Current through Register 2024 Notice Reg. No. 12, March 22, 2024
(a) As a condition for enrollment, continued
enrollment, or enrollment at a new, additional, or change in location, an
applicant or provider shall meet the Standards of Participation specified in
Chapter 7 (commencing with Section
14000) and Chapter 8 (commencing
with Section
14200) of Part 3 of Division 9 of
the Welfare and Institutions Code, and Division 3, Title 22, California Code of
Regulations, and either:
(1) Be certified by
the Department to participate in the Medi-Cal program and be a:
(A) Clinic licensed by the Department
pursuant to Chapter 1 (commencing with Section
1200) of Division 2 of the Health
and Safety Code, including a clinic, operated by a licensed clinic, that is
exempt from licensure pursuant to Section
1206(h)
of the Health and Safety Code; or
(B) Health facility licensed by the
Department pursuant to Chapter 2 (commencing with Section
1250) of Division 2 of the Health
and Safety Code; or
(C) Adult day
health care provider licensed pursuant to Chapter 3.3 (commencing with Section
1570) of Division 2 of the Health
and Safety Code; or
(D) Home health
agency licensed pursuant to Chapter 8 (commencing with Section
1725) of Division 2 of the Health
and Safety Code; or
(E) Hospice
licensed pursuant to Chapter 8.5 (commencing with Section
1745) of Division 2 of the Health
and Safety Code; or
(2)
Submit to the Department a completed application package on forms specified in
subsection (c), below, Section
51000.35, and Section
51000.45. These forms shall:
(A) Contain complete and accurate
information.
(B) Be signed under
penalty of perjury by an individual who is the sole proprietor, partner,
corporate officer, or by an official representative of a governmental entity or
non-profit organization, who has the authority to legally bind the applicant
seeking enrollment, or the provider seeking continued enrollment, or the
provider seeking enrollment at a new, additional, or change in location, as a
Medi-Cal provider.
(C) Contain an
original signature in ink.
(D) Be
notarized by a Notary Public, unless the applicant or provider is licensed
pursuant to Division 2 (commencing with Section
500) of the Business and
Professions Code, the Osteopathic Initiative Act, the Chiropractic Initiative
Act, or is a lawfully organized group consisting of persons who are so
licensed. The Certificate of Acknowledgement signed by the Notary Public shall
be in the form specified in Section
1189 of the
Civil Code.
(b)
For applicants or providers enrolled pursuant to subdivision (a)(2), the
following events require the submission of a new complete application package:
(1) When there is a change of ownership as
defined in Section
51000.6;
(2) When 50 percent or more of the assets
owned by the corporation at the location for which a provider number has been
issued are sold or transferred;
(3)
When a new Taxpayer Identification (ID) Number is issued by the IRS;
(4) When the Board of Pharmacy requires a new
site permit, pursuant to Chapter 9 (commencing with Section
4000) Division 2 of the Business
and Professions Code;
(5) When the
deletion of one or more rendering providers for a provider group, results in
one remaining rendering provider.
(6) When there is a cumulative change, of 50
percent or more in the person(s) with an ownership or control interest since
the information provided in the last complete application package that was
approved for enrollment;
(7) When a
transferee applicant meets the requirements for successor liability with joint
and several liability set forth in Section
51000.32.
(c) The applicant or provider, when required
pursuant to subsection (a)(2) through (b), shall complete, as applicable:
(1) The "Medi-Cal Provider Group
Application," DHS 6203 (Rev. 07/05), incorporated by reference herein;
or
(2) The "Medi-Cal Provider
Application," DHS 6204 (Rev. 07/05), incorporated by reference herein;
or
(3) One of the applications from
the following list, each incorporated by reference herein, which is applicable
to their provider type:
(A) "Medi-Cal Durable
Medical Equipment Provider Application," DHS 6201 (Rev. 07/05).
(B) "Medi-Cal Orthotics and Prosthetics
Provider Application," DHS 6202 (Rev. 07/05).
(C) "Medi-Cal Pharmacy Provider Application,"
DHS 6205 (Rev. 07/05).
(D)
"Medi-Cal Medical Transportation Provider Application," DHS 6206 (Rev.
07/05).
(E) "Medi-Cal Physician
Application/Agreement," DHS 6210 (Rev. 07/05).
(F) "Medi-Cal Rendering Provider
Application/Disclosure Statement/Agreement for Physician/Allied/Dental
Providers," DHCS 6216 (Rev. 2/15).
(G) "Medi-Cal Nonphysician Medical
Practitioner and Licensed Midwife Application," DHS 6248 (Rev.
07/05).
(H) "Drug Medi-Cal
Substance Use Disorder Clinic Application," DHCS 6001 (Rev.12/14).
(I) "Drug Medi-Cal Substance Use Disorder
Medical Director/Licensed Substance Use Disorder Treatment
Professional/Substance Use Disorder Nonphysician Medical Practitioner
Application/Agreement/Disclosure Statement," DHCS 6010 (Rev.
12/14).
(4) One of the
applications specified in (c)(2) or (c)(3)(G) for each nonphysician medical
practitioner and licensed midwife under the supervision of a physician and
surgeon.
(d) The
applicant or provider, when required pursuant to subsection (a) through (b)
above, shall indicate on the application:
(1)
Whether the applicant or provider is requesting enrollment, or continued
enrollment, enrollment at a new, additional, or change in location, or
enrollment pursuant to subsection (b) above, and the provider's current
provider number(s) or group number(s) if any.
(2) Whether the applicant or provider is a
governmental entity or is a partnership, unincorporated sole proprietorship,
corporation or limited liability company. If the applicant or provider is a
partnership, a copy of the fully executed partnership agreement shall be
submitted with the application.
(3)
The legal name under which the applicant or provider is applying for
enrollment, continued enrollment, enrollment at a new, additional or change in
location, or enrollment pursuant to subsection (b) above. The legal name of the
individual, partnership, provider group, association, corporation, institution,
or entity, shall be the name currently on file with the Internal Revenue
Service (IRS). If the applicant or provider is using a fictitious name, a copy
of the Fictitious Business Name Statement, or Fictitious Name Permit, shall be
submitted with the application.
(4)
The business address of the applicant or provider.
(5) The business telephone number of the
applicant or provider.
(6) The pay
to address, if different from the business address specified on the
application.
(7) The mailing
address, if different from the business or pay to addresses.
(8) If the applicant or provider is an
individual, the date of birth and gender of the applicant or
provider.
(9) If the applicant or
provider is an individual, the driver's license number or state-issued
identification card number, and the state of issuance, of the applicant or
provider. A copy of the applicant's or provider's valid driver's license, or
state-issued identification card, shall be submitted with the application. The
driver's license or state-issued identification card shall be issued within the
50 United States or the District of Columbia.
(10) The license or certificate number, or
other approval to provide health care services, of the applicant or provider,
including those of the rendering provider(s) in a provider group, and the
effective and expiration dates. A copy of the valid license, certificate, or
other approval, shall be submitted with the application.
(11) The Medicare billing number, if the
applicant or provider is enrolled in the Medicare program.
(12) The Taxpayer Identification Number
issued by the IRS under the name of the applicant or provider, or the social
security number issued under the name of the applicant or provider. A copy of
the IRS Form 941, Form 8109-C, Letter 147-C, or Form SS-4 (Confirmation
Notification) shall be submitted with the application.
(13) The provider type of the applicant or
provider and, if the applicant or provider is a physician, all of the
following:
(A) A listing of his/her
specialt(y)ies.
(B) The location,
current status and past history of all hospital privileges.
(C) If requesting preferred provider status,
documentation shall be submitted at the time of submission of the application
package to show that the physician meets all of the criteria listed in the
Provider Bulletin, titled "Preferred Provider Status" dated February 2004,
accessible on the Medi-Cal web site at
www.medi-cal.ca.gov at the
Provider Enrollment link, under Statutes, Regulations and Provider
Bulletins.
(14) The
names, social security numbers (optional), and dates of birth of all rendering
providers, if the applicant is a provider group applicant.
(15) The applicant's or provider's Seller's
Permit number, if applicable. A copy of the Seller's Permit shall be submitted
with the application.
(16) If the
applicant intends to provide or the provider currently provides durable medical
equipment as defined in Section
51160, or is a medical device
retailer as defined in Section
51251, or claims reimbursement for
the items listed in Section
51521 or
51526, the applicant or provider
shall submit the "Medi-Cal Durable Medical Equipment Provider Application," DHS
6201 (Rev. 07/05), with the information specified in (A) through (D) below.
This requirement does not apply to a provider who is authorized to submit
claims for reimbursement for durable medical equipment, incontinence medical
supplies, or prosthetic and orthotic appliances based on enrollment in the
Medi-Cal program as a provider type other than a Durable Medical Equipment and
Medical Supply Provider.
(A) A statement
indicating whether the applicant or provider has a retail business open and
available to the general public that is readily identifiable as a place in
which the applicant or provider sells, rents or leases durable medical
equipment or medical supply items either in stock on the premises, or in a
warehouse under the applicant's or provider's direct control, and has an
established place of business, as specified in Section
51000.60.
(B) The days and hours of operation of the
applicant's or provider's business.
(C) The address of any warehouse(s) under the
direct control of the applicant or provider in which the applicant or provider
engages in sales, leasing, or rental of items, and if applicable, the name(s),
address(es), and telephone number(s) of the person(s) who hold an ownership
interest in the warehouse(s).
(D) A
statement of the composition and percentage of the applicant's or provider's
current business activities including whether the applicant intends to provide
or provider currently provides:
1.
Beds.
2. Incontinence medical
supplies.
3. Ostomy
supplies.
4. Infusion equipment and
supplies.
5. Oxygen equipment and
supplies.
6. Urinary catheters,
bags and related supplies.
7.
Wheelchairs.
(17) If the applicant or provider is a
pharmacy as defined in Section
51106 and provides pharmaceutical
services as defined in Section
51107, the applicant or provider
shall submit the "Medi-Cal Pharmacy Provider Application," DHS 6205 (Rev.
07/05), with the following information:
(A) A
statement indicating whether the applicant or provider has a retail established
place of business that meets the criteria specified in Section
51000.60. If the applicant or
provider does not have a business open and available to the general public, an
explanation shall be provided.
(B)
The National Council for Prescription Drug Programs (NCPDP) number.
(C) The Drug Enforcement Agency (DEA)
registration certificate, and the effective and expiration dates. A copy of the
DEA registration shall be submitted with the application, if controlled
substances are dispensed.
(D) The
California State Board of Pharmacy (CSBP) permit number and the effective date.
A copy of the CSBP permit shall be submitted with the application.
(E) The name of the pharmacist-in-charge at
the business address, as required by Section
4113
of the Business and Professions Code.
(F) The driver's license number or
state-issued identification card, and the state of issuance, of the
pharmacist-in-charge. A copy of the driver's license, or state-issued
identification card of the pharmacist-in-charge shall be submitted with the
application.
(G) The social
security number (optional) of the pharmacist-in-charge.
(H) The information specified in subsections
(d)(16)(B) through (D), above, and the percentage of the applicant's or
provider's total business activities represented by the sale of prescription
drugs, and meets the requirements of Welfare and Institutions Code Section
14043.34.
(I) The license number of the
pharmacist-in-charge. A copy of the license issued to the pharmacist-in-charge
shall be submitted with the application.
(18) If the applicant intends to provide or
the provider currently provides medical transportation services as defined in
Section 51151, and claims reimbursement
for services as a provider of medical transportation as defined in Section
51152, or provides nonemergency
medical transportation as defined in Section
51151.7, the applicant or provider
shall submit the "Medi-Cal Medical Transportation Provider Application," DHS
6206 (Rev. 07/05), with the following information:
(A) For emergency transportation by
ambulance, the California Highway Patrol (CHP) certificate number and the date
of issuance. A copy of the CHP certificate shall be submitted with the
application.
(B) For nonemergency
medical transportation, as defined in Section
51151.7, by litter van or
wheelchair van registered with DMV as a commercial vehicle, the vehicle
identification number (VIN), make and model, year, and license plate number of
each vehicle. Proof of full coverage commercial insurance for each vehicle,
indicating the VIN for each covered vehicle, shall be submitted.
(C) For air ambulance transportation, the
Federal Aviation Administration (FAA) certificate number. A copy of the FAA
certificate and a statement on company letterhead of where the aircraft is
hangared shall be submitted with the application.
(D) For each driver of nonemergency medical
ground transportation vehicles and for each pilot of aircraft(s) employed by
the applicant or provider:
1. Full legal
name.
2. California driver's
license number and the expiration date. A copy of the valid California driver's
license shall be submitted with the application.
3. Driving history printout issued by the
Department of Motor Vehicles (DMV). A copy of the driving history printout
shall be submitted with the application.
4. Medical examination report, DL-51, issued
by the DMV and the effective and expiration dates. A copy of the DL-51 shall be
submitted with the application.
5.
A copy of the certificates for first aid and CPR specified in Sections
51231.1 and
51231.2 shall be submitted with
the application.
6. A copy of the
standard pre-employment drug and alcohol lab test results shall be submitted
with the application.
7. Pilot's
license number of the pilot. A copy of the license shall be submitted with the
application.
(E) Days and
hours of business operation.
(F)
Geographic area within which the city or county has issued a business license
or permit to provide medical transportation services. A copy of the license or
permit shall be submitted with the application.
(G) The documentation required by Sections
51231.1 and
51231.2.
(19) If the applicant intends to provide or
the provider currently provides lab services as defined in Section
51137.1, or
51137.2, a Clinical Laboratory
Improvement Amendment (CLIA) certificate appropriate for the level of testing
performed and a state license or registration shall be submitted. If the
applicant or provider performs a test included within the 80000 series of the
Physician's Current Procedural Terminology (CPT) codes, a CLIA certificate
appropriate for the level of testing performed shall also be submitted if the
applicant or provider performs or submits claims for any of the following CPT
codes: 78110, 78111, 78120, 78121, 78122, 78130, 78160, 78191, 78270, 78271 and
78272. A copy of the CLIA certificate and the state license or registration
shall be submitted with the application.
(20) If the applicant or provider is a
nonphysician medical practitioner or licensed midwife as defined in Sections
51170,
51170.1,
51170.2,
51170.3 and
51191, the applicant or provider
shall submit the "Medi-Cal Nonphysician Medical Practitioner and Licensed
Midwife Application," DHS 6248 (07/05) with the following information:
(A) For the nonphysician medical practitioner
and licensed midwife:
1. The
license/certification number of the applicant or provider, and the effective
and expiration dates. A copy of the valid license or certificate shall be
submitted with the application.
2.
Date first employed by employing provider including verification of
employment.
3. Maximum work hours
per week at this location.
4. Hours
of supervision per week at this location.
5. For nurse practitioners, the duration of
the nurse practitioner training program and the name of the school providing
the training program, or equivalent experience.
(B) For the employing provider:
1. Legal Name that is currently on file with
the Internal Revenue Service (IRS).
2. Medical License Number. A copy of the
valid license shall be submitted with the application.
3. Provider number.
4. Business address.
5. Type of facility at the business
address.
6. Type of service
delivered at the business address.
7. Business telephone number.
8. Other Medi-Cal provider(s), if any, for
whom the applicant currently works, including the name, provider number,
business address of each employing provider and the maximum hours per week the
applicant works.
(C) For
the supervising provider:
1. Legal Name that
is currently on file with the Internal Revenue Service (IRS).
2. Medical License Number. A copy of the
valid license shall be submitted with the application.
3. Provider number.
4. Driver's license number or state-issued
identification card number, and the state of issuance, of the applicant or
provider. A copy of the applicant's or provider's valid driver's license, or
state-issued identification card, shall be submitted with the application. The
driver's license or state-issued identification card shall be issued within the
50 United States or the District of Columbia.
5. Business telephone number.
6. Type of practice/specialty.
7. Name of each nonphysician medical
practitioner or licensed midwife supervised, the provider type, and the maximum
number of hours worked.
(21) For the individual signing the
application, who shall have the authority to legally bind the applicant or
provider seeking enrollment, continued enrollment, enrollment at a new,
additional, or change in location, or enrollment pursuant to subsection (b)
above, the following shall be provided:
(A)
The full legal name and title.
(B)
Date of birth.
(C)
Gender.
(D) Social security number
(optional).
(E) The driver's
license number or state-issued identification card number and state of
issuance. The driver's license or state-issued identification card shall be
issued within the 50 United States or the District of Columbia. A copy of the
valid driver's license, or state-issued identification card, shall be submitted
with the application.
(22) If the applicant or provider is a
substance use disorder clinic, the applicant or provider shall comply with
Sections 51341.1,
51490.1,
51516.1, and shall submit a "Drug
Medi-Cal Substance Use Disorder Clinic Application," DHCS 6001 (Rev. 12/14)
with the following information and documentation:
(A) A list of all substance use disorder
treatment professionals, licensed substance use disorder treatment
professionals, and substance use disorder nonphysician medical practitioners,
including:
1. Whether each staff member is
licensed, certified, or registered, and if so, the licensing, certifying, or
registering organization, also include the effective date and expiration date
of each individuals licensure, certification, or registration.
2. Proof of certification, or registration of
all substance use disorder treatment professionals, as required by California
Code of Regulations, Title 9, Section
13010.
3. The NPI of each licensed substance use
disorder treatment professional, and substance use disorder nonphysician
medical practitioner, and if applicable, each substance use disorder treatment
professional.
(B) Whether
the applicant or provider provides residential services at the business
address. If the applicant or provider provides residential services but is not
licensed by the Department or another governmental agency, an explanation shall
be included with the application.
(C) If the applicant or provider provides
residential substance use disorder treatment services, a valid residential
license shall be submitted with the application.
(D) If the applicant is providing narcotic
treatment services, a copy of the valid Narcotic Treatment Program
license.
(E) The service modalities
provided by the applicant or provider.
(F) Upon the Department's request, if the
applicant or provider is a governmental entity, corporation, or limited
liability company, a copy of current board minutes that contains the name of
the individual authorized to sign on behalf of the applicant or
provider.
(G) For the Substance Use
Disorder Medical Director:
1. Legal
name;
2. Medical license number and
a copy of the valid license; and
3.
NPI number.
(23) If the applicant or provider is a
substance use disorder medical director, the applicant or provider shall submit
the "Drug Medi-Cal Substance Use Disorder Medical Director/Licensed Substance
Use Disorder Treatment Professional/Substance Use Disorder Nonphysician Medical
Practitioner Application/Agreement/Disclosure Statement," DHCS 6010 (Rev.
12/14) with the name and address of each substance use disorder clinic overseen
by the substance use disorder medical director applicant or
provider.
1. New
section filed 9-28-99 as an emergency; operative 9-28-99 (Register 99, No. 40).
A Certificate of Compliance must be transmitted to OAL by 3-27-2000 or
emergency language will be repealed by operation of law on the following day.
Submitted to OAL for printing only pursuant to section
78, AB 1107 (Chapter 146, Statutes
of 1999).
2. New section, including amendments, refiled 11-24-99 as
an emergency; operative 11-24-99 (Register 99, No. 48). A Certificate of
Compliance must be transmitted to OAL by 5-22-2000 or emergency language will
be repealed by operation of law on the following day. Submitted to OAL for
printing only pursuant to section
78, AB 1107 (Chapter 146, Statutes
of 1999).
3. New section refiled 5-5-2000 as an emergency; operative
5-22-2000 (Register 2000, No. 18). A Certificate of Compliance must be
transmitted to OAL by 9-19-2000 or emergency language will be repealed by
operation of law on the following day.
4. New section refiled
8-28-2000 as an emergency; operative 9-6-2000 (Register 2000, No. 35). A
Certificate of Compliance must be transmitted to OAL by 1-4-2001 or emergency
language will be repealed by operation of law on the following
day.
5. Certificate of Compliance as to 8-28-2000 order, including
amendment of section, transmitted to OAL 12-26-2000 and filed 2-8-2001
(Register 2001, No. 6).
6. Amendment of section and NOTE filed
2-3-2003 as an emergency; operative 2-3-2003 (Register 2003, No. 6). Emergency
amendments exempt from OAL review pursuant to Welfare and Institutions Code
section
14043.75.
Amendments to remain in effect for 180 days pursuant to section
78, chapter 146, Statutes of 1999
(AB 1107). A Certificate of Compliance must be transmitted to OAL by 8-4-2003
or emergency language will be repealed by operation of law on the following
day.
7. Amendment of section and NOTE refiled 8-5-2003 as an
emergency; operative 8-5-2003 (Register 2003, No. 32). Emergency amendments
exempt from OAL review pursuant to Welfare and Institutions Code section
14043.75.
Amendments to remain in effect for 180 days pursuant to section
78, chapter 146, Statutes of 1999
(AB 1107). A Certificate of Compliance must be transmitted to OAL by 2-2-2004
or emergency language will be repealed by operation of law on the following
day.
8. Amendment, including further amendment of section and NOTE,
refiled 2-3-2004 as an emergency; operative 2-3-2004 (Register 2004, No. 6).
Emergency amendments exempt from OAL review pursuant to Welfare and
Institutions Code section
14043.75.
A Certificate of Compliance must be transmitted to OAL by 6-2-2004 or emergency
language will be repealed by operation of law on the following
day.
9. Reinstatement of section as it existed prior to 2-3-2004
emergency amendment by operation of Government Code section
11346.1(f)
(Register 2004, No. 24).
10. Amendment refiled 6-8-2004 as an
emergency; operative 6-8-2004 (Register 2004, No. 24). A Certificate of
Compliance must be transmitted to OAL by 10-6-2004 or emergency language will
be repealed by operation of law on the following day.
11.
Reinstatement of section as it existed prior to 6-8-2004 emergency amendment by
operation of Government Code section
11346.1(f)
(Register 2004, No. 41).
12. Amendment of section heading, section
and NOTE filed 9-29-2004 as an emergency; operative 10-7-2004 (Register 2004,
No. 41). A Certificate of Compliance must be transmitted to OAL by 2-4-2005 or
emergency language will be repealed by operation of law on the following day.
Deemed emergency exempt from OAL pursuant to Welfare and Institutions Code
section
14043.75.
13.
Amendment of section heading, section and NOTE refiled 1-27-2005 as an
emergency; operative 2-5-2005 (Register 2005, No. 4). A Certificate of
Compliance must be transmitted to OAL by 6-6-2005 or emergency language will be
repealed by operation of law on the following day. Deemed emergency exempt from
OAL review pursuant to Welfare and Institutions Code section
14043.75.
14.
Amendment of section heading, section and NOTE refiled 6-2-2005 as an
emergency; operative 6-7-2005 (Register 2005, No. 22). A Certificate of
Compliance must be transmitted to OAL by 10-5-2005 or emergency language will
be repealed by operation of law on the following day. Deemed emergency exempt
from OAL review pursuant to Welfare and Institutions Code section
14043.75.
15.
Certificate of Compliance as to 6-2-2005 order, including further amendment of
section, transmitted to OAL 9-29-2005 and filed 11-10-2005 (Register 2005, No.
45).
16. Amendment of subsections (d)(1), (d)(20)(B)3.,
(d)(20)(B)8., (d)(20)(C)3. and (e) and amendment of NOTE filed with the
Secretary of State on 2-28-2008 (Register 2008, No. 9). Exempt from review by
the Office of Administrative Law pursuant to Welfare and Institutions Code
section
14043.45.
17.
Change without regulatory effect amending subsection (d)(13)(C) filed 1-23-2009
pursuant to section
100, title 1, California Code of
Regulations (Register 2009, No. 4).
18. Amendment of subsection
(c)(3)(F), new subsections (c)(3)(H)-(I) and (d)(22)-(23) and amendment of NOTE
filed 8-17-2015 as a deemed emergency exempt from OAL review pursuant to
Welfare and Institutions Code section
14043.75;
operative 8-17-2015 (Register
2015,
No. 34). A Certificate of Compliance must be transmitted to OAL by 2-16-2016 or
emergency language will be repealed by operation of law on the following
day.
19. Certificate of Compliance as to 8-17-2015 order transmitted
to OAL 12-30-2015 and filed 2-11-2016 (Register 2016, No.
7).
Note: Authority cited: Section
20, Health and Safety Code; and
Sections
10725,
14043.45,
14043.75
and
14124.5,
Welfare and Institutions Code. Reference: Sections
14021,
14021.3,
14021.5,
14021.6,
14021.33,
14043.15,
14043.2,
14043.25,
14043.26,
14043.36,
14043.37,
14043.62,
14043.7,
14053,
14107,
14124.1,
14124.2,
14124.24,
14124.25,
14131,
14132.21,
14132.905,
14133
and
14133.1,
Welfare and Institutions Code; and Title 45, Code of Federal Regulations,
Sections 162.408 and
162.412.
