California Code of Regulations
Title 9 - Rehabilitative and Developmental Services
Division 1 - Department of Mental Health
Chapter 11 - Medi-Cal Specialty Mental Health Services
Subchapter 4 - Federal Financial Participation
Article 1 - General
Section 1840.112 - MHP Claims Certification and Program Integrity

Universal Citation: 9 CA Code of Regs 1840.112

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) Each MHP shall comply with all state and federal statutory and regulatory requirements for certification of claims, including Title 42, Code of Federal Regulations Sections 438.604, 438.606, and Section 438.608, which are hereby incorporated by reference.

(b) Each MHP shall certify to the Department, in writing, each monthly claim prior to submission to the State for reimbursement. The certification shall attest to the following for each beneficiary with services included in the claim:

(1) An assessment of the beneficiary was conducted in compliance with the requirements established in the MHP contract with the Department.

(2) The beneficiary was eligible to receive Medi-Cal services at the time the services were provided to the beneficiary.

(3) The services included in the claim were actually provided to the beneficiary.

(4) Medical necessity was established for the beneficiary as defined under this chapter for the service or services provided, for the timeframe in which the services were provided.

(5) A client plan was developed and maintained for the beneficiary that met all client plan requirements established in the MHP contract with the Department

(6) For each beneficiary with day rehabilitation, day treatment intensive or EPSDT supplemental specialty mental health services included in the claim, all requirements for MHP payment authorization in the MHP contract for day rehabilitation, day treatment intensive and EPSDT supplemental specialty mental health services were met, and any reviews for such service or services were conducted prior to the initial authorization and any re-authorization periods as established in the MHP contract with the Department.

(c) In compliance with title 42 CFR sections 433.15 and 455.18, the MHP's chief financial officer or equivalent or an individual with authority delegated by the chief financial officer shall sign the certification under penalty of perjury that the State share of payment for services covered by the claim has been provided in order to satisfy the matching requirement for federal financial participation.

(d) The MHP shall have mechanisms that support the certification, including the certification that the services for which claims were submitted were actually provided to the beneficiary.

1. New section filed 6-19-2003 as an emergency; operative 7-1-2003 (Register 2003, No. 25). A Certificate of Compliance must be transmitted to OAL by 10-29-2003 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 7-1-2003 order transmitted to OAL 10-6-2003 and filed 11-18-2003 (Register 2003, No. 47).
3. Repealer and new section filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).
4. New subsection (c) filed 10-18-2010; operative 11-17-2010 (Register 2010, No. 43).

Note: Authority cited: Sections 5775, 14043.75 and 14680, Welfare and Institutions Code. Reference: Sections 5718, 5719, 5724, 5767, 5776, 5777, 5778 and 14684, Welfare and Institutions Code; 42 CFR Part 433, Section 433.51, Part 438, Sections 438.604, 438.606 and 438.608; and Part 455, Section 455.18.

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