reglab/statecodes huggingface dataset:
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.230 - Medi-Cal Hospital Reimbursement Improvement Act of 2013 › Section 14169.65.

14169.65. (a) Upon receipt of a letter that indicates likely federal approval that the director determines is sufficient for implementation under Section 14169.63, or upon the receipt of federal approval, the following shall occur:
(1) To the maximum extent possible, and consistent with the availability of funds in the fund, the department shall make all of the payments under Sections 14169.54, 14169.55, and 14169.56, including, but not limited to, supplemental payments and increased capitation payments, prior to the end of a program period, except that the increased capitation payments under Section 14169.56 shall not be made until federal approval is obtained for these payments.
(2) The department shall make supplemental payments to hospitals under this article consistent with the timeframe described in Section 14169.66 or a modified timeline developed pursuant to Section 14169.64.
(b) If any payment or payments made pursuant to this section are found to be inconsistent with federal law, the department shall recoup the payments by means of withholding or any other available remedy.
(c) This section shall not affect the department’s ongoing authority to continue, after the end of a program period, to collect quality assurance fees imposed on or before the end of the program period.
(Amended by Stats. 2014, Ch. 442, Sec. 35. (SB 1465) Effective September 18, 2014. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52. This section was added by Stats. 2013, Ch. 657 (SB 239).)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.230 - Medi-Cal Hospital Reimbursement Improvement Act of 2013 › Section 14169.66.

14169.66. The department shall make disbursements from the fund consistent with the following:
(a) Fund disbursements shall be made periodically within 15 days of each date on which quality assurance fees are due from hospitals.
(b) The funds shall be disbursed in accordance with the order of priority set forth in subdivision (b) of Section 14169.53, except that funds may be set aside for increased capitation payments to managed care health plans pursuant to subdivision (e) of Section 14169.56.
(c) The funds shall be disbursed in each payment cycle in accordance with the order of priority set forth in subdivision (b) of Section 14169.53 as modified by subdivision (b), and so that the supplemental payments and direct grants to hospitals and the increased capitation payments to managed health care plans are made to the maximum extent for which funds are available.
(d) To the maximum extent possible, consistent with the availability of funds in the fund and the timing of federal approvals, the supplemental payments and direct grants to hospitals and increased capitation payments to managed health care plans under this article shall be made before the last day of a program period.
(e) The aggregate amount of funds to be disbursed to private hospitals shall be determined under Sections 14169.54 and 14169.55. The aggregate amount of funds to be disbursed to managed health care plans shall be determined under Section 14169.56. The aggregate amount of direct grants to designated and nondesignated public hospitals shall be determined under Section 14169.58.
(Amended by Stats. 2014, Ch. 442, Sec. 36. (SB 1465) Effective September 18, 2014. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52. This section was added by Stats. 2013, Ch. 657 (SB 239).)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.230 - Medi-Cal Hospital Reimbursement Improvement Act of 2013 › Section 14169.67.

14169.67. Notwithstanding any other provision of this article, supplemental payments or other payments under this article shall only be required and payable in any quarter for which a fee payment obligation exists.
(Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.230 - Medi-Cal Hospital Reimbursement Improvement Act of 2013 › Section 14169.68.

14169.68. (a) In order to ensure that the proceeds of the quality assurance fee, the matching amount provided by the federal government, and any interest earned on those proceeds are used to supplement existing funding for hospital services provided to Medi-Cal patients and not supplant such funding, the aggregate fee-for-service payments under the Medi-Cal program to hospitals for hospital services furnished on and after January 1, 2014, for each fiscal year or portion thereof that is in a program period shall not be less than the aggregate amounts that would have been paid for those services under the rates and payment methodologies in effect on December 31, 2013. This provision shall be applied separately for each category of hospital services.
(b) For purposes of this section, all of the following definitions shall apply:
(1) “Aggregate amounts” means payments that would have been made on a fee-for-service basis to a hospital under Medi-Cal where the nonfederal share of the payments would have been appropriated from state general funds with the exception of disproportionate share replacement payments made under Section 14166.11. Aggregate amounts do not include payments made pursuant to Article 5.228 (commencing with Section 14169.1).
(2) “Aggregate fee-for-service payments” means all payments made on a fee-for-service basis to a hospital under Medi-Cal where the nonfederal share of the payments were appropriated from state general funds with the exception of disproportionate share replacement payments made under Section 14166.11. Aggregate fee-for-service payments do not include payments made under this article.
(3) “Hospital services” means all services covered under Medi-Cal furnished by a hospital, including, but not limited to, hospital inpatient services, hospital outpatient services, skilled nursing facility services furnished by a hospital, and subacute services furnished by a hospital.
(c) Disproportionate share replacement payments to private hospitals shall be not less than the amount determined pursuant to Section 14166.11. For purposes of this subdivision, references to Section 14166.11 are to the version of Section 14166.11 in effect on the effective date of this article.
(d) This section shall be implemented only to the extent it does not violate federal law and only to the extent available federal financial participation is not jeopardized.
(e) This section shall not require a rate or level of funding to be maintained where federal financial participation for the rate or level of funding has been reduced or eliminated by federal law.
(Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.230 - Medi-Cal Hospital Reimbursement Improvement Act of 2013 › Section 14169.70.

14169.70. Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this article by means of provider bulletins, all plan letters, or other similar instruction, without taking regulatory action. The department shall also provide notification to the Joint Legislative Budget Committee and to the fiscal and appropriate policy committees of the Legislature within five working days when the above-described action is taken in order to inform the Legislature that the action is being implemented.
(Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.230 - Medi-Cal Hospital Reimbursement Improvement Act of 2013 › Section 14169.71.

14169.71. Notwithstanding any other provision of this article, the director may proportionately reduce the amount of any supplemental payments or increased capitation payments under this article to the extent that the payment would result in the reduction of other amounts payable to a hospital or managed health care plan due to the application of federal law.
(Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.230 - Medi-Cal Hospital Reimbursement Improvement Act of 2013 › Section 14169.72.

14169.72. This article shall become inoperative if any of the following occurs:
(a) The effective date of a final judicial determination made by any court of appellate jurisdiction or a final determination by the United States Department of Health and Human Services or the federal Centers for Medicare and Medicaid Services that the quality assurance fee established pursuant to this article, or Section 14169.54 or 14169.55, cannot be implemented. This subdivision shall not apply to any final judicial determination made by any court of appellate jurisdiction in a case brought by hospitals located outside the state.
(b) The federal Centers for Medicare and Medicaid Services denies approval for, or does not approve on or before the last day of a program period, the implementation of Sections 14169.52, 14169.53, 14169.54, and 14169.55, and the department fails to modify Section 14169.52, 14169.53, 14169.54, or 14169.55 pursuant to subdivision (d) of Section 14169.53 in order to meet the requirements of federal law or to obtain federal approval.
(c) The Legislature fails to appropriate moneys in the fund in the annual Budget Act, or fails to appropriate such moneys in a separate bill enacted within thirty (30) days following enactment of the annual Budget Act.
(d) The department has sought but has not received federal financial participation for the supplemental payments and other costs required by this article for which federal financial participation has been sought.
(e) A lawsuit related to this article is filed against the state and a preliminary injunction or other order has been issued that results in a financial disadvantage to the state. For purposes of this subdivision, “financial disadvantage to the state” means either of the following:
(1) A loss of federal financial participation.
(2) A net General Fund cost incurred due to the act.
(f) The proceeds of the fee and any interest and dividends earned on deposits are not deposited into the fund or are not used as provided in Section 14169.53.
(g) The proceeds of the fee, the matching amount provided by the federal government, and interest and dividends earned on deposits in the fund are not used as provided in Section 14169.68.
(Amended November 8, 2016, by initiative Proposition 52, Sec. 4.1. Article 5.230, commencing with Section 14169.50, is conditionally inoperative as prescribed in this section. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.230 - Medi-Cal Hospital Reimbursement Improvement Act of 2013 › Section 14169.73.

14169.73. In the event this article becomes inoperative pursuant to Section 14169.72, all of the following shall apply:
(a) No hospital shall be required to pay the fee except for any fee owed prior to the article becoming inoperative.
(b) The director shall execute a declaration stating that he or she has determined that the article is inoperative and shall state the basis for this determination. The director shall retain the declaration and provide a copy, within five working days of the execution of the declaration, to the fiscal and appropriate policy committees of the Legislature. In addition, the director shall post the declaration on the department’s Internet Web site and the director shall send the declaration to the Secretary of State, the Secretary of the Senate, the Chief Clerk of the Assembly, and the Legislative Counsel.
(c) Upon execution of the declaration described in subdivision (b), the director shall implement a plan, in consultation with the hospital community and the Legislature, to wind down the program consistent with the purposes of the article, including the recoupment of payments made under this article if ordered by a court.
(Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed by Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.230 - Medi-Cal Hospital Reimbursement Improvement Act of 2013 › Section 14169.74.

14169.74. Beginning with the proposed budget for the 2014–15 fiscal year, and each fiscal year thereafter, the Department of Finance shall report in the Governor’s proposed budget and the May Revision the difference in General Fund benefit for the upcoming fiscal year resulting from this article and what was anticipated at the time the Budget Act of 2013 was enacted. It is the intent of the Legislature that additional General Fund benefit be appropriated to supplement, and not supplant, funding for health and human service programs, which may include the cost of medical interpreters.
(Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed by Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.230 - Medi-Cal Hospital Reimbursement Improvement Act of 2013 › Section 14169.75.

14169.75. Notwithstanding subdivision (k) of Section 14167.35, subdivisions (a), (i), and (j) of Section 14167.35, creating the fund, are not repealed and shall remain operative as long as this article remains operative.
(Amended November 8, 2016, by initiative Proposition 52, Sec. 4.2. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.230 - Medi-Cal Hospital Reimbursement Improvement Act of 2013 › Section 14169.76.

14169.76. This article is repealed on January 1 of the year following the date on which the article becomes inoperative.
(Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Repealed, by its own provisions, on January 1 after inoperative date prescribed in Section 14169.72. Note: Repeal affects Article 5.230, commencing with Section 14169.50. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.231 - Medi-Cal Hospital Reimbursement Improvement and Restoration Act of 2013 › Section 14169.81.

14169.81. (a) Notwithstanding Sections 14105.191 and 14105.192, reimbursement for services provided by skilled nursing facilities that are distinct parts of general acute care hospitals shall be determined, for dates of service on or after October 1, 2013, without application of the reductions and limitations set forth in Sections 14105.191 and 14105.192.
(b) For dates of service on or after January 1, 2024, the department shall adopt a rate year based on the calendar year for skilled nursing facilities that are distinct parts of general acute care hospitals, including subacute care units.
(c) In implementing this section, the department shall seek any federal approvals it deems necessary. This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized.
(d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this section by means of provider bulletins or notices, policy letters, or other similar instructions, without taking regulatory action.
(Amended by Stats. 2023, Ch. 42, Sec. 155. (AB 118) Effective July 10, 2023.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.231 - Medi-Cal Hospital Reimbursement Improvement and Restoration Act of 2013 › Section 14169.82.

14169.82. (a) In consultation with the hospital community, as defined in Section 14169.51, the department shall develop proposed modifications to the quality assurance fee program under Article 5.230 (commencing with Section 14169.50) to collect additional fees solely designated for use under this section. In addition, the department shall consult with the hospital community to enable intergovernmental transfers from nondesignated public hospitals solely designated for use under this section. The department shall notify the Joint Legislative Budget Committee and fiscal and appropriate policy committees 30 working days prior to implementing a modification pursuant to this section.
(b) To the extent federal financial participation is not jeopardized and consistent with federal law, and subject to the conditions set forth in subdivision (c), the department shall pay Medi-Cal managed care plans rate range increases, as defined by paragraph (4) of subdivision (b) of Section 14301.4, for the purpose of increasing payments to private hospitals and nondesignated public hospitals in counties that do not have designated public hospitals. Nondesignated public hospitals shall be given priority relative to accessing rate range funds in counties where a nondesignated public hospital is the only public hospital.
(c) Payments to Medi-Cal managed care plans pursuant to subdivision (b) are conditioned on both of the following:
(A) The Medi-Cal managed care plan shall pay all of the rate range increases provided under this section as additional payments to private hospitals and nondesignated public hospitals for providing and making available services to Medi-Cal enrollees of the plan.
(B) The amount of the increases to Medi-Cal managed care plans shall be limited to the total amount of payments possible, including federal financial participation, based on the amount of fees actually collected and intergovernmental transfers actually provided pursuant to subdivision (a) as the nonfederal share for these payments.
(Added by Stats. 2013, Ch. 657, Sec. 7. (SB 239) Effective October 8, 2013.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.231 - Medi-Cal Hospital Reimbursement Improvement and Restoration Act of 2013 › Section 14169.83.

14169.83. To the extent permitted by federal law and other federal requirements, the director shall develop and describe in provider bulletins and on the department’s Internet Web site a process by which a private general acute care hospital located outside the state that serves Medi-Cal beneficiaries may opt in to pay the quality assurance fee on all applicable categories of patient days and receive supplemental payments for the Medi-Cal program patient days pursuant to Article 5.230 (commencing with Section 14169.50), in the same manner that the hospital could participate if it were located in the state. Notwithstanding Section 14169.51, the department shall rely on reliable data to make reasonable estimates or projections made with respect to the hospital as to the data, including, but not limited to, the days data source, used for the following: acute psychiatric days, annual fee-for-service days, annual managed care days, annual Medi-Cal days, fee-for-service days, general acute care days, high acuity days, managed care days, Medi-Cal days, Medi-Cal fee-for-service days, Medi-Cal managed care days, Medi-Cal managed care fee days, outpatient base amount, and transplant days, used to calculate the fees due and the supplemental payments. The director may modify the procedure set forth in this section to the minimum extent necessary to comply with applicable law, in consultation with the hospital community as defined in Section 14169.51.
(Added by Stats. 2013, Ch. 657, Sec. 7. (SB 239) Effective October 8, 2013.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.3 - Audit, Appeal, and Recovery of Overpayments › Section 14170.

14170. (a) (1) Amounts paid for services provided to Medi-Cal beneficiaries shall be audited by the department in the manner and form prescribed by the department. The department shall maintain adequate controls to ensure responsibility and accountability for the expenditure of federal and state funds. Cost reports and other data submitted by providers to a state agency for the purpose of determining reasonable costs for services or establishing rates of payment shall be considered true and correct unless audited or reviewed by the department within 18 months after July 1, 1969, the close of the period covered by the report, or after the date of submission of the original or amended report by the provider, whichever is later. Moreover the cost reports and other data for cost reporting periods beginning on January 1, 1972, and thereafter shall be considered true and correct unless audited or reviewed within three years after the close of the period covered by the report, or after the date of submission of the original or amended report by the provider, whichever is later.
(2) (A) Nothing in this section shall be construed to limit the correction of cost reports or rates of payment when inaccuracies are determined to be the result of intent to defraud, or when a delay in the completion of an audit is the result of willful acts by the provider or inability to reach agreement on the terms of final settlement.
(B) Nothing in this section shall be construed to preclude the department from further review of cost reports and other data for cost reporting periods beginning on January 1, 1998, after the three-year period contained in paragraph (1) of subdivision (a), where after the three-year period the department discovers information not customarily contained in these cost reports and other data for the fiscal periods in question that indicates the provider may have engaged in practices that have resulted in overreimbursement.
(3) Notwithstanding any other provision of law, nursing facilities and all categories of intermediate care facilities for the developmentally disabled which have received and are receiving funds for salary increases pursuant to Sections 14110.6 and 14110.7 shall maintain payroll and personnel records for examination by auditors from the department and the Labor Commissioner beginning March 1985 until the records have been audited, or until December 31, 1992, whichever occurs first.
(b) Notwithstanding any other provision of law, costs reported for reimbursement purposes relative to Medi-Cal beneficiaries in nursing facilities that are distinct parts of acute care hospitals shall be audited by the department at least annually. The audits may be performed on a sample basis and, when the sample is statistically reliable, as determined by the department, may be used for ratesetting purposes.
(Amended by Stats. 2000, Ch. 322, Sec. 32. Effective January 1, 2001.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.3 - Audit, Appeal, and Recovery of Overpayments › Section 14170.1.

14170.1. (a) Prior to the issuance to a provider of pharmaceutical services of any demand for payment pursuant to an audit or examination conducted under Sections 10722 and 14170, the amount of any underpayment to the provider for validly submitted claims or for valid claims which have inadvertently not been submitted and which arose during the audit period shall be determined and credited toward the amount of any overpayment due to the department. This section shall apply to all audits and examinations conducted under Sections 10722 and 14170 relative to amounts paid during the audit period for services provided to Medi-Cal beneficiaries. No audit may be reopened to provide for underpayments in which a final decision has been reached pursuant to Section 14171 or in which a certificate has been filed pursuant to Section 14172.
(b) When a provider of pharmaceutical services asserts that a claim has been underpaid for purposes of receiving a credit against overpayments, as authorized by this section, the provider shall submit to the department information and documentation sufficient to resolve any dispute as to whether such claim was in fact underpaid.
(c) For purposes of this section, the term “underpayments” shall include errors made by the pharmacist and errors made by the fiscal intermediary in determining payments for claims submitted within the billing time limits specified in Section 14115.
(Amended by Stats. 1986, Ch. 562, Sec. 1.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.3 - Audit, Appeal, and Recovery of Overpayments › Section 14170.5.

14170.5. (a) No provider’s claims for reimbursement under this chapter shall be subject to any special claims review procedure for a period in excess of nine months unless the department shows cause why the provider’s claims for reimbursement should continue to be subject to special claims review procedures.
(b) The department shall provide notice to a provider of its reasons for determining that the provider shall be subject to extended special claims review.
(Added by Stats. 1987, Ch. 608, Sec. 1.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.3 - Audit, Appeal, and Recovery of Overpayments › Section 14170.8.

14170.8. (a) Notwithstanding any other provision of law, every primary supplier of pharmaceuticals, medical equipment, or supplies shall maintain accounting records to demonstrate the manufacture, assembly, purchase, or acquisition and subsequent sale, of any pharmaceuticals, or medical equipment, or supplies to providers, as defined in Section 14043.1. Accounting records shall include, but not be limited to, inventory records, general ledgers, financial statements, purchase and sales journals and invoices, prescription records, bills of lading, and delivery records. For purposes of this section the term “primary suppliers” shall mean any manufacturer, principal labeler, assembler, wholesaler, or retailer.
(b) Accounting records maintained pursuant to subdivision (a) shall be subject to audit or examination by the department or its agents. This audit or examination may include, but is not limited to, verification of what was claimed by the provider. These accounting records shall be maintained for 10 years from the date of sale or the date of service.
(c) This section shall not apply to any clinic licensed pursuant to subdivision (a) of Section 1204 of the Health and Safety Code or to any manufacturer of prescription drugs registered with the federal Food and Drug Administration in accordance with Section 510 of the Food, Drug, and Cosmetic Act (21 U.S.C. Sec. 360).
(Amended by Stats. 2022, Ch. 47, Sec. 125. (SB 184) Effective June 30, 2022.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.3 - Audit, Appeal, and Recovery of Overpayments › Section 14170.11.

14170.11. (a) No person or entity shall submit a claim to the department or its fiscal intermediaries for reimbursement under the Medi-Cal program for a nerve conduction test or for electromyography unless the person or entity’s records contains a copy, for each person performing each test or electromyography, for which a claim is submitted, a certificate or diploma of satisfactory completion of a neurology or physical medicine and rehabilitation residency program accredited by the Accreditation Council of Graduate Medical Education (ACGME).
(b) The department may identify by publication, in provider bulletins or similar instructions, requirements that reimbursement from the Medi-Cal program shall only be made for the provision of certain procedures, tests, examinations, or other medical services provided by persons who possess a particular level of education, experience, and training as evidenced by satisfactory completion of medical residency programs or board certification in a particular field and that those submitting claims shall maintain a copy of this certificate or diploma.
(c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific, this section by means of all county letters, provider bulletins, or similar instructions. Thereafter, the department may adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code.
(Added by Stats. 2004, Ch. 228, Sec. 25. Effective August 16, 2004.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.3 - Audit, Appeal, and Recovery of Overpayments › Section 14170.12.

14170.12. Effective January 1, 2012, and notwithstanding Section 19130 of the Government Code, the State Department of Health Care Services may enter into contracts with one or more eligible Medicaid Recovery Audit Contractors (RACs) pursuant to Section 1396a(a)(42)(B) of Title 42 of the United States Code.
(Added by Stats. 2012, Ch. 797, Sec. 26. (SB 1529) Effective January 1, 2013.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.3 - Audit, Appeal, and Recovery of Overpayments › Section 14171.5.

14171.5. Any institutional provider of health care services that obtained reimbursement under this chapter to which it is not entitled shall be subject to the following interest charges or penalties:
(a) When it is established upon audit that the provider has claimed payments under this chapter to which it is not entitled, the provider shall pay, in addition to the amount improperly received, interest at the rate specified by subdivision (h) of Section 14171.
(b) When it is established upon audit that the provider claimed payments related to services or costs that the department had previously notified the provider in an audit report that the costs or services were not reimbursable, the provider shall pay in addition to the amount improperly claimed, a penalty of 10 percent of the amount improperly claimed after this notice, plus the cost of the audit. In addition, interest shall be assessed at the rate specified in subdivision (h) of Section 14171. Providers who wish to preserve appeal rights or to challenge the department’s positions regarding appeal issues, may claim the cost or services and not be reimbursed therefor if they are identified and presented separately on the cost report.
(c) When it is established that the provider fraudulently claimed and received payments under this chapter, the provider shall pay a penalty of 25 percent of the amount improperly claimed, plus the cost of the audit, in addition to the amount thereof. In addition, interest will be assessed at the rate specified by subdivision (h) of Section 14171. A fraudulent claim is a claim upon which the provider has been convicted of fraud upon the program. Nothing in this section shall prevent the imposition of any other civil or criminal penalties to which the provider may be liable.
(d) Appeals to action taken in subdivisions (a), (b), and (c) of Section 14171.5 above are subject to the administrative appeals process provided by Section 14171.
(e) Penalties paid by providers under subdivisions (a), (b), and (c) of Section 14171.5 are not reimbursable by the program.
(f) As used in this section, “the cost of the audit” includes actual hourly wages, travel, and incidental expenses at rates allowable by Department of General Services rules, and applicable overhead costs.
(Amended by Stats. 2016, Ch. 31, Sec. 283. (SB 836) Effective June 27, 2016.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.3 - Audit, Appeal, and Recovery of Overpayments › Section 14172.

14172. (a) Except as provided in subdivision (b), if any amount is due and payable and unpaid as the result of an overpayment to a provider of health care services, durable medical equipment, or incontinence supplies identified through an audit or examination conducted by or on behalf of the director, and the findings of the audit or examination are completed and no appeal is taken or the director has issued a final decision on the appeal pursuant to Section 14171, and 90 days have elapsed from the completion of that audit or examination or issuance of that final decision on appeal, the director may, not later than three years after the payment became due and owing, file in the office of the Clerk of the Superior Court of Sacramento County, and with the clerk of the superior court of the county in which the provider has its principal place of business, a certificate containing the following:
(1) Interest, as prescribed by Section 14171.
(2) A statement that the director has complied with this article prior to the filing of the certificate.
(3) A request that judgment be entered against the provider in the amount set forth in the certificate.
The clerk immediately upon the filing of the certificate shall enter a judgment for the State of California against the provider in the amount set forth in the certificate. The judgment may be filed by the clerk in a looseleaf book entitled “Health Care Overpayment Recovery Judgments.”
(b) If the provider seeks judicial review of the final decision of the director pursuant to subdivision (k) of Section 14171 and notice of that action is properly served on the director within 90 days of the issuance of the final decision of the director, the director shall not file any certificate as provided in subdivision (a).
If the provider does not seek judicial review of the final decision of the director pursuant to subdivision (k) of Section 14171 and does not properly serve notice within 90 days from the date of the final decision of the director, the director may file the certificate provided in subdivision (a). If the provider seeks judicial review of the final decision of the director more than 90 days from the date of the decision in accordance with subdivision (k) of Section 14171, the director shall within 10 days after receiving notice of that action release any lien imposed pursuant to this article and any judgment entered is for all purposes null and void.
(Amended by Stats. 2003, Ch. 62, Sec. 333. Effective January 1, 2004.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.3 - Audit, Appeal, and Recovery of Overpayments › Section 14173.

14173. An abstract of a judgment obtained pursuant to subdivision (a) of Section 14172 or a copy thereof may be recorded with the county recorder of any county. From the time of recording, the judgment shall constitute a lien upon all real or personal property of the provider in that county owned by the provider at the time, or which the provider may afterwards but before the lien expires, acquire. The lien shall have the force, effect and priority of a judgment lien and shall continue for 10 years from the time of recording of the abstract of judgment obtained pursuant to subdivision (a) of Section 14172 unless sooner released or otherwise discharged.
The lien may, within 10 years from the date of recording of the abstract of judgment or within 10 years from the date of the last extension of the lien in the manner herein provided, be extended by recording a new abstract in the office of the county recorder of any county. From the date of such recording the lien shall be extended for 10 years unless sooner released or otherwise discharged.
Execution shall issue upon such a judgment upon request of the director in the same manner as execution may issue upon other judgments. Sale shall be held under such execution as prescribed in the Code of Civil Procedure. In all proceedings under this section, the director or his authorized agents may act on behalf of the state.
(Amended by Stats. 1982, Ch. 328, Sec. 43. Effective June 30, 1982.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.3 - Audit, Appeal, and Recovery of Overpayments › Section 14174.

14174. The right of the director to use the summary judgment procedure contained in this article shall be in addition to any other collection procedure available to him. No action taken by the director shall be construed to be an election to pursue the summary judgment procedure to the exclusion of any other collection procedure.
(Amended by Stats. 1978, Ch. 429.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.3 - Audit, Appeal, and Recovery of Overpayments › Section 14175.

14175. The director may release any lien imposed pursuant to subdivision (a) of Section 14172 if he finds that the liability represented by the lien, including any interest accrued thereon, has been paid or is legally unenforceable.
(Amended by Stats. 1978, Ch. 429.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.3 - Audit, Appeal, and Recovery of Overpayments › Section 14176.

14176. The director may recover a due and payable overpayment made to a provider which is or has been participating under the provisions of this chapter by means of a repayment agreement executed between such provider and the director, and by any other means available at law.
(Amended by Stats. 1978, Ch. 429.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.3 - Audit, Appeal, and Recovery of Overpayments › Section 14176.5.

14176.5. Whenever it has been determined, pursuant to an audit conducted by the department, that an overpayment for Medi-Cal services has been made to a hospital for services rendered from January 1, 1992, to December 31, 1997, the department may forgive all or part of the debt arising from the overpayment, and interest, if the hospital is all of the following:
(a) A disproportionate share hospital, as defined in Section 14105.98.
(b) Located in Kern County or Monterey County.
(c) A nonprofit hospital, as defined in Section 127050 of the Health and Safety Code, or not affiliated with a hospital system.
(Added by Stats. 2001, Ch. 649, Sec. 2. Effective January 1, 2002.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.3 - Audit, Appeal, and Recovery of Overpayments › Section 14177.

14177. When it has been determined that a provider of health care services participating under the provisions of this chapter has received an overpayment which is due and payable, the director may recover such overpayment by offset against any amount currently due to a provider under the provisions of this chapter or Chapter 8 (commencing with Section 14200) of this part.
(Added by Stats. 1977, Ch. 1046.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.3 - Audit, Appeal, and Recovery of Overpayments › Section 14178.

14178. (a) Counties shall be held harmless in accordance with the provisions of this section for state funds to be recouped pursuant to audit exceptions issued for acts performed prior to July 1, 1982.
(b) Audit exception for the purpose of this section shall be defined as follows: Demands for recovery resulting from those audit reports issued by the Department of Health Services in which no final settlement or administrative decision adopted by the director has been arrived at prior to the effective date of this section.
(c) Such forgiveness of audit exceptions shall apply only to the state’s share of payments made in support of the Medi-Cal program. Counties shall retain liability for payment of the federal portion of payments made for Medi-Cal services unless and until the federal government agrees to waive their rights for repayment of federal share.
(d) Audit exceptions regarding county claims related to nonprogram benefits shall remain unaffected by the provisions of the section. County claims for nonprogram benefits shall include claims for return on equity, claims for bad debts, claims for uncompensated care, and any other claims not compensable pursuant to Title XIX of the federal Social Security Act.
(e) The amount of the recoupment of the federal portion of valid audit exceptions pursuant to subdivision (c) shall be determined pursuant to the existing administrative appeals process.
(f) No provision of this section shall apply to any audit report issued by the Department of Health Services after the effective date of this section relating to acts performed subsequent to July 1, 1982.
(Amended by Stats. 1982, Ch. 1594, Sec. 66. Effective September 30, 1982.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 5.4 - Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project › Section 14182.1.

14182.1. (a) Beginning March 2011, the department shall convene a stakeholder workgroup to review the existing encounter, claims, and financial data submission process required by the department under managed care health plan contracts. The workgroup members shall be selected by the department and shall include interested representatives from Medi-Cal managed care health plans, managed care health plan associations, hospitals, individual health care providers, physician groups, and consumer representatives. In reviewing the process, the department shall consider input from the stakeholder workgroup and develop data quality submission standards by October 2011.
(b) Beginning January 1, 2012, managed care health plans shall comply with the quality submission standards developed pursuant to subdivision (a) when submitting data to the department. The director may impose a penalty for each month that a managed care health plan fails to submit data in compliance with these standards. The penalty shall be in proportion to that plan’s failure to comply with the data submission standards, as the director in his or her sole discretion determines, and in no event shall the penalty exceed 2 percent of the total monthly capitation rate for that plan.
(c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action. Prior to issuing any letter or similar instrument authorized pursuant to this section, the department shall notify and consult with stakeholders, including advocates, providers, and beneficiaries. The department shall notify the appropriate policy and fiscal committees of the Legislature of its intent to issue instructions under this section at least five days in advance of the issuance. If the department elects to adopt regulations, the adoption of regulations shall be deemed an emergency and necessary for the immediate preservation of the public peace, health and safety, or general welfare.
(Amended by Stats. 2011, Ch. 296, Sec. 335. (AB 1023) Effective January 1, 2012.)