, by clicking the “Provider

    Enrollment” link. Questions may be directed to DHCS by calling

    (916) 323-1945, Monday through Friday, 8 a.m. to 5 p.m.

Pharmacy, DME and Clinical Also see “Address Change Forms for Providers” on a previous page

    Laboratory Providers for more information.


Eligibility Verification When a provider elects to verify a recipient’s Medi-Cal eligibility, the

    Obligates Provider to provider has agreed to accept an individual as a Medi-Cal patient once the Render Services information obtained verifies that the individual is eligible to receive

    Medi-Cal benefits. The provider is then bound by the rules and

    regulations governing the Medi-Cal program once a Medi-Cal patient

    has been accepted into the provider’s care.

     After receiving verification that a recipient is Medi-Cal eligible, a

    provider cannot deny services because:

    ; The recipient has other health insurance coverage in addition

    to Medi-Cal. Providers must not bill the recipient for private

    insurance cost-sharing amounts such as deductibles,

    coinsurance or copayments because such payments are

    covered by Medi-Cal up to the Medi-Cal maximum allowances.

    Providers are reminded that Medi-Cal is the payer of last resort.

    Medicare and Other Health Coverage must be billed prior to

    submitting claims to Medi-Cal.

1 Provider Guidelines September 2008

prov guide


    ; The recipient has both Medicare and Medi-Cal. Providers

    must not treat the recipient as if the recipient is eligible only for

    Medicare and then collect Medicare deductibles and

    coinsurance from the recipient, according to a 1983 United

    States District Court decision, Samuel v. California Department

    of Health Services.

    ; The service requires the provider to obtain authorization.

    Circumstances That A provider may decline to treat a recipient, even after eligibility Exempt Providers From verification has been requested, under the following circumstances: Rendering Services

    ; The recipient has refused to pay or obligate to pay the required

    Share of Cost (SOC).

    ; The recipient has only limited Medi-Cal benefits and the

    requested services are not covered by Medi-Cal. (For example,

    the recipient is eligible for pregnancy-related services only and

    the requested service is immunization.)

    ; The recipient is required to receive the requested services

    from a designated health plan. This includes cases in which

    the recipient is enrolled in a Medi-Cal managed care plan or

    has private insurance through a Health Maintenance

    Organization or exclusive provider network, and the provider is

    not a member provider of that health plan.

    ; The provider cannot render the particular service(s) that the

    recipient requires.

    ; The recipient is not eligible for Medi-Cal for the month in which

    the service is requested.

    ; The recipient is unable to present corroborating identification

    with the Benefits Identification Card (BIC) to verify that he or

    she is the individual to whom the BIC was issued.

    Payments From When Medi-Cal eligibility has been verified, providers must submit Recipients a claim for reimbursement according to the rules and regulations of

    the Medi-Cal program. Providers must not attempt to obtain payment

    from recipients for the cost of Medi-Cal covered health care services.

    Payment received by providers from DHCS in accordance with

    Medi-Cal fee structures constitutes payment in full.

    Provider Billing after For information about billing Medi-Cal after reimbursing the Beneficiary Reimbursement beneficiary, refer to the Provider Billing after Beneficiary

    Reimbursement (Conlan v. Shewry) section of the Part 2 manual.

    1 Provider Guidelines February 2008

     prov guide


    Non-SOC Payments Unless it is used to satisfy an SOC requirement, any payment Must be Refunded received from a Medi-Cal recipient must be refunded upon receipt of

    a Medi-Cal Remittance Advice Details (RAD) reflecting payment for

    that service.


    Rendering Provider When services are rendered by an individual professional, but the Billing by Group billing is done by a group or clinic, each rendering provider member or Clinic of a group or clinic must have their own National Provider Identifier

    (NPI) number registered separately from the group’s NPI. Refer to

     the claim completion section of the appropriate Part 2 manual for



Introduction Section 14040.5 of the Welfare and Institutions Code (W&I Code)

    requires DHCS to enroll billing intermediaries. This law was

    implemented to help identify billing intermediaries who fraudulently

    bill the Medi-Cal program for providers and who willfully misrepresent

    themselves. This legislation provides guidelines for DHCS to enroll

    hard copy Medi-Cal billing intermediaries. Failure to comply with this

    legislation could result in suspension from billing the Medi-Cal


     DHCS requires hardcopy Medi-Cal billing intermediaries to:

    ; Register with DHCS

    ; Obtain an identifier code

    ; Enter the identifier code in the Remarks field (Box 80)/

    Reserved for Local Use field (Box 19) of the claim submitted

    for payment

     DHCS requires all Medi-Cal providers to:

    ; Inform DHCS when using hard copy-only intermediaries

     Billing intermediaries include any entity including a partnership,

    corporation, sole proprietorship or person billing Medi-Cal on behalf of

    a provider pursuant to a contractual relationship with a provider.

    People directly employed by the provider who prepare and submit

    claims for the provider are not subject to this legislation.

1 Provider Guidelines December 2008

prov guide


    Instructions to Providers All providers who use hard copy billing intermediaries must notify Who Use Hard Copy DHCS by completing the Provider: Medi-Cal Hardcopy Biller

    Billing Intermediaries Notification Form. Providers are to return this form to DHCS Provider

    Enrollment Division at the address noted on a previous page.

    Because the billing companies may not receive notification of these

    requirements, providers should also notify the billing companies by

    sending them the Biller: Medi-Cal Hardcopy Biller Application

    Agreement, along with a copy of this manual page. (Samples of

    these forms are included at the end of this section.)

Billing Intermediary All billing intermediaries are responsible for submitting the Biller:

    Registration Numbers Medi-Cal Hardcopy Biller Application Agreement to DHCS Provider

    Enrollment Division. Once DHCS receives the application form, the

    billing services will be notified of their registration number. The billing

    services will then be required to enter this number in the Remarks

    field (Box 80)/Reserved for Local Use field (Box 19) on all claims they

    submit to Medi-Cal.

    Where to Submit Both the provider notification and the biller application forms (or any Notification and future changes) should be submitted to DHCS Provider Enrollment Application Forms Division using the address and telephone number listed on a previous


    Instructions for CMC Billing companies that submit Computer Media Claims (CMC) in Submitters Who Also addition to hard copy claims do not need to apply. Instead, they Bill Hard Copy should enter their CMC submitter number in the Remarks field

    (Box 80)/Reserved for Local Use field (Box 19) when billing hard copy


1 Provider Guidelines February 2008

Report this document

For any questions or suggestions please email