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 1 - General Provisions › Section 14042.

14042. Each contract for fiscal intermediary services shall provide for an automated system for verifying the eligibility of Medi-Cal recipients. The automated eligibility verification system shall provide the health care provider with a unique method of identifying the eligibility of the beneficiary. The provider shall include the eligibility identifier on the claim for payment. Where a recipient’s eligibility has been verified by the automated system and the provider provides a unique identifier on the claim form, the director may not require any label, card impression, or any other evidence to establish the recipient’s eligibility. The automated system for eligibility verification shall provide for the continuous updating of recipient eligibility determination.
The department shall periodically test the automated system for verifying recipient eligibility for completeness and accuracy, and report the findings of such testing to the Legislature. Unless and until the automated system for verifying recipient eligibility is accurate in at least 97 percent of the cases tested, the director shall provide for the issuance of proof-of-eligibility labels, or identity cards from which an identifying impression may be taken, or other evidence of eligibility to be used as a secondary recipient eligibility verification system. Notwithstanding the inability to provide verification of a recipient’s eligibility through use of the automated system for eligibility verification, presentation of a claim for service with evidence of recipient eligibility as is provided for by the secondary system shall conclusively establish the recipient’s eligibility.
On-line access shall be available to providers, at their discretion, upon the payment of a reasonable fee. The department shall establish the amount of the fees charged to providers for on-line access, which shall be based upon the costs of providing on-line access to providers.
(Added by Stats. 1982, Ch. 1508, 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 1 - General Provisions › Section 14042.2.

14042.2. (a) The Legislature finds and declares the following:
(1) The Medi-Cal Managed Care Ombudsman helps resolve issues between Medi-Cal managed care members and health plans, assists members with managed care related questions and problems, and answers questions from members.
(2) A pattern of inquiries, complaints, and grievances may be indicators of systemic problems regarding coverage and problems with access to care and warrant consideration.
(b) On a quarterly basis, the State Department of Health Care Services shall report on calls received by the Medi-Cal Managed Care Ombudsman. At a minimum, the report shall include the following:
(1) The number of contacts received, separated by inquiries and complaints.
(2) The average wait time for callers to answer.
(3) The number of calls abandoned.
(4) The result of contacts, including destination of referred calls, when possible.
(5) The average call time.
(6) Complaints, by issue type.
(7) The number of calls referred to another area of the department or to the Department of Managed Health Care for resolution.
(c) All data collected and reported shall include demographic information of beneficiaries, including race, ethnicity, age, gender, preferred language, language members were assisted in, and county of residence, and health plans of beneficiaries, to the extent known to the department at the time of the call. The department shall request, but not require, this information from members during the calls.
(d) The quarterly report shall include contacts from county mental health plan beneficiaries, as defined in Section 14700, including the requirements of subdivisions (a) and (b).
(e) The quarterly report shall be posted on the department’s internet website.
(f) The fourth quarterly report issued each year also shall include information pertaining to the following:
(1) Training protocols for staff, including cultural and linguistic competency.
(2) Assessment of contacts trends and actions taken by the State Department of Health Care Services as a result of contacts received.
(3) Consumer assistance protocols, procedures, and referral tools.
(Added by renumbering Section 14043.1 (as added by Stats. 2017, Ch. 52, Sec. 23) by Stats. 2019, Ch. 497, Sec. 320. (AB 991) Effective January 1, 2020.)
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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.

14043. In order to ensure the proper and efficient administration of the Medi-Cal program, every applicant, as defined in subdivision (b) of Section 14043.1, and every provider, as defined in subdivision (o) of Section 14043.1, shall be subject to the requirements of this article.
(Amended by Stats. 2010, Ch. 192, Sec. 1. (AB 1783) Effective January 1, 2011. Note: Sections 14040 to 14042 are located following Section 14029.91, at the end of Article 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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.17.

14043.17. (a) Notwithstanding any other law, within 30 calendar days of receiving confirmation of certification for enrollment as a Medi-Cal provider for an affiliate primary care clinic that is licensed pursuant to Section 1218.1 of the Health and Safety Code, the department shall provide written notice to the applicant informing the applicant that its Medi-Cal enrollment is approved.
(b) The department shall enroll the affiliate primary care clinic retroactive to the date of certification.
(c) This section shall not be construed to limit the department’s authority pursuant to Section 14043.37, 14043.4, or 14043.7 to conduct background checks, preenrollment inspections, or unannounced visits.
(Added by Stats. 2014, Ch. 356, Sec. 1. (AB 2051) Effective January 1, 2015.)
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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.2.

14043.2. (a) Whether or not regulations for certification are adopted under Section 14043.15, in order to be enrolled as a provider, or for enrollment as a provider to continue, an applicant or provider may be required to sign a provider agreement and shall disclose all information as required in federal Medicaid regulations and any other information required by the department. Applicants, providers, and persons with an ownership or control interest, as defined in federal Medicaid regulations, shall submit their date of birth and their social security number or numbers to the department, to the full extent allowed under federal law. Corporations with an ownership or control interest, as defined in federal Medicaid regulations, shall submit their taxpayer identification number and all business address locations and post office box addresses. The director may designate the form of a provider agreement by provider type. Failure to disclose the required information, or the disclosure of false information, shall result in denial of the application for enrollment or shall make the provider subject to temporary suspension from the Medi-Cal program, which shall include temporary deactivation of the provider’s number or numbers, including all business addresses used by the provider to obtain reimbursement from the Medi-Cal program.
(b) The director shall notify the provider of the temporary suspension and deactivation of the provider’s number or numbers, including all business addresses used by the provider, and the effective date thereof. Notwithstanding Section 100171 of the Health and Safety Code and Section 14123, proceedings after the imposition of sanctions provided for in subdivision (a) shall be in accordance with Section 14043.65.
(Amended by Stats. 2012, Ch. 797, Sec. 6. (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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.25.

14043.25. (a) The application form for enrollment, the provider agreement, and all attachments or changes to either, shall be signed under penalty of perjury.
(b) The department may require that the application form for enrollment, the provider agreement, and all attachments or changes to either, submitted by an applicant or provider licensed pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, the Osteopathic Initiative Act, or the Chiropractic Initiative Act, be notarized.
(c) Application forms for enrollment, provider agreements, and all attachments or changes to either, submitted by an applicant or provider not subject to subdivision (b) shall be notarized. This subdivision shall not apply with respect to providers under the In-Home Supportive Services program or any providers that choose to enroll electronically.
(d) The department shall collect an application fee for enrollment, including continued enrollment or enrollment at a new location or a change in location. The application fee shall not be collected from individual physicians or nonphysician practitioners, from providers that are enrolled in Medicare or another state’s Medicaid program or Children’s Health Insurance Program, from providers that submit proof that they have paid the applicable fee to a Medicare contractor or to another state’s Medicaid program, or pursuant to an exemption or waiver pursuant to federal law. The application fee collected shall be in the amount calculated by the federal Centers for Medicare and Medicaid Services in effect for the calendar year during which the application for enrollment is received by the department.
(Amended by Stats. 2015, Ch. 271, Sec. 3. (SB 299) Effective September 4, 2015.)
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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.29.

14043.29. (a) If, at the end of the period for which provisional provider status or preferred provisional provider status was granted under Section 14043.26, all of the following conditions are met, the provisional status shall cease and the provider shall be enrolled in the Medi-Cal program without designation as a provisional provider:
(1) The provider has demonstrated an appropriate volume of business.
(2) The provisional provider status or preferred provisional provider status has not been terminated or if it has been terminated, the act of termination was rescinded.
(3) The provider continues to meet the standards for enrollment in the Medi-Cal program as set forth in this article and Section 51000 and following of Title 22 of the California Code of Regulations.
(b) (1) An applicant or a provider who applied for enrollment or continued enrollment in the Medi-Cal program, prior to May 1, 2003, and for whom the application has not been approved or denied, or who has not received a notice on or before January 1, 2004, that the department is exercising its authority under Section 14043.37, 14043.4, or 14043.7 to conduct background checks, preenrollment inspections, or unannounced visits, shall be granted provisional provider status effective on January 1, 2004. Applications from applicants or providers who have been so noticed prior to January 1, 2004, shall be processed in accordance with subdivision (h) of Section 14043.26.
(2) Applications from applicants or providers that have been received by the department after May 1, 2003, but prior to January 1, 2004, shall be processed in accordance with Section 14043.26, except that these application packages shall be deemed to have been received by the department on January 1, 2004.
(Amended by Stats. 2009, Ch. 298, Sec. 27. (AB 1540) Effective January 1, 2010.)
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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.3.

14043.3. A provider shall be required to reimburse those Medi-Cal funds received during any period for which material information was not reported, or reported falsely, to the department.
(Added by Stats. 1999, Ch. 146, Sec. 37. Effective July 22, 1999.)
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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.34.

14043.34. (a) As a condition of a pharmacy’s participation in the Medi-Cal program, the pharmacy shall have in stock and regularly dispense prescription drugs.
(b) For purposes of this section, “prescription drugs” means any drug unsafe for self use by a person, and includes either of the following:
(1) Any drug that bears the legend: “Rx Only” or “Caution: federal law prohibits dispensing without prescription” or words of similar import.
(2) Any other drug that by federal or state law can be lawfully dispensed by the prescription of a licensed physician and surgeon.
(Added by Stats. 2000, Ch. 322, Sec. 18. 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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.35.

14043.35. Sections 14043.2, 14043.25, and 14043.3 shall not limit the authority granted the director and the rights granted providers in Section 14123. Action taken under the authority granted in Section 14123 shall be taken in accordance with that section.
(Added by Stats. 1999, Ch. 146, Sec. 37. Effective July 22, 1999.)
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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.36.

14043.36. (a) The department shall not enroll any applicant that has been convicted of any felony or misdemeanor involving fraud or abuse in any government program, or related to neglect or abuse of a patient in connection with the delivery of a health care item or service, or in connection with the interference with or obstruction of any investigation into health care related fraud or abuse or that has been found liable for fraud or abuse in any civil proceeding, or that has entered into a settlement in lieu of conviction for fraud or abuse in any government program, within the previous 10 years. In addition, the department may deny enrollment to any applicant that, at the time of application, is under investigation by the department or any state, local, or federal government law enforcement agency for fraud or abuse pursuant to Subpart A (commencing with Section 455.12) of Part 455 of Title 42 of the Code of Federal Regulations. The department shall not deny enrollment to an otherwise qualified applicant whose felony or misdemeanor charges did not result in a conviction solely on the basis of the prior charges. If it is discovered that a provider is under investigation by the department or any state, local, or federal government law enforcement agency for fraud or abuse, that provider shall be subject to temporary suspension from the Medi-Cal program, which shall include temporary deactivation of the provider’s number, including all business addresses used by the provider to obtain reimbursement from the Medi-Cal program.
(b) If it is discovered that a provider has been terminated under Medicare or under the Medicaid program or Children’s Health Insurance Program in any other state, the provider shall not be enrolled in, or shall be subject to termination from, the Medi-Cal program, which shall include deactivation of the provider’s enrolled numbers and all business addresses used to obtain reimbursement from the Medi-Cal program.
(c) The director shall notify in writing the provider of the temporary suspension and deactivation of the provider’s number, which shall take effect 15 days from the date of the notification. Notwithstanding Section 100171 of the Health and Safety Code, proceedings after the imposition of sanctions provided for in subdivision (a) shall be in accordance with Section 14043.65.
(d) A temporary suspension may be lifted when a resolution of an investigation for fraud or abuse occurs.
(Amended by Stats. 2015, Ch. 271, Sec. 5. (SB 299) Effective September 4, 2015.)
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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.37.

14043.37. The department may complete a background check on applicants for the purpose of verifying the accuracy of the information provided to the department for purposes of enrolling in the Medi-Cal program and in order to prevent fraud and abuse. The background check may include, but is not limited to, the following:
(a) Onsite inspection prior to enrollment.
(b) Review of business records.
(c) Data searches.
(Amended by Stats. 2000, Ch. 322, Sec. 20. 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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.4.

14043.4. If discrepancies are found to exist during the preenrollment period, the department may conduct additional inspections prior to enrollment. Failure of a provider to remediate discrepancies as prescribed by the director may result in denial of the application for enrollment. The department may deactivate all of the provider’s business addresses if the department determines that the discrepancies are material to the provider’s continued enrollment and the provider’s compliance with program requirements at the additional business addresses.
(Amended by Stats. 2015, Ch. 271, Sec. 7. (SB 299) Effective September 4, 2015.)
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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.45.

14043.45. (a) Notwithstanding whether a National Provider Identification (NPI) number is required by the rules issued by the Centers for Medicare and Medicaid Services implementing the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the department may require that an applicant or provider submit an NPI number.
(b) For transactions not specifically identified as covered transactions under the HIPAA NPI rules, the department may require that a provider use a National Provider Identification number on those transactions, or the department may issue the provider a unique identification number or numbers that shall be used on all transactions.
(c) Notwithstanding any other provisions of law, the department may, without taking regulatory action pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, implement, interpret, or make specific this section by means of a provider bulletin or similar instruction. The department shall notify and consult with interested parties and appropriate stakeholders in implementing, interpreting, or making specific this statute, including taking all of the following actions:
(1) Notifying provider representatives of the proposed action or change. The notice shall occur at least 10 business days prior to the meeting provided for in paragraph (2).
(2) Scheduling at least one meeting with interested parties and appropriate stakeholders to discuss the action or change.
(3) Allowing for written input regarding the action or change.
(4) Providing at least 30 days’ advance notice of the effective date of the action or change.
(d) This section shall apply to any health care program administered by the department or its agents or contractors.
(Repealed and added by Stats. 2007, Ch. 188, Sec. 45. Effective August 24, 2007.)
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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.47.

14043.47. (a) A provider doing business as a sole proprietorship, partnership, or professional corporation under Part 4 (commencing with Section 13400) of Division 3 of the Corporations Code or a rendering physician provider in a group who utilizes nonphysician medical practitioners to provide services, goods, supplies, or merchandise to Medi-Cal beneficiaries shall meet the specific supervisory requirements applicable to such providers, pursuant to the Business and Professions Code or other state or federal law.
(b) A provider doing business as a sole proprietorship, partnership, or professional corporation under Part 4 (commencing with Section 13400) of Division 3 of the Corporations Code or a rendering physician provider in a group who fails to comply with the requirements of this section is subject to temporary suspension from the Medi-Cal program and deactivation of the provider’s number, including all business addresses.
(c) A physician doing business as a sole proprietorship, partnership, or professional corporation under Part 4 (commencing with Section 13400) of Division 3 of the Corporations Code or a rendering physician provider in a group may not be enrolled at more than three business addresses unless there is a ratio of at least one physician providing supervision for every three locations.
(d) A physician doing business as a sole proprietorship, partnership, or professional medical corporation under Part 4 (commencing with Section 13400) of Division 3 of the Corporations Code or a rendering physician provider in a group who fails to comply with the requirements of this section is subject to temporary suspension from the Medi-Cal program and deactivation of all of his or her number, including all business addresses.
(Amended by Stats. 2007, Ch. 188, Sec. 47. Effective August 24, 2007.)
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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.5.

14043.5. Subject to Article 4 (commencing with Section 19130) of Chapter 5 of Division 5 of Title 2 of the Government Code, the department may enter into contracts to secure consultant services or information technology including, but not limited to, software, data, or analytical techniques or methodologies for the purpose of fraud or abuse detection and prevention. Contracts under this section shall be exempt from the Public Contract Code.
(Added by Stats. 1999, Ch. 146, Sec. 37. Effective July 22, 1999.)
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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.55.

14043.55. (a)  The department may implement a 180-day moratorium on the enrollment of providers in a specific provider of service category, on a statewide basis or within a geographic area, except that no moratorium shall be implemented on the enrollment of providers who are licensed as clinics under Section 1204 of the Health and Safety Code, health facilities under Chapter 2 (commencing with Section 1250) of the Health and Safety Code, clinics exempt from licensure under Section 1206 of the Health and Safety Code, or natural persons licensed or certified under Division 2 (commencing with Section 500) of the Business and Professions Code, the Osteopathic Initiative Act, or the Chiropractic Initiative Act, when the director determines this action is necessary to safeguard public funds or to maintain the fiscal integrity of the program. This moratorium may be extended or repeated when the director determines this action is necessary to safeguard public funds or to maintain the fiscal integrity of the program. The authority granted in this section shall not be interpreted as a limitation on the authority granted to the department in Section 14105.3.
(b) If the Secretary of the United States Department of Health and Human Services establishes a temporary moratorium on enrollment as described in federal regulations, the department shall establish a corresponding moratorium covering the same period and provider types, even if those provider types would not ordinarily be subject to a moratorium under this section, unless the department determines that the imposition of the moratorium will adversely impact beneficiaries access to medical assistance. A federal moratorium adopted under this subdivision shall not be subject to the director’s determinations regarding safeguards of public funds and program integrity or other prerequisites that are necessary to implement a state-initiated moratorium.
(Amended by Stats. 2015, Ch. 271, Sec. 8. (SB 299) Effective September 4, 2015.)
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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.6.

14043.6. (a) Except as provided in subdivision (b), the department shall automatically suspend, as a provider in the Medi-Cal program, any individual who, or any entity that, has a license, certificate, or other approval to provide health care, which is revoked or suspended by a federal, California, or another state’s licensing, certification, or approval authority, has otherwise lost that license, certificate, or approval, or has surrendered that license, certificate, or approval while a disciplinary hearing on that license, certificate, or approval was pending. The automatic suspension shall be effective on the date that the license, certificate, or approval was revoked, lost, or surrendered.
(b) The department may elect to not suspend an individual or entity as a provider in the Medi-Cal program pursuant to subdivision (a) if the revocation, suspension, or loss of the individual or entity’s license, certification, or approval authority in another state or the pending disciplinary hearing during which the individual or entity surrendered the license, certification, or approval authority in another state is based solely on conduct that is not deemed to be unprofessional conduct under California law. The department shall seek any federal approvals it deems necessary to implement this subdivision. This subdivision shall be implemented only to the extent that the department obtains any necessary federal approvals and federal financial participation under the Medi-Cal program is available and not otherwise jeopardized.
(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 subdivision (b), in whole or in part, by means of plan or county letters, information notices, plan or provider bulletins, or similar written instructions.
(Amended by Stats. 2023, Ch. 261, Sec. 4. (SB 487) Effective January 1, 2024.)
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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.61.

14043.61. (a) A provider shall be subject to suspension if claims for payment are submitted for the services, goods, supplies, or merchandise provided, directly or indirectly, to a Medi-Cal beneficiary, by an individual or entity that is suspended, excluded, or otherwise ineligible because of a sanction to receive, directly or indirectly, reimbursement from the Medi-Cal program and the individual or entity is listed on either the Suspended and Ineligible Provider List, published by the department, to identify suspended and otherwise ineligible providers, or any list published by the federal Office of Inspector General regarding the suspension or exclusion of individuals or entities from the federal Medicare and medicaid programs, to identify suspended, excluded, or otherwise ineligible providers.
(b) Notwithstanding Section 100171 of the Health and Safety Code, the imposition of the sanction provided for in subdivision (a) shall be appealable in accordance with Section 14043.65.
(Amended by Stats. 2007, Ch. 188, Sec. 48. Effective August 24, 2007.)
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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.62.

14043.62. (a) The department shall deactivate, immediately and without prior notice, the provider’s number, including all business addresses used by a provider to obtain reimbursement from the Medi-Cal program when warrants or documents mailed to a provider’s mailing address or its pay to address, if any, or its service or business address, are returned by the United States Postal Service as not deliverable or when a provider has not submitted a claim for reimbursement from the Medi-Cal program for one year. Prior to taking this action the department shall use due diligence in attempting to contact the provider at its last known telephone number and ascertain if the return by the United States Postal Service is by mistake or shall use due diligence in attempting to contact the provider by telephone or in writing to ascertain whether the provider wishes to continue to participate in the Medi-Cal program. If deactivation pursuant to this section occurs, the provider shall meet the requirements for reapplication as specified in this article or the regulations adopted thereunder.
(b) For purposes of this section:
(1) “Mailing address” means the address that the provider has identified to the department in its application for enrollment as the address at which it wishes to receive general program correspondence.
(2) “Pay to address” means the address that the provider has identified to the department in its application for enrollment as the address at which it wishes to receive warrants.
(3) “Service or business address” means the address that the provider has identified to the department in its application for enrollment as the address at which the provider will provide services to program beneficiaries.
(Amended by Stats. 2007, Ch. 188, Sec. 49. Effective August 24, 2007.)
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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.65.

14043.65. (a) Notwithstanding any other law, any applicant whose application for enrollment as a provider or whose certification is denied; or any provider who is denied continued enrollment or certification, or denied enrollment for a new location, who has been temporarily suspended, who has had payments suspended, who has had one or more business addresses used to obtain reimbursement from the Medi-Cal program deactivated, or whose provisional provider status or preferred provisional provider status has been terminated pursuant to this article or Section 14107.11, or Section 100185.5 of the Health and Safety Code, or who has had a civil penalty imposed pursuant to subdivision (a) of Section 14123.25; or any billing agent, as defined in Section 14040, when the billing agent’s registration has been denied pursuant to subdivision (e) of Section 14040.5, may appeal this action by submitting a written appeal, including any supporting evidence, to the director or the director’s designee. If the appeal is of a suspension of payment pursuant to Section 14107.11, the appeal to the director or the director’s designee shall be limited to the credibility of the allegation supporting the payment suspension, as described in subdivision (d) of Section 14107.11, and shall not encompass investigation or adjudication of the allegation. The appeal procedure shall not include a formal administrative hearing under the Administrative Procedure Act and shall not result in reactivation of any deactivated provider numbers during appeal. An applicant, provider, or billing agent that files an appeal pursuant to this section shall submit the written appeal along with all pertinent documents and all other relevant evidence to the director or to the director’s designee within 60 days of the date of notification of the department’s action. The director or the director’s designee shall review all of the relevant materials submitted and shall issue a decision within 90 days of the receipt of the appeal. The decision may provide that the action taken should be upheld, continued, or reversed, in whole or in part. The decision of the director or the director’s designee shall be final. Any further appeal shall be required to be filed in accordance with Section 1085 of the Code of Civil Procedure.
(b) No applicant whose application for enrollment as a provider has been denied pursuant to Section 14043.2, 14043.36, or 14043.4 may reapply for a period of three years from the date the application is denied. The three-year period shall commence upon the date of the denial notice.
(Amended by Stats. 2012, Ch. 797, Sec. 20. (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 1.3 - Provider Enrollment, Application, and Participation › Section 14043.75.

14043.75. (a) The director may, in consultation with interested parties, by regulation, adopt, readopt, repeal, or amend additional measures to prevent or curtail fraud and abuse. Regulations adopted, readopted, repealed, or amended pursuant to this section shall be deemed emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). These emergency regulations shall be deemed necessary for the immediate preservation of the public peace, health and safety, or general welfare. Emergency regulations adopted, amended, or repealed pursuant to this section shall be exempt from review by the Office of Administrative Law. The emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and publication in the California Code of Regulations.
(b) Notwithstanding any other law, the director may, without taking regulatory action pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, implement, interpret, or make specific Sections 14043.15, 14043.25, 14043.26, 14043.27, 14043.28, 14043.29, 14043.341, and 14043.38 by means of a provider bulletin or similar instruction. The department shall notify and consult with interested parties and appropriate stakeholders in implementing, interpreting, or making specific those provisions described in this subdivision, including all of the following:
(1) Notifying provider representatives of the proposed action or change. The notice shall occur at least 10 business days prior to the meeting provided for in paragraph (2).
(2) Scheduling at least one meeting with interested parties and appropriate stakeholders to discuss the action or change.
(3) Allowing for written input regarding the action or change.
(4) Providing at least 30 days’ advance notice of the effective date of the action or change.
(Amended by Stats. 2012, Ch. 797, Sec. 23. (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 1.3 - Provider Enrollment, Application, and Participation › Section 14045.

14045. (a) A provider shall not submit a reimbursement request to the Medi-Cal program containing a beneficiary’s social security number if the department has issued that beneficiary a Medi-Cal beneficiary identification card containing a beneficiary number with the issuance date included in that number.
(b) This section shall not apply to the submission of a request by a provider for beneficiary eligibility.
(c) In order to reduce medical fraud and the black market for stolen social security cards, the State Department of Health Care Services may establish an automated HIPAA-compliant system using HIPAA transactions whereby all providers can access a beneficiary’s identification card number for submitting reimbursement requests.
(d) When the provider makes a good faith effort to obtain a recipient’s beneficiary identification card number, this section shall not apply to the following types of services, or the following provider types, until the time that the department is able to establish a system described in subdivision (c):
(1) A hospital licensed pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code.
(2) A long-term health care facility, as defined in Section 1418 of the Health and Safety Code.
(3) A primary care clinic that is licensed pursuant to subdivision (a) of Section 1204 of the Health and Safety Code.
(4) Emergency medical transportation services.
(5) A hospital-based physician.
(Amended by Stats. 2008, Ch. 179, Sec. 246. Effective January 1, 2009.)
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 1.4 - Peer Support Specialist Certification Program › Section 14045.10.

14045.10. The Legislature finds and declares all of the following:
(a) Peer providers in California provide individualized support, coaching, facilitation, and education to clients with mental health care needs and substance use disorders in a variety of settings. Yet, no statewide scope of practice, standardized curriculum, training standards, supervision standards, or certification protocol is available.
(b) The United States Department of Veterans Affairs and at least 48 states utilize standardized curricula and certification protocols for peer support services.
(c) The federal Centers for Medicare and Medicaid Services (CMS) recognizes that the experiences of peer support specialists, as part of an evidence-based model of care, can be an important component in a state’s delivery of effective mental health and substance use disorder treatment. The CMS encourages states to offer comprehensive programs.
(d) A substantial number of research studies demonstrate that peer supports improve client functioning, increase client satisfaction, reduce family burden, alleviate depression and other symptoms, reduce homelessness, reduce hospitalizations and hospital days, increase client activation, and enhance client self-advocacy.
(e) Certification can increase the diversity and effectiveness of the behavioral health workforce through the use of peers with lived experience.
(Added by Stats. 2020, Ch. 150, Sec. 2. (SB 803) Effective January 1, 2021.)
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 1.4 - Peer Support Specialist Certification Program › Section 14045.11.

14045.11. It is the intent of the Legislature that the peer support specialist certification program, established under this article, achieve all of the following:
(a) Support the ongoing provision of services for individuals experiencing mental health care needs, substance use disorder needs, or both, by certified peer support specialists.
(b) Support coaching, linkage, and skill building of individuals with mental health needs, substance use disorder needs, or both, and to families or significant support persons.
(c) Increase family support by building on the strengths of families and helping them achieve a better understanding of mental illness in order to help individuals achieve desired outcomes.
(d) Support collaboration with others providing care or support to the individual or family.
(e) Assist parents, families, and individuals in developing coping mechanisms and problem-solving skills in order to help individuals achieve desired outcomes.
(f) Promote skill building for individuals in the areas of socialization, recovery, self-sufficiency, self-advocacy, development of natural supports, and maintenance of skills learned in other support services.
(g) Encourage employment under the peer support specialist certification to reflect the culture, ethnicity, sexual orientation, gender identity, mental health service experiences, and substance use disorder experiences of the individuals the peer support specialists serve.
(Added by Stats. 2020, Ch. 150, Sec. 2. (SB 803) Effective January 1, 2021.)
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 1.4 - Peer Support Specialist Certification Program › Section 14045.12.

14045.12. For purposes of this article, the following definitions apply:
(a) “Certification” means the activities related to the verification that an individual has met all of the requirements under this article and that the individual may provide peer support specialist services pursuant to this article.
(b) “Certified” means all federal and state requirements have been satisfied by an individual who is seeking designation under this article, including completion of curriculum and training requirements, testing, and agreement to uphold and abide by the code of ethics.
(c) “Code of ethics” means the standards to which a peer support specialist is required to adhere.
(d) “Core competencies” means the foundational and essential knowledge, skills, and abilities required for peer specialists.
(e) “Cultural competence” means a set of congruent behaviors, attitudes, and policies that come together in a system or agency that enables that system or agency to work effectively in cross-cultural situations. A culturally competent system of care acknowledges and incorporates, at all levels, the importance of language and culture, intersecting identities, assessment of cross-cultural relations, knowledge and acceptance of dynamics of cultural differences, expansion of cultural knowledge, and adaptation of services to meet culturally unique needs to provide services in a culturally competent manner.
(f) “Department” means the State Department of Health Care Services.
(g) “Peer support specialist” means an individual who is 18 years of age or older, who has self-identified as having lived experience with the process of recovery from mental illness, substance use disorder, or both, either as a consumer of these services or as the parent or family member of the consumer, and who has been granted certification under a county peer support specialist certification program.
(h) “Peer support specialist services” means culturally competent services that promote engagement, socialization, recovery, self-sufficiency, self-advocacy, development of natural supports, and identification of strengths. Peer support specialist services include, but are not limited to, prevention services, support, coaching, facilitation, or education that is individualized and is conducted by a certified peer support specialist.
(i) “Recovery” means a process of change through which an individual improves their health and wellness, lives a self-directed life, and strives to reach their full potential. This process of change recognizes cultural diversity and inclusion, and honors the different routes to resilience and recovery based on the individual and their cultural community.
(Added by Stats. 2020, Ch. 150, Sec. 2. (SB 803) Effective January 1, 2021.)
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 1.4 - Peer Support Specialist Certification Program › Section 14045.14.

14045.14. (a) Subject to department approval, a county, or an agency representing the county, may develop a peer support specialist certification program in accordance with this article and any standards established by the department. That county, or an agency representing that county, shall oversee and enforce the certification requirements developed pursuant to this article. To request department approval of the county peer support specialist program, a county, or an agency representing the county, shall do all of the following:
(1) Submit to the department a peer support specialist program plan describing how the peer support specialist program will meet all of the federal and state requirements for the certification and oversight of peer support specialists.
(2) Submit to periodic reviews conducted by the department to ensure adherence to all federal and state requirements.
(3) Submit annual peer support specialist program reports to the department.
(b) If a county chooses not to develop peer support specialist certification programs in accordance with this article, the county may fund peer programs to the extent those programs meet all requirements of the applicable funding source.
(c) The Legislature finds that peer support specialist certification is conducted at the state level in other states, but this section passes this responsibility to counties. Subject to an appropriation by the Legislature, the state shall fund the startup costs to implement this section.
(Added by Stats. 2020, Ch. 150, Sec. 2. (SB 803) Effective January 1, 2021.)
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 1.4 - Peer Support Specialist Certification Program › Section 14045.15.

14045.15. (a) To receive a certification under this article, an applicant shall meet all of the following requirements:
(1) Be at least 18 years of age.
(2) Possess a high school diploma or equivalent degree.
(3) Be self-identified as having experience with the process of recovery from mental illness or substance use disorder either as a consumer of these services or as the parent or family member of the consumer.
(4) Be willing to share their experience.
(5) Have a strong dedication to recovery.
(6) Agree, in writing, to adhere to a code of ethics.
(7) Successfully complete the curriculum and training requirements for a peer support specialist.
(8) Pass a certification examination approved by the department for a peer support specialist.
(b) To maintain certification under this article, a certified peer support specialist shall meet both of the following requirements:
(1) Adhere to the code of ethics and biennially sign an affirmation.
(2) Complete any required continuing education, training, and recertification requirements.
(Added by Stats. 2020, Ch. 150, Sec. 2. (SB 803) Effective January 1, 2021.)