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 1 - Application and Enrollment › Section 51000.52 - Provider Numbers

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 When provisional provider status or preferred provisional provider status is
					 granted, a provider number shall be used by the provider for each business
					 address for which an application package has been approved. This provider
					 number shall be used exclusively for the locations for which it is issued,
					 except for providers subject to paragraphs (1), (2), or (3) below:
(1) If the practice of the provider's
					 profession or delivery of services, goods, supplies, or merchandise is such
					 that services, goods, supplies, or merchandise are rendered or delivered only
					 at locations other than the provider's business address and this practice or
					 delivery of services, goods, supplies, or merchandise has been disclosed in the
					 application package approved by the Department when the provisional provider
					 status or preferred provisional provider status was granted; or
(2) If a provider submits claims under an
					 existing provider number for services rendered at an additional or change in
					 location, pursuant to Section
					 51000.51(b);
					 or
(3) A rendering provider in a
					 group uses only one provider number, which does not change by location or
					 provider group.
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 1 - Application and Enrollment › Section 51000.53 - Deactivation of a Provider Number(s) or Location(s)

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Department shall deactivate,
					 immediately and without prior notice, a provider's provider number(s) or
					 location(s) used to obtain reimbursement from the Medi-Cal program, under the
					 following circumstances:
(1) When warrants or
					 documents mailed to a provider's mailing address, pay to address, or business
					 address, are returned by the United States Postal Service as not
					 deliverable.
(2) When a provider
					 has not submitted a claim for reimbursement from the Medi-Cal program for one
					 year.
(3) When the person or entity
					 that was enrolled no longer exists by operation of law or otherwise.
(4) When an application for change in
					 location, pursuant to Welfare and Institutions Code Section
					 14043.26(k),
					 is approved the prior location shall be deactivated.
(5) When the provider has a license,
					 certificate, or other approval to provide healthcare revoked or suspended by a
					 federal, California, or another state's licensing, certification, or approval
					 authority, or 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.
(6) When a provider receives written notice
					 that it is subject to the requirement for continued enrollment pursuant to
					 Section 51000.55 and fails to respond to
					 the Department within the time frames required by Sections
					 51000.50 and
					 51000.55.
(7) When a provider submits a written request
					 for termination or deactivation of its provider number(s) or
					 location(s).
(8) When an
					 application submitted pursuant to Section
					 51000.30(b) is
					 approved, and the provider transferor and transferee applicant meet the
					 requirements set forth in Section
					 51000.32, the provider status of
					 the transferor at that location shall be deactivated.
(9) When an application submitted pursuant to
					 Section 51000.30(b) is
					 denied on the transferee applicant's failure to meet the criteria specified in
					 Section 51000.50(a), the
					 provider transferor's provider number or location shall be
					 deactivated.
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 1 - Application and Enrollment › Section 51000.70 - Substance Use Disorder Medical Director Utilization

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each substance use disorder clinic shall have a licensed
						physician designated as the substance use disorder medical director, who is an
						agent of the substance use disorder clinic. The substance use disorder medical
						director shall meet the following requirements:
(a) Not be excluded from participation in any
					 State or Federal Medicare or Medicaid program; and
(b) Be enrolled in Medi-Cal as a substance
					 use disorder medical director; and
(c) Be acting in compliance with all laws and
					 requirements of the Medi-Cal program.
1. New
						section filed 8-17-2015 as a deemed emergency exempt from OAL review pursuant
						to Welfare and Institutions Code section
						14043.75;
						operative 8-17-2015 (Register
						2015,
						No. 34). A Certificate of Compliance must be transmitted to OAL by 2-16-2016 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 8-17-2015 order transmitted
						to OAL 12-30-2015 and filed 2-11-2016 (Register 2016, No.
						7).
Note: Authority cited: Section
						  20, Health and Safety Code;
						  Sections
						  10725,
						  14043.75,
						  14043.47(c)
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14021,
						  14021.3,
						  14021.5,
						  14021.6,
						  14021.33,
						  14021.51,
						  14043.7,
						  14107,
						  14124.1,
						  14124.2,
						  14124.24,
						  14124.25,
						  14131,
						  14133
						  and
						  14133.1,
						  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 1 - Application and Enrollment › Section 51000.75 - Licensed Substance Use Disorder Treatment Professional and Substance Use Disorder Nonphysician Medical Practitioner Utilization

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each substance use disorder clinic shall list all
						licensed substance use disorder treatment professionals and substance use
						disorder nonphysician medical practitioners, utilized at the business address,
						on the "Drug Medi-Cal Substance Use Disorder Clinic Application," DHCS 6001
						(Rev. 12/14). Each licensed substance use disorder treatment professional shall
						meet the following requirements:
(a)
					 Not be excluded from participation in any State or Federal Medicare or Medicaid
					 program; and
(b) Be enrolled in
					 Medi-Cal as a licensed substance use disorder treatment professional or a
					 substance use disorder nonphysician medical practitioner.
1. New
						section filed 8-17-2015 as a deemed emergency exempt from OAL review pursuant
						to Welfare and Institutions Code section
						14043.75;
						operative 8-17-2015 (Register
						2015,
						No. 34). A Certificate of Compliance must be transmitted to OAL by 2-16-2016 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 8-17-2015 order transmitted
						to OAL 12-30-2015 and filed 2-11-2016 (Register 2016, No.
						7).
Note: Authority cited: Section
						  20, Health and Safety Code;
						  Sections
						  10725,
						  14043.75
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14021,
						  14021.3,
						  14021.5,
						  14021.6,
						  14021.33,
						  14021.51,
						  14043.7,
						  14107,
						  14124.1,
						  14124.2,
						  14124.24,
						  14124.25,
						  14131,
						  14133
						  and
						  14133.1,
						  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 1.3 - General Provisions › Section 51001 - Beneficiary. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Amendment filed 6-5-67 as an emergency; effective upon filing. Certificate of
						Compliance filed 6-9-67 (Register 67, No. 23).
2. Amendment filed
						6-22-87; operative 7-22-87 (Register 87, No. 27).
3. Renumbering of
						former article 1 to article 1.3 and repealer of section filed 9-28-99 as an
						emergency; operative 9-28-99 (Register 99, No. 40). A Certificate of Compliance
						must be transmitted to OAL by 3-27-2000 or emergency language will be repealed
						by operation of law on the following day. Submitted to OAL for printing only
						pursuant to section
						78, AB 1107 (Chapter 146, Statutes
						of 1999).
4. Renumbering of former article 1 to article 1.3 and
						repealer of section refiled 11-24-99 as an emergency; operative 11-24-99
						(Register 99, No. 48). A Certificate of Compliance must be transmitted to OAL
						by 5-22-2000 or emergency language will be repealed by operation of law on the
						following day. Submitted to OAL for printing only pursuant to section
						78, AB 1107 (Chapter 146, Statutes
						of 1999).
5. Renumbering of former article 1 to article 1.3, and
						repealer of section refiled 5-5-2000 as an emergency; operative 5-22-2000
						(Register 2000, No. 18). A Certificate of Compliance must be transmitted to OAL
						by 9-19-2000 or emergency language will be repealed by operation of law on the
						following day.
6. Renumbering of former article 1 to article 1.3,
						and repealer of section refiled 8-28-2000 as an emergency; operative 9-6-2000
						(Register 2000, No. 35). A Certificate of Compliance must be transmitted to OAL
						by 1-4-2001 or emergency language will be repealed by operation of law on the
						following day.
7. Certificate of Compliance as to 8-28-2000 order
						transmitted to OAL 12-26-2000 and filed 2-8-2001 (Register 2001, No.
						6).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14000
						  and
						  14005,
						  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 1.3 - General Provisions › Section 51002 - Beneficiary Billing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A
					 provider of service under the Medi-Cal program shall not submit claims to or
					 demand or otherwise collect reimbursement from a Medi-Cal beneficiary, or from
					 other persons on behalf of the beneficiary, for any service included in the
					 Medi-Cal program's scope of benefits in addition to a claim submitted to the
					 Medi-Cal program for that service, except to:
(1) Collect payments due under a contractual
					 or legal entitlement pursuant to Section
					 14000(b)
					 of the Welfare and Institutions Code.
(2) Bill a long-term care patient for the
					 amount of his liability.
(3)
					 Collect copayment pursuant to Welfare and Institutions Code Section
					 14134.
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 1.3 - General Provisions › Section 51002.5 - Submission of Electronic Treatment Authorization Requests (eTARs)

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Department
					 shall consider the capacity of a provider to comply with the requirements of
					 Welfare and Institutions Code Section
					 14133.01,
					 as it pertains to the submission of eTARs, including:
(1) Allowing a provider a reasonable time to
					 establish the infrastructure necessary for the generation of eTARs.
(2) Offering a provider the opportunity to
					 participate in education and training provided by the Department on the
					 generation and submission of eTARs.
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 1.3 - General Provisions › Section 51003 - Treatment Authorization Requests (TARs)

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) "Prior authorization," or "authorization"
					 means authorization granted by a designated Medi-Cal consultant or by a Primary
					 Care Case Management (PCCM) plan and is obtained through submission and
					 approval of a TAR. The responsibilities of the Medi-Cal consultant shall not be
					 delegated, except to the extent provided under Sections
					 51013 and
					 51014. Authorization may be
					 granted by a PCCM plan only for beneficiaries enrolled in that PCCM plan and
					 the responsibilities of the PCCM plan shall not be delegated except as provided
					 under Section
					 51003.7.
(b) A TAR received by the Department from a
					 Fee-For-Service Medi-Cal provider shall be reviewed for medical necessity
					 only.
(c) "Reauthorization" means
					 authorization of a new TAR for continuation of previously authorized Medi-Cal
					 services.
(1) "Request for Non-Acute
					 Continuing Services," as used in Section
					 51014.1(e), means
					 a new TAR for continuation of previously approved services received by the
					 Department from Fee-For-Service Medi-Cal providers in the following categories:
(A) Long-Term Care, specifically Skilled
					 Nursing Facility, Intermediate Care Facility and Subacute levels of
					 care.
(B) General Inpatient Hospice
					 Care.
(C) Home and Community-Based
					 Waiver Services, including all related services.
(D) Early Periodic Screening Diagnosis and
					 Treatment (EPSDT) Supplemental Home Nursing and Related Services.
(E) All other non-acute services under the
					 Medi-Cal program when the treating physician (i.e., the physician, podiatrist,
					 or dentist who is treating the beneficiary and certifying that the services
					 must be continued) substantiates on or with the request in writing that the
					 same level or frequency of services should be continued because the treatment
					 goal approved on the original TAR has not been achieved, without regard to the
					 length of time the service has been provided. To meet the requirement to
					 substantiate the need for continuing care, justification of medical necessity
					 shall be submitted pursuant to subsection (d).
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 1.3 - General Provisions › Section 51003.1 - Provider Appeal Process for Treatment Authorization Requests (TARs)

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A provider of
					 services may appeal the decision of a Medi-Cal consultant regarding a Treatment
					 Authorization Request (TAR), as follows:
(1)
					 The provider shall submit a TAR appeal within 180 calendar days from the date
					 of the decision on the original TAR.
(2) When the last day of the 180 calendar day
					 appeal period falls on a Saturday, Sunday or Holiday, the final date to submit
					 the TAR appeal will be the next business day.
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 1.3 - General Provisions › Section 51003.3 - Prior Authorization of Personal Care Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
"Prior Authorization," "reauthorization," or "approval"
						of a beneficiary of Medi-Cal personal care benefits means authorization granted
						by the staff of the designated county department.
1.
						Renumbering of former section
						51003.1 to section
						51003.3, including amendment of
						section and NOTE, filed 2-22-2007; operative 3-24-2007 (Register 2007, No.
						8).
Note: Authority cited: Section
						  14132.95,
						  Welfare and Institutions Code; Section
						  8, Chapter 939, Statutes of 1992;
						  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 1.3 - General Provisions › Section 51003.7 - Prior Authorization Under Primary Care Case Management Contracts

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) All Medi-Cal
					 covered services not included in the PCCM plan contract as part of the
					 capitated services provided to a PCCM plan member are subject to prior
					 authorization by the member's PCCM plan except:
(1) Dental Services.
(2) Emergency services as defined in section
					 51056(a).
(3) Those services determined by the
					 Department to be exempt from PCCM plan prior authorization requirements as
					 specified in each PCCM plan contract. In determining which services shall not
					 be subject to prior authorization, the Department shall consider the factors
					 specified in section
					 51159(a).
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 1.3 - General Provisions › Section 51004 - Copayment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Copayment as
					 used in these regulations refers to a specified amount of money which a
					 beneficiary must expend for an outpatient visit to or by a provider, for each
					 prescribed drug and for nonemergency services received in an emergency room as
					 set forth in Welfare and Institutions Code Section
					 14134.
(b) A visit means all services provided on
					 one occasion by one provider and billed on one claim.
(c) A drug prescription means a written
					 instruction by a physician for the preparation and dispensing of a
					 medicine.
(d) Perinatal care means
					 services received during the full period of getation and the first month
					 following birth.
1.
						Repealer filed 5-14-76 as an emergency; effective upon filing (Register 76, No.
						20). For prior history, see Register 72, No. 18.
2. Certificate of
						Compliance filed 9-8-76 (Register 76, No. 37).
3. New section 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.
4. Certificate of
						Compliance transmitted to OAL 3-16-82 and filed 4-16-82 (Register 82, No.
						16).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code; Section
						  133.5 of Chapter 102, Statutes of
						  1981; and Section
						  2 of Chapter 237, Statutes of
						  1981. Reference: Section
						  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 1.3 - General Provisions › Section 51005 - Other Health Care Coverage

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Wherever beneficiaries eligible for
					 benefits under this program are also eligible for the same benefits, either
					 full or partial, under any other State or Federal medical care program or under
					 other contractual or legal entitlement, including but not limited to a private
					 group or indemnification insurance program or the Federal Medicare program, the
					 Department shall require the full utilization of benefits available through the
					 other programs, before utilizing Medi-Cal covered benefits. This requirement
					 shall not apply to beneficiaries covered under Medi-Cal capitated contracting
					 arrangements except to the extent permitted under the capitated contract.
(1) The maximum reimbursement by Medi-Cal for
					 services rendered to beneficiaries with other State, Federal, or private health
					 care coverage shall be the reimbursement calculated on a claim for similar
					 services established under chapter 7 (sections
					 14000 through
					 14199) of the Welfare and
					 Institutions Code, less the amount of the payment made by the other State,
					 Federal, or private health care program.
(2) Where a claim for medical services
					 involves coverage under both the Medicare and Medi-Cal programs, the maximum
					 reimbursement by Medi-Cal shall be the amount established for similar services
					 under chapter 7 (sections
					 14000 through
					 14199) of the Welfare and
					 Institutions Code, less the amount paid by Medicare. In the event the
					 Department cannot for any reason establish the amount it would have paid for
					 similar services, the maximum reimbursement shall be the amount of the Medicare
					 deductible and coinsurance claimed.
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 1.3 - General Provisions › Section 51006 - Out-of-State Coverage

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Necessary out-of-state medical care, within the limits of the program, is
					 covered only under the following conditions:
(1) When an emergency arises from accident,
					 injury or illness; or
(2) Where the
					 health of the individual would be endangered if care and services are postponed
					 until it is feasible that he return to California; or
(3) Where the health of the individual would
					 be endangered if he undertook travel to return to California; or
(4) When it is customary practice in border
					 communities for residents to use medical resources in adjacent areas outside
					 the State; or
(5) When an
					 out-of-state treatment plan has been proposed by the beneficiary's attending
					 physician and the proposed plan has been received, reviewed and authorized by
					 the Department before the services are provided. The Department may authorize
					 such out-of-state treatment plans only when the proposed treatment is not
					 available from resources and facilities within the State.
(6) Prior authorization is required for all
					 out-of-state services, except:
(A) Emergency
					 services as defined in Section
					 51056.
(B) Services provided in border areas
					 adjacent to California where it is customary practice for California residents
					 to avail themselves of such services. Under these circumstances, program
					 controls and limitations are the same as for services from providers within 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 1.3 - General Provisions › Section 51007 - Discrimination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
No provider of services receiving payment through this
						program shall discriminate against any beneficiary on the basis of race, color,
						age, sex, religion, ancestry, national origin or physical or mental
						disability.
1.
						Amendment filed 6-5-67 as an emergency; effective upon filing. Certificate of
						Compliance filed 6-9-67 (Register 67, No. 23).
2. Amendment 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
						  10000
						  and
						  14100.1,
						  Welfare and Institutions Code; and Section
						  11135,
						  Government 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 1.3 - General Provisions › Section 51008 - Bills for Service

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Except for good cause, bills for service provided pursuant to the Medi-Cal
					 Program (Welfare and Institutions Code, Division 9, Part 3, Chapter 7), shall
					 be received by the fiscal intermediary, or otherwise as designated by the
					 Director, not later than the sixth month following the month of service and
					 shall be in the form prescribed by the Director.
(b) As used in this section:
(1) "Month of service" means the month in
					 which a:
(A) Service is provided or supplies
					 are furnished.
(B) Dental
					 prosthesis, custom-made eye appliance, custom-made prosthetic appliance, or
					 custom-made orthotic appliance is ordered from the fabricating
					 laboratory.
(C) Trial period prior
					 authorized or required under these regulations is completed for a prosthetic
					 appliance or orthotic appliance covered under Section
					 51315, a hearing aid covered under
					 Section 51319, or an item of durable
					 medical equipment covered under Section
					 51321.
"Good cause" means circumstances beyond the control of
						the provider, as specified in Section
						51008.5.
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 1.3 - General Provisions › Section 51008.1 - Upper Billing Limit

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Bills submitted pursuant to Section
					 51008 for durable medical
					 equipment as defined in Section
					 51160, medical supplies authorized
					 pursuant to Section
					 51320, or incontinence medical
					 supplies listed in Section
					 51526(c) shall
					 not exceed an amount that is the lesser of:
(1) The usual charges made to the general
					 public, or
(2) The net purchase
					 price of the item, which shall be documented in the provider's books and
					 records, plus no more than a 100 percent mark-up. Documentation shall include,
					 but not be limited to, evidence of purchase such as invoices or receipts.
(A) Net purchase price is defined as the
					 actual cost to the provider to purchase the item from the seller, including any
					 rebates, refunds, discounts or any other price reducing allowances, known by
					 the provider at the time of billing the Medi-Cal program for the item, that
					 reduce the item's invoice amount.
(B) The net purchase price shall reflect
					 price reductions guaranteed by any contract to be applied to the item(s) billed
					 to the Medi-Cal program.
(C) The
					 net purchase price shall not include provider costs associated with late
					 payment penalties, interest, inventory costs, taxes, or labor.
(D) Where a custom wheelchair as defined in
					 (d) is subject to the provisions of this regulation, the provider may bill the
					 provider's cost of labor to assemble the custom wheelchair which is above the
					 100 percent mark-up, only when the inclusion of the actual labor cost would
					 result in a bill that exceeds the net purchase price of the entire custom
					 wheelchair plus a 100 percent mark-up. Regardless of any codes used to bill the
					 wheelchair base or frame of a custom wheelchair, where inclusion of the
					 provider's actual cost for assembly of the custom wheelchair exceeds the amount
					 of the allowed 100 percent mark-up, the provider shall be allowed to add to the
					 bill submitted under 51008 that actual cost of labor that exceeds the 100
					 percent mark-up to the claim line that would otherwise have been used to bill
					 only the custom wheelchair's base or frame.
(E) If the provider's actual cost of labor is
					 included in the bill, the actual time spent assembling the entire custom
					 wheelchair shall be itemized by hours or fractions thereof and the per hour
					 cost of labor, and each shall be documented in the provider's books and
					 records.
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 1.3 - General Provisions › Section 51008.5 - Billing Procedures for Claims Delayed by Good Causes

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Department, upon review of
					 substantiating documentation received to justify good cause for late submittal
					 of the claim, may receive and authorize the processing of late claims if the
					 reason for delayed submission is due to the following circumstances which are
					 beyond the control of the provider:
(1)
					 Failure of the patient or legal representative, due to deliberate concealment
					 or physical or mental incapacity, to present identification as a Medi-Cal
					 beneficiary. Delayed billing shall be submitted not later than 60 days after
					 the date certified by the provider as the date the patient was first identified
					 as a Medi-Cal beneficiary. The date certified by the provider as the date the
					 patient was first identified shall not be later than one year after the month
					 in which the service was rendered. Identification of a patient as a Medi-Cal
					 beneficiary means presentation of any of the following for the month of
					 service:
(A) Medi-Cal card.
(B) MEDI label.
(C) Proof of eligibility (POE)
					 label.
(D) Any of the above
					 indicating Kaiser, Ross-Loos or CHAMPUS coverage, when accompanied by denial of
					 coverage or an explanation of the other coverage by that
					 carrier.
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 1.3 - General Provisions › Section 51009 - Confidential Nature of Records

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
All individual medical records of beneficiaries acquired
						by individuals or institutions providing care, the Department, or any other
						state or local agency, or by any organization contracting to provide
						administrative services under this program, shall be confidential and shall not
						be released without the written consent of the beneficiary or his personal
						representative. This shall not preclude the release of statistical or summary
						data or information in which individual beneficiaries are not, and cannot be,
						identified, nor shall it preclude exchange of information between individuals
						or institutions providing care, fiscal intermediaries, and state or local
						official agencies. Neither shall this section preclude exchange of information
						necessary for the purpose of effecting recovery as provided in Welfare and
						Institutions Code, Sections
						10020
						through
						10025,
						14024
						and
						14124.70
						through
						14124.79
						with persons liable thereunder.
1. Refiled
						6-5-67 as an emergency; effective upon filing, Certificate of Compliance filed
						6-9-67 (Register 67, No. 23).
2. Amendment filed 11-15-68; effective
						thirtieth day thereafter (Register 68, No. 43).
3. Amendment filed
						7-13-73; effective thirtieth day thereafter (Register 73, No.
						28).
4. Editorial correction (Register 81, No. 38).
5.
						New NOTE filed 12-13-84 (Register 84, No. 50).
Note: Authority cited: Sections
						  10725,
						  14100.2
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14100.2,
						  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 1.3 - General Provisions › Section 51011 - Identification of Beneficiary

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) All out-of-hospital and inpatient
					 services may be provided subject to the limitations specified in the scope of
					 benefits, and subject to the Medical Assistance classification of the
					 beneficiary upon presentation by a beneficiary of a valid medical care
					 eligibility card issued by a local welfare department, except where these
					 regulations specify that prior authorization for a specific service is
					 required, and evidence of such authorization is presented or furnished, such
					 card shall be deemed adequate authorization to provide services up to the
					 expiration date specified on the card. Limitations to personal care services
					 are specified in Section
					 51350.
1. Refiled
						6-5-67 as an emergency; effective upon filing. Certificate of Compliance filed
						6-9-67 (Register 67, No. 23).
2. Amendment of subsection (a) 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 1.3 - General Provisions › Section 51011.1 - Year 2000 Alternate Procedure for Verification of Eligibility. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 12-27-99 as an emergency; operative 12-27-99 (Register 99, No.
						53). A Certificate of Compliance must be transmitted to OAL by 4-25-2000 or
						emergency language will be repealed by operation of law on the following
						day.
2. Repealed by operation of Government Code section
						11346.1(g)
						(Register 2001, No. 46).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14018.2,
						  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 1.3 - General Provisions › Section 51013 - California Children Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A beneficiary under age 21 who has a medical or surgical
						condition which would qualify for services under California Children Services,
						shall be referred to that program for case management and prior authorization
						by the appropriate local or state administrative agency for California Children
						Services. Medical care not provided through California Children Services shall
						be provided through the procedures established in these
						regulations.
1. Refiled
						6-5-67 as an emergency; effective upon filing. Certificate of Compliance filed
						6-9-67 (Register 67, No. 23).
2. Amendment filed 6-22-87; operative
						7-22-87 (Register 87, No. 27).
3. Editorial correction of first
						sentence (Register 95, No. 45).
Note: Authority cited: Sections
						  10725,
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14000
						  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 1.3 - General Provisions › Section 51014 - Vocational Rehabilitation Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Whenever a service is requested on behalf of a Medi-Cal
						beneficiary on the basis that such service is needed for vocational
						rehabilitation, that beneficiary shall be referred in writing by the Medi-Cal
						consultant to the State Department of Rehabilitation for counseling and
						evaluation.
1. New
						section filed 5-31-68; effective thirtieth day thereafter (Register 68, No.
						21).
2. Amendment filed 12-7-87; operative 1-6-88 (Register 87, No.
						50).
Note: Authority cited: Sections
						  10725,
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14113,
						  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 1.3 - General Provisions › Section 51014.1 - Fair Hearing Related to Denial, Termination or Reduction in Medical Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) In addition to
					 any notice mailed pursuant to section
					 50179,
					 53261,
					 53452,
					 56261, or
					 56452, each beneficiary shall be
					 informed in writing, at the time of application to the program and by the
					 Department on a quarterly basis thereafter, of the right to a fair hearing upon
					 receipt of notice of:
(1) Any action, other
					 than approval, including but not limited to deferral or denial, taken by the
					 Department or a Medi-Cal managed care plan on a request by a provider for any
					 medical service.
(2) Any intended
					 action by the Department or a Medi-Cal managed care plan to terminate or reduce
					 any medical service.
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 1.3 - General Provisions › Section 51014.2 - Medical Assistance Pending Fair Hearing Decision

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Continued medical assistance as set forth
					 in (b), (c), and (d) below, pending a hearing decision shall be provided only
					 if the beneficiary appeals in writing to the Department for a hearing within 10
					 days of the mailing or personal delivery of the notice of action pursuant to
					 section 51014.1(c), (e) or
					 (f), or before the effective date of
					 action.
(b) In the case of a
					 termination or reduction pursuant to section
					 51014.1(c),
					 authorization shall be maintained until the period covered by the existing
					 authorization expires, the date a hearing decision is rendered, or the date on
					 which the hearing is otherwise withdrawn or closed, whichever is
					 earliest.
(c) In the case of a
					 termination of acute care services pursuant to section
					 51014.1(f), acute
					 care authorization pending a hearing shall begin:
(1) The first day after the previously
					 approved length of stay for continuing acute care if the request for extension
					 by a provider was submitted to the on-site Medi-Cal reviewer during the first
					 on-site visit after the previously approved length of stay expired.
(2) The sixth day of hospitalization if a
					 request for extension pursuant to section
					 51003(c)(2)(B)5.
					 was submitted to the on-site Medi-Cal reviewer during the first on-site visit
					 after the first five days of hospitalization.
(3) The day the request for extension was
					 submitted to the Department or to the Medi-Cal managed care plan if neither (1)
					 nor (2) apply.
(4) The date of the
					 termination decision if a decision on the request for extension was initially
					 deferred pending the receipt of additional information.
Authorization pending a hearing pursuant to this
						subdivision shall end on the date a hearing decision is rendered, the date on
						which the hearing appeal is withdrawn or closed, the date the treating
						physician documents that the beneficiary is ready for lower level of care, or
						the date of discharge, whichever is earliest.
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 1.3 - General Provisions › Section 51015 - Provider Grievances and Complaints

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
When a provider of services has a grievance or complaint
						concerning the processing or payment of his claims for services provided under
						the Medical Assistance Program the following procedures must be met:
(a) The provider shall initiate an appeal, by
					 submitting a grievance or complaint in writing, within 90 days of the action
					 precipitating the grievance or complaint, to the appropriate fiscal
					 intermediary identifying the claims involved and specifically describing the
					 disputed action or inaction regarding such claims.
(b) The fiscal intermediary shall acknowledge
					 the written grievance or complaint within 15 days of its receipt.
(c) The fiscal intermediary shall determine
					 whether or not the grievance or complaint shall be referred to professional
					 peer review.
(1) When the grievance or
					 complaint is not referred to professional peer review, the fiscal intermediary
					 shall review the merits of the grievance or complaint and send a written
					 decision of its conclusion and reasons therefor to the provider within 30 days
					 of the acknowledgment of the receipt of the grievance or complaint.
(2) When the grievance or complaint is
					 referred to professional peer review:
(A) All
					 parties concerned shall be notified that the referral has been made to
					 professional peer review and that a final determination will require up to 60
					 days from the acknowledgment of receipt of the grievance or
					 complaint.
(B) The professional
					 peer review shall make its evaluation and submit its findings and
					 recommendations to the fiscal intermediary and the provider within 30 days of
					 the referral from the fiscal intermediary.
(C) The fiscal intermediary, after taking
					 into consideration the findings and recommendations of the professional peer
					 review, shall send a written decision to the
					 provider.
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 1.3 - General Provisions › Section 51015.1 - Special Claims Review Appeals. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						Section filed 12-20-78; effective thirtieth day thereafter (Register 78, No.
						51).
2. Repealer filed 6-24-2003; operative 7-24-2003 (Register
						2003, No. 26).
Note: Authority cited: Sections
						  14105,
						  14124.5
						  and
						  14133(b),
						  Welfare and Institutions Code. Reference: Sections
						  14104.5
						  and
						  14133(b),
						  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 1.3 - General Provisions › Section 51015.2 - Providers of Personal Care Services Grievance and Complaints

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Notwithstanding Section
						51015, when a provider of personal
						care services has a grievance or complaint concerning the processing or payment
						of money for services rendered, the following procedures must be met:
(a) The provider shall initiate an appeal, by
					 submitting a grievance or complaint in writing within 90 days of the action
					 precipitating the grievance or complaint, to the designated county department
					 identifying the claims involved and specifically describing the disputed action
					 or inaction regarding such claims.
(b) The designated county department shall
					 acknowledge the written grievance or complaint within 15 days of its
					 receipt.
(c) The designated county
					 department shall review the merits of the grievance or complaint and send a
					 written decision of its conclusion and reasons to the provider within 30 days
					 of the acknowledgement of the receipt of the grievance or complaint.
(d) After following this procedure, a
					 provider who is not satisfied with the decision by the designated county
					 department may seek appropriate judicial remedies in compliance with Section
					 14104.5
					 of the Welfare and Institutions Code, no later than one year after receiving
					 notice of the decision.
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 1.5 - Provider Audit Appeals › Section 51017 - Provider Audit Hearing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A provider may request a hearing under the provisions of
						this article to examine any disputed audit or examination finding which results
						in an adjustment to Medi-Cal program reimbursement or reimbursement rates by
						submitting a Statement of Disputed Issues to the Department in accordance with
						Section 51022.
1.
						Amendment filed 7-15-85; effective thirtieth day thereafter (Register 85, No.
						29).
Note: Authority cited: Sections
						  14105,
						  14124.5
						  and
						  14171,
						  Welfare and Institutions Code. Reference: Section
						  14171,
						  Welfare and Institutions Code.