reglab/statecodes huggingface dataset:
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51460 - Special Claims Review

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 Department may place any provider on special claims review for specific or all
					 services provided. The special claims review may be performed by the
					 Department, or by the fiscal intermediary under direction of the Department.
					 Special claims review may be imposed on a provider upon a determination that
					 the provider has submitted improper claims, including claims which incorrectly
					 identify or code services provided.
(b) A provider, while on special claims
					 review, shall furnish any material requested by the Department in order to
					 substantiate specific or all claims subject to special claims review.
(c) The Department shall provide written
					 notice to any provider placed on special claims review. The written notice
					 shall include the following:
(1) Services
					 determined to have been improperly billed by the provider.
(2) Services subject to special claims
					 review.
(3) Documentation to be
					 submitted with all claims subject to special claims review.
(4) Instructions for submission of claims
					 subject to special claims review.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51461 - Orders for Suspension or Placement on Prior Authorization. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 2-25-70; designated effective 4-1-70 (Register 70, No. 9). For
						prior history, see Register 68, No. 21.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51463 - Requests for Hearing. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Amendment filed 11-15-68; effective thirtieth day thereafter (Register 68, No.
						43).
2. Repealer filed 2-25-70; designated effective 4-1-70
						(Register 70, No. 9).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51464 - When Hearing Not Requested. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 5-31-68; effective thirtieth day thereafter (Register 68, No.
						21).
2. Repealer filed 2-25-70; designated effective 4-1-70
						(Register 70, No. 9).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51465 - Review by the Director. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Amendment filed 11-15-68; effective thirtieth day thereafter (Register 68, No.
						43). For prior history, see Register 68, No. 21.
2. Repealer filed
						2-25-70; designated effective 4-1-70 (Register 70, No.
						9).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51466 - Disclosure of Significant Beneficial Interest

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A provider shall not bill or submit a
					 claim for service involving the referral of a beneficiary to or from another
					 provider unless each provider has disclosed any significant beneficial interest
					 existing between the providers. Disclosure shall be accomplished by completing
					 and submitting a Medi-Cal Personal Disclosure Statement of Significant
					 Beneficial Interest form as provided by the Department.
(b) A provider that fails to comply with (a)
					 or that submits a false or incorrect disclosure shall be subject to suspension
					 from participation or payment under the Medi-Cal program.
(c) For the purpose of this section:
(1) "Significant beneficial interest" means
					 any financial interest held by a provider, or a member of the provider's
					 immediate family, in another provider that is equal to or greater than the
					 lesser of the following:
(A) Five per cent of
					 the whole.
(B)
					 $25,000.00.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51466.1 - Significant Beneficial Interest. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 9-27-72; designated effective 11-1-72 (Register 72, No.
						40).
2. Repealer filed 4-25-80; effective thirtieth day thereafter
						(Register 80, No. 17).
Note: Authority cited: Sections
						  14022
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14022
						  and
						  14124.5,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51467 - Advertising. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 6-23-66 as an emergency; effective upon filing; Certificate of
						Compliance included (Register 66, No. 19).
2. Amendment filed
						4-17-67; effective thirtieth day thereafter (Register 67, No.
						16).
3. Repealer filed 7-25-79; effective thirtieth day thereafter
						(Register 79, No. 30).
Note: Authority cited: Section
						  14124.5,
						  Welfare and Institutions Code. Reference: Chapter 905, Statutes of
						  1978.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51469 - Decertification. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 11-15-68; effective thirtieth day thereafter (Register 68, No.
						43).
2. Repealer filed 2-25-70; designated effective 4-1-70
						(Register 70, No. 9).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51470 - Billing for Benefits Provided

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A provider shall not bill or submit a
					 claim to the Department or a fiscal intermediary for Medi-Cal benefits not
					 provided to a Medi-Cal beneficiary.
(b) A dental prosthesis, custom-made eye
					 appliance, custom-made prosthetic applicance, or custom-made orthotic appliance
					 shall be deemed provided after diligent attempts to effect delivery have proved
					 unsuccessful or delivery is impossible due to circumstances beyond the control
					 of the provider. Payment for undelivered appliances shall be limited to 80% of
					 the amount which would have been payable had delivery been accomplished.
					 Undelivered appliances for which claims are submitted and paid shall be
					 retained by the provider for a period not less than one year from the date it
					 was ordered from the fabricating laboratory for purposes of delivery to the
					 beneficiary or the Department on demand. If delivery is made to the patient or
					 a representative of the Department on demand within one year of the date of
					 service, the payment on the original claim can be adjusted to provide a total
					 compensation equal to that which would have been forthcoming had delivery been
					 made on the date of service.
(c)
					 Services provided by a selected substitute provider shall be considered to have
					 been provided by the billing provider if all of the following conditions are
					 met:
(1) Services are provided during the
					 temporary absence of the billing provider.
(2) The substitute provider is also a
					 qualified Medi-Cal provider.
(3)
					 The substitute provider has an agreement with the billing provider to provide
					 services in the absence of the billing provider and not to independently bill
					 for the same service.
(4) The claim
					 clearly identifies the substitute provider by name and provider
					 number.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51471 - Seeking Reimbursement from Beneficiaries. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 8-6-70; designated effective 9-7-70 (Register 70, No.
						32).
2. Amendment filed 9-30-71 as an emergency; designated
						effective 10-1-71 (Register 71, No. 40).
3. Certificate of
						Compliance--Section
						11422.1,
						Gov. Code, filed 1-25-72 (Register 72, No. 5).
4. Amendment filed
						8-8-78; effective thirtieth day thereafter (Register 78, No. 32).
5.
						New subsection (a)(3) filed 11-17-81 as an emergency; effective upon filing
						(Register 81, No. 47). A Certificate of Compliance must be transmitted to OAL
						within 120 days or emergency language will be repealed on
						3-17-82.
6. Certificate of Compliance transmitted to OAL 3-16-82 and
						filed 4-16-82 (Register 82, No. 16).
7. Editorial correction of NOTE
						filed 12-14-84 (Register 84, No. 50).
8. Repealer filed 6-28-89;
						operative 7-28-89 (Register 89, No. 26).
Note: Authority cited: Sections
						  10725,
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14019.3,
						  14019.4,
						  14105
						  and
						  14134,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51471.1 - Reimbursements for Program Underpayments

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Providers shall cooperate with the Department in making
						reimbursements to beneficiaries for Medi-Cal program underpayments. Providers
						shall provide such beneficiaries with documentation of claims for reimbursement
						on forms provided by the Department. Providers shall accept an underpayment
						adjustment from the Medi-Cal program for such beneficiaries and reimburse such
						beneficiaries the full amount of that adjustment, up to the amount actually
						received in payment from the beneficiary for the medical services in
						question.
1. New
						section filed 3-21-77 as an emergency; effective upon filing (Register 77, No.
						13). For prior history, see Register 77, No. 13.
2. Certificate of
						Compliance filed 5-20-77 (Register 77, No. 21).
3. Editorial
						correction of first sentence (Register 95, No.
						45).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14005.7,
						  14017
						  and
						  14018,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51472 - Sub-Standard Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
No provider shall render to a Medi-Cal beneficiary health
						care services which are below or less than the standard of acceptable
						quality.
1. New
						sections 51472 through
						51478 filed 2-25-70; designated
						effective 4-1-70 (Register 70, No. 9).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51473 - Excessive Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
No provider shall render to any Medi-Cal beneficiary, or
						submit a claim for reimbursement for, any health care service or services
						clearly in excess of accepted standards of practice.
1. New
						section filed 2-25-70; designated effective 4-1-70 (Register 70, No. 9). * For
						technical reasons, History Note printed in Register 80, No.
						13.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51473.1 - Referral for Excessive Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A provider shall not refer any Medi-Cal
					 beneficiary for any health care service which is clearly in excess of accepted
					 standards of practice.
(b) A
					 provider shall not prescribe drugs for any beneficiary that are clearly beyond
					 the beneficiary's legitimate medical needs.
1.
						Amendment filed 8-16-78 as an emergency; designated effective 8-16-78 (Register
						78, No. 32). For prior history, see Register 72, No. 40.
2.
						Certificate of Compliance filed 12-12-78 (Register 78, No. 50). For prior
						history, see Register 78, No. 32.
3. Editorial correction of NOTE
						filed 12-14-84 (Register 84, No. 50).
Note: Authority cited: Section
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14103.6,
						  14103.75
						  and
						  14133,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51473.2 - Services to Children

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A
					 provider may render Medi-Cal program services to a child without parental
					 consent only under those conditions specified by the California Civil Code,
					 Division First, Part 1.
(b) Claims
					 for reimbursement shall be submitted and paid for only those health care
					 services provided in accordance with (a) above.
1. New
						section filed 10-31-78 as an emergency; designated effective 11-1-78 (Register
						78, No. 44).
2. Certificate of Compliance filed 2-6-79 (Register 79,
						No. 6).
3. Editorial Correction of NOTE filed 12-13-84 (Register 84,
						No. 50).
4. Amendment of subsection (a) filed 7-15-85; effective
						thirtieth day thereafter (Register 85, No. 29).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14008,
						  14008.5
						  and
						  14010,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51474 - False Advertising. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 2-25-70; designated effective 4-1-70 (Register 70, No. 9). * For
						technical reasons, History Note printed in Register 80, No. 13.
2.
						Repealer filed 7-15-85; effective thirtieth day thereafter (Register 85, No.
						29).
Note: Authority cited: Section
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14124.5,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51475 - Refusal to Render Services. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 2-25-70; designated effective 4-1-70 (Register 80, No. 13). * For
						technical reasons, History Note printed in Register 80, No. 13.
2.
						Repealer filed 7-15-85; effective thirtieth day thereafter (Register 85, No.
						29).
Note: Authority cited: Section
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14124.5,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51476 - Keeping and Availability of Records

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each provider shall keep, maintain, and
					 have readily retrievable, such records as are necessary to fully disclose the
					 type and extent of services provided to a Medi-Cal beneficiary. Required
					 records shall be made at or near the time at which the service is rendered.
					 Such records shall include, but not be limited to the following:
(1) Billings.
(2) Treatment authorization
					 requests.
(3) All medical records,
					 service reports, and orders prescribing treatment plans.
(4) Records of medications, drugs, assistive
					 devices, or appliances prescribed, ordered for, or furnished to
					 beneficiaries.
(5) Copies of
					 original purchase invoices for medication, appliances, assistive devices,
					 written requests for laboratory testing and all reports of test results, and
					 drugs ordered for or supplied to beneficiaries.
(6) Copies of all remittance advices which
					 accompany reimbursement to providers for services or supplies provided to
					 beneficiaries.
(7) Identification
					 of the person rendering services. Records of each service rendered by
					 nonphysician medical practitioners (as defined in Title 22, CCR, Section
					 51170) shall include the signature
					 of the nonphysician medical practitioner and the countersignature of the
					 supervising physician to the extent required by the applicable professional
					 licensing statutes and regulations.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51476.1 - Pharmacy and Clinic with Special Permit Records of Pharmaceutical Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Pharmacy
					 records or records of drugs dispensed by a clinic that has obtained a special
					 permit pursuant to Business and Professions Code Section
					 4063
					 et seq. shall be maintained and readily retrievable. Original written
					 prescription orders presented to the pharmacist or clinic shall be retained.
					 Oral prescription orders shall be reduced to writing, by hand or machine, and
					 retained. The records describing the provision of a pharmaceutical service or a
					 clinic dispensed drug to a Medi-Cal beneficiary, shall include, but not be
					 limited to the following:
(1) Full
					 beneficiary name.
(2) Name,
					 category of professional licensure and license number of the
					 prescriber.
(3) Name, strength, and
					 quantity of the drug or medical supply dispensed, as applicable.
(4) Directions for use of the drug or medical
					 supply.
(5) Name of the principal
					 labeler of any multi-source drug or medical supply dispensed when not
					 specifically identified by the brand name of the drug dispensed.
(6) Date of service.
(7) Name or initials of the pharmacist or
					 clinic dispenser that provided the service.
(8) A unique number to identify each
					 pharmaceutical service or drug billed to the program. This number shall be the
					 "prescription number" required on the claim form.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51476.2 - Personal Care Services Records

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each county shall keep, maintain, and have readily
						retrievable, such records as are necessary to fully disclose the type and
						extent of personal care services provided to a Medi-Cal beneficiary. Records
						shall be made at or near the time the service is rendered or the assessment or
						other activity is performed. Such records shall include, but not be limited to
						the following:
(a)
					 Timesheets
(b) Assessment forms and
					 notes
(c) All service records, care
					 plans, and orders/prescriptions ordering personal care.
1. New
						section filed 4-14-93 as an emergency; operative 4-14-93. Submitted to OAL for
						printing only pursuant to section
						8, AB 1773 (Chapter 939, Statutes
						of 1992) (Register 93, No. 16).
Note: Authority cited: Section
						  14132.95,
						  Welfare and Institutions Code; Section
						  8, Chapter 939, Statutes of 1922;
						  Section 3, Chapter 7, Statutes of 1993.
						  Reference: Section
						  14132.95,
						  Welfare and Institutions Code; Section
						  1396 d(a)(7) of Title 42, of the
						  United States Code; Article 7 (commencing with Section
						  12300) of Part 3 of Division 9 of
						  the Welfare and Institutions Code; Section
						  440.170(f) of
						  Title 42 of the Code of Federal
						  Regulations.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51477 - Confidential Beneficiary Information. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 2-25-70; designated effective 4-1-70 (Register 70, No. 9). * For
						technical reasons, History Note printed in Register 80, No. 13).
2.
						Repealer filed 7-15-85; effective thirtieth day thereafter (Register 85, No.
						29).
Note: Authority cited: Section
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14124.5,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51478 - Prohibition of Rebate, Refund, or Discount

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
No provider shall offer, give, furnish, or deliver any
						rebate, refund, commission preference, patronage dividend, discount, or any
						other gratuitous consideration, in connection with the rendering of health care
						service to any Medi-Cal beneficiary. No provider shall solicit, request,
						accept, or receive, any rebate, refund, commission, preference, patronage
						dividend, discount, or any other gratuitous consideration, in connection with
						the rendering of health care service to any Medi-Cal
						beneficiary.
1. New
						section filed 2-25-70; designated effective 4-1-70 (Register 70, No. 25). * For
						technical reasons, History Note printed in Register 80, No. 13).
2.
						Amendment filed 10-23-86; effective thirtieth day thereafter (Register 86, No.
						43).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14105,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51479 - Change of Order or Prescription

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
No provider shall dispense prescription drugs or devices
						in an amount different from that prescribed without the prescriber's
						authorization, except for prescriptions refilled in accordance with:
(a) Business and Professions Code Section
					 4064.
(b) Health and Safety Code Section
					 11201.
1. New
						section filed 1-22-71; designated effective 3-1-71 (Register 71, No.
						4).
2. Amendment filed 2-21-79; designated effective sixtieth day
						after filing (Register 79, No. 8).
3. Editorial correction of NOTE
						filed 12-14-84 (Register 84, No. 50).
4. Change without regulatory
						effect redesignating subsections (1)-(2) as subsections (a)-(b) and amending
						newly designated subsection (a) and NOTE filed 9-23-2019 pursuant to section
						100, title 1, California Code of
						Regulations (Register
						2019,
						No. 39).
Note: Authority cited: Section
						  20, Health and Safety Code; and
						  Sections
						  14019.5,
						  14105,
						  14105.7
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14053,
						  14105,
						  14105.7
						  and
						  14132,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51480 - Discriminatory Billings

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) No
					 provider shall bill or submit a claim for reimbursement for the rendering of
					 health care services to a Medi-Cal beneficiary in any amount greater or higher
					 than the usual fee charged by the provider to the general public for the same
					 service.
(b) Notwithstanding (a)
					 above, if an organized outpatient clinic renders services without charge to the
					 general public under programs other than Titles XVIII or XIX financed by
					 federal or state funds, Medi-Cal may be considered a third party payor and be
					 billed for Medi-Cal covered services when rendered to Medi-Cal beneficiaries,
					 provided that:
(1) The clinic has an
					 established fee schedule; and
(2)
					 It ascertains from all individuals served whether they have any third party
					 coverage for medical care or services, and, where such coverage is available,
					 that third party coverage is billed and diligent efforts made to collect such
					 claimed amounts; and
(3) Medi-Cal
					 is not the only third party payor from which the clinic seeks
					 payment.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51481 - Forbidden Conduct

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
No provider shall engage in conduct inimical to the
						public health, morals, welfare and safety of any Medi-Cal
						beneficiary.
1. New
						NOTE filed 12-14-84 (Register 84, No. 50).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14123,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51482 - Unwarranted Inpatient Discharge

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
No provider shall order or cause the discharge of a
						Medi-Cal beneficiary inpatient from any facility without a valid medical-social
						reason which warrants discharge.
1. New
						NOTE filed 12-14-84 (Register 84, No. 50).
Note: Authority cited: Sections
						  10725,
						  14105,
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14105,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51483 - Provider Requirements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
No provider who fails to meet and comply with the
						requirements specified in the Definitions (Article 2 of Chapter 3 of these
						Regulations) and Standards (Article 3 of Chapter 3 of these Regulations), and
						no provider who fails to continue to meet and comply with the requirements
						specified in said Definitions and Standards, shall participate in the
						California Medical Assistance Program.
1. Change
						without regulatory effect adding NOTE (Register 86, No.
						49).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14123,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51483.1 - Personal Care Provider Requirements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
All providers of personal care program services must be
						approved by Department of Health Services and shall sign the "Personal Care
						Program Provider/Enrollment Agreement" form [SOC 426(1/93)] designated by the
						Department agreeing to comply with all applicable laws and regulations
						governing Medi-Cal and personal care service. Beneficiaries shall be given a
						choice of service provider.
1. New
						section filed 4-14-93 as an emergency; operative 4-14-93. Submitted to OAL for
						printing only pursuant to section
						8, AB 1773 (Chapter 939, Statutes
						of 1992) (Register 93, No. 16).
Note: Authority cited: Section
						  14132.95,
						  Welfare and Institutions Code; Section
						  8, Chapter 939, Statutes of 1922;
						  Section 3, Chapter 7, Statutes of 1993.
						  Reference: Section
						  14132.95,
						  Welfare and Institutions Code; Section
						  1396 d(a)(7) of Title 42, of the
						  United States Code; Article 7 (commencing with Section
						  12300) of Part 3 of Division 9 of
						  the Welfare and Institutions Code; Section
						  440.170(f) of
						  Title 42 of the Code of Federal
						  Regulations.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51484 - Billing for Suspended Provider

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
No provider shall bill or submit a claim for or on behalf
						of any provider who has been suspended from participation in the California
						Medical Assistance Program, for any services rendered in whole or in part by
						any such suspended provider during the term of such
						suspension.
1. New
						NOTE filed 5-9-84 (Register 84, No. 19).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14123,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51485 - Submission of False Information

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
No provider shall submit or cause to be submitted any
						false or misleading statement of material fact when complying with departmental
						regulations, or in connection with any claim for reimbursement, or any request
						for authorization of services.
1. New
						section filed 1-22-71; designated effective 3-1-71 (Register 71, No.
						4).
2. Amendment filed 8-31-79; effective thirtieth day thereafter
						(Register 79, No. 35).
3. Editorial correction of NOTE filed
						12-14-84 (Register 84, No. 50).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14107,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51485.1 - Civil Money Penalties

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The Director may assess civil money penalties against a person or provider
					 ("provider") pursuant to Welfare and Institutions Code Section
					 14123.2
					 after a determination that the provider knows or has reason to know that items
					 or services:
(1) Were not provided as
					 claimed,
(2) Are not reimbursable
					 under the Medi-Cal Program as provided in subsection (d), or
(3) Were claimed in violation of an agreement
					 with the State.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51486 - Medi-Cal Card Labels

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) No
					 provider shall remove more labels from a Medi-Cal card than are necessary to
					 submit a claim for reimbursement for each service, drug, or item
					 provided.
(b) No provider shall
					 remove any label from a Medi-Cal card to bill for any service provided to any
					 person other than the beneficiary identified on such card.
1. New
						section filed 9-30-71 as an emergency; designated effective 10-1-71 (Register
						71, No. 40).
2. Certificate of Compliance--Section
						11422.1,
						Gov. Code, filed 1-25-72 (Register 72, No. 50).
3. Amendment of
						subsection (a) filed 9-27-72; designated effective 11-1-72 (Register 72, No.
						40).
4. New NOTE filed 5-9-84 (Register 84, No.
						19).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14105
						  and
						  14107,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51487 - Examinations of Beneficiaries

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
No provider shall prohibit or interfere with the
						examination of Medi-Cal Program beneficiaries by any duly authorized
						representative of the Department acting in the scope and course of his
						employment.
1. New
						section filed 9-27-72; designated effective 11-1-72 (Register 72, No.
						40).
2. New NOTE filed 12-13-84 (Register 84, No.
						50).
Note: Authority cited: Sections
						  10725,
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14100.1,
						  14104,
						  14105
						  and
						  14133,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51488 - Pharmaceutical Postservice -Postpayment On-Site Reviews Including Clinics with Special Permits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 Department, during on-site reviews of pharmaceutical providers, including
					 clinics with special permits, may review the records of the provider related to
					 the provision of Medi-Cal services to determine compliance with Medi-Cal
					 statutes and regulations. The Department may consider the following in deciding
					 that a provider has received an overpayment:
(1) The drug was ordered or authorized by a
					 licensed prescriber ineligible to participate in the Medi-Cal
					 program.
(2) The dispensed drug,
					 strength and quantity were not the same as the drug, strength and quantity that
					 were ordered or authorized.
(3) The
					 drug dispensed was not a covered benefit.
(4) The Medi-Cal program was inappropriately
					 charged.
(5) The recipient was
					 ineligible to receive Medi-Cal benefits.
(6) The drug was dispensed contrary to the
					 provisions of Section
					 51513.6.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51488.1 - Pharmaceutical Recovery Standards Including Clinics with Special Permits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Department
					 shall recover the following pharmaceutical overpayments from pharmaceutical
					 providers, including clinics with special permits, at their respective recovery
					 rates:
(1) Services not rendered. 100% of the
					 ingredient cost and professional fee, if any, paid shall be recovered where:
(A) The services billed were not
					 provided.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51488.2 - Statistical Extrapolation for Medi-Cal Pharmacy Reviews

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 4-9-80; effective thirtieth day thereafter (Register 80, No.
						15).
2. Editorial correction of NOTE filed 12-14-84 (Register 84,
						No. 50).
3. Repealer filed 4-13-88; operative 5-13-88 (Register 88,
						No. 17).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14103.6,
						  14107,
						  14123,
						  14124.1,
						  14124.2,
						  14133,
						  14133.1,
						  14170,
						  14176
						  and
						  14177,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51488.3 - Underpayment Adjustments to Medi -Cal Reviews of Pharmacies and Clinics With Special Permits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) For
					 the purpose of determining underpayment adjustments to a Medi-Cal recovery
					 action, underpayment shall mean a payment amount within the audit period
					 identified by the pharmacy or clinic with a special permit as being deficient.
					 The underpayment may be due to a billing error made by the pharmacy or clinic
					 with a special permit or an incorrect payment made by the fiscal intermediary
					 for claims submitted within the billing time limits as specified in Section
					 51008.
(b) The pharmacy or clinic with a special
					 permit shall submit a written statement of findings of underpayment to the
					 Department of Health Services prior to issuance of a demand for payment of
					 identified underpayments. This written statement shall provide specific
					 documentation pursuant to Section
					 51476 to support the contention of
					 the pharmacy or clinic with a special permit that an underpayment
					 occurred.
(c) Should a probability
					 sample be used in auditing a pharmacy or a clinic with a special permit having
					 qualified underpaid amounts in the sample, both the overpayments and
					 underpayments shall be extrapolated to the audit period universe in determining
					 the recoverable amount due.
(d) No
					 review may be reopened to provide for underpayments in which a final decision
					 has been reached pursuant to Section
					 14171
					 of the Welfare and Institutions Code.
(e) For the purpose of this section, a valid
					 claim shall mean any claim, for service dates within the audit period, that
					 meets all of the requirements for billing established under Articles 1, 6, and
					 7 of this Chapter.
1. New
						section filed 12-2-85; effective thirtieth day thereafter (Register 85, No.
						49).
2. Amendment of section heading, text and NOTE filed 1-6-94;
						operative 2-7-94 (Register 94, No. 1).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code; and Section
						  208,
						  Health and Safety Code. Reference: Sections
						  10722,
						  14115,
						  14132,
						  14170,
						  14170.1,
						  14171
						  and
						  14172,
						  Welfare and Institutions Code; and Section
						  4063,
						  Business and Professions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51488.4 - Adjustments to Medi-Cal Pharmacy and Clinic with a Special Permit Reviews for Unsubmitted Claims

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Valid claims as defined in Section
					 51488.3(e), which
					 have inadvertently not been submitted for payment, shall be submitted to the
					 fiscal intermediary for adjudication and shall be credited toward the amount of
					 any overpayment due the Department of Health Services as a result of an onsite
					 review.
(b) The pharmacy or clinic
					 with a special permit shall submit specific written documentation pursuant to
					 Section 51476 to support the contention
					 that the previously unsubmitted claim is a valid claim. The documentation shall
					 be submitted to the Department of Health Services prior to issuance of a demand
					 for payment of identified overpayments.
(c) No review may be reopened to provide for
					 underpayments in which a final decision has been reached pursuant to Section
					 14171
					 of the Welfare and Institutions Code.
1. New
						section filed 12-2-85; effective thirtieth day thereafter (Register 85, No.
						49).
2. Amendment of section heading, subsection (b) and NOTE filed
						1-6-94; operative 2-7-94 (Register 94, No. 1).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code; and Section
						  208,
						  Health and Safety Code. Reference: Sections
						  10722,
						  14115,
						  14132,
						  14170,
						  14170.1,
						  14171
						  and
						  14172,
						  Welfare and Institutions Code; and section
						  4063,
						  Business and Professions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51489 - Eligibility for Payment for Paramedic Ambulance Services. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 4-20-82 as an emergency; effective upon filing (Register 82, No.
						18).
2. Order of Repeal of 4-20-82 emergency order filed 4-29-82 by
						OAL pursuant to Government Code Section
						11349.6
						(Register 82, No. 18).
3. New section filed 7-6-82 as an emergency;
						effective upon filing (Register 82, No. 28). A Certificate of Compliance must
						be transmitted to OAL within 120 days or emergency language will be repealed on
						11-3-82.
4. Certificate of Compliance as to 7-6-82 order transmitted
						to OAL 11-3-82 and filed 12-3-82 (Register 82, No. 49).
5. Repealer
						filed 8-9-85; effective thirtieth day thereafter (Register 85, No.
						32).
Note: Authority cited: Section
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14132,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51490 - Claim Submission Requirements for Short-Doyle Medi-Cal Providers

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) All claims for
					 community mental health and drug abuse services provided to Medi-Cal
					 beneficiaries by a Short-Doyle Medi-Cal provider shall be submitted through the
					 Short-Doyle Medi-Cal system.
(b)
					 Except for good cause, as specified in Section
					 51008 and approved by the
					 Department, claims for Short-Doyle Medi-Cal services shall be presented to the
					 Department of Mental Health no later than two months after the month of
					 service. The Department of Mental Health shall present such claims to the
					 Department no later than three months after the month of service.
(c) The State Department of Mental Health
					 shall resubmit a claim, which has been returned by the Department for
					 correction or additional information, no later than three months after the
					 month in which the claim was sent by the Department.
1. New
						section filed 1-31-85 as an emergency; designated effective 2-1-85 (Register
						85, No. 7). A Certificate of Compliance must be transmitted to OAL within 120
						days or emergency language will be repealed on 6-3-85. For prior history, see
						Register 84, No. 48.
2. Certificate of Compliance including
						amendment transmitted to OAL 5-17-85 and filed 6-14-85 (Register 85, No.
						24).
3. Amendment of subsections (b) and (c) filed 12-14-95 as an
						emergency; operative 12-14-95 (Register 95, No. 50). A Certificate of
						Compliance must be transmitted to OAL by 4-12-96 or emergency language will be
						repealed by operation of law on the following day.
4. Reinstatement
						of subsections as they existed prior to emergency amendment filed 12-14-95 by
						operation of Government Code section
						11346.1
						(Register 96, No. 16).
5. Amendment of subsections (b) and (c) filed
						4-16-96 as an emergency; operative 4-16-96 (Register 96, No. 16). A Certificate
						of Compliance must be transmitted to OAL by 8-14-96 or emergency language will
						be repealed by operation of law on the following day.
6. Certificate
						of Compliance as to 4-16-96 order transmitted to OAL 8-13-96 and filed 9-25-96
						(Register 96, No. 39).
Note: Authority cited: Sections
						  10725,
						  14021.5
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14021.5,
						  Welfare and Institutions Code.