22 CCR 51000.40
California
Reporting of Additional or Changed Information to Provider Applications.
22 CCR 51000.40
Source text
32 segments
22 CCR 51000.40
22 CCR 51000.40
§ 51000.40. Reporting of Additional or Changed Information to Provider Applications.
(a)
A provider, including a provider group, shall report to the Department within 35 days of any addition or change in the information previously submitted in the application package.
(b)
A provider, including a provider group, shall complete the form “Medi-Cal Supplemental Changes,” DHCS 6209 (Rev. 12/14), incorporated by reference herein, to add or change the following information, or to request the following actions:
(1)
“Pay to”, unless the provider is a substance use disorder clinic, or “mailing” address.
(2)
Business telephone number.
(3)
Managing employee.
(4)
Pharmacist-in-charge, if the provider is a pharmacy.
(5)
Medicare billing number.
(6)
Business activities, if the provider currently provides durable medical equipment and/or incontinence medical supplies and:
(A)
The change requires the issuance of a new license, permit, or certificate; or
(B)
The provider is adding or deleting incontinence medical supplies.
(7)
Name under which the provider or provider group is doing business (DBA).
(8)
CLIA number.
(9)
Deactivation of a provider number.
(10)
Re-issuance of a Provider Identification Number (PIN), unless the provider is a substance use disorder clinic.
(11)
For provider of medical transportation services:
(A)
Vehicle or aircraft information.
(B)
Driver or pilot information, or the addition of information on a new driver or pilot.
(C)
The days and/or hours of operation of the applicant's or provider's business.
(D)
The geographic area(s) served.
(12)
A change of less than 50 percent in the person(s) with an ownership or control interest, as defined in Section 51000.15, of the provider, or provider group that does not result in a new Taxpayer Identification Number being issued by the IRS. Any cumulative change of 50 percent or more in the person(s) with an ownership or control interest, since the information provided in the last complete application package was approved for enrollment, requires a new application required pursuant to Section 51000.30(b)(6).
(13)
Specialty Code.
(14)
For a substance use disorder clinic the following additional actions:
(A)
A change of the substance use disorder medical director or physicians making medical necessity determinations for beneficiaries.
(B)
Deletion or addition of service modalities.
(C)
A change of any substance use disorder treatment professional or licensed substance use disorder treatment professional providing counseling services.
(c)
A nonphysician medical practitioner or licensed midwife shall complete the “Medi-Cal Nonphysician Medical Practitioner and Licensed Midwife Application,” DHS 6248 (Rev. 07/05), to report to the Department any change in information previously submitted, as required pursuant to Section 51000.30(d), to add or change the following information, or to request the following actions:
(1)
Delete a nonphysician medical practitioner or licensed midwife;
(2)
Change the supervising physician, when the employing provider remains the same;
(3)
Change the hours of supervision;
(4)
Change the maximum hours worked per week.
(d)
The Department may require the provider to submit a new application package when the provider uses the form “Medi-Cal Supplemental Changes,” DHCS 6209 (Rev. 12/14) to report information not listed in subsection (b) above.
Source outline
31 anchors in this source