Instructions for Form DHCS6065A "Good Cause Certification" - California

This document contains official instructions for Form DHCS6065A, Good Cause Certification - a form released and collected by the California Department of Health Care Services. An up-to-date fillable Form DHCS6065A is available for download through this link.

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Download Instructions for Form DHCS6065A "Good Cause Certification" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
COMPLETION INSTRUCTIONS FOR GOOD CAUSE CERTIFICATION 6065A
GENERAL
The DHCS Good Cause Certification form is used by a Drug Medi-Cal provider to request a waiver of the 30-day Drug Medi-Cal billing limitation.
* A Good Cause Certification form must be completed for each Delay Reason Code used.
* Do not send this form to DHCS unless the specified claims require pre-approval for Delay Reason Codes 4 and 11.
* Retain a copy of the form at the provider site for auditing or monitoring purposes. Note: For county-contracted providers, send the original form to the county.
* Prior approval from DHCS is required prior to submitting this form for Delay Reason Codes 4 and 11. See the DMC Provider Billing Manual for details.
DELAY REASON CODES (see California Code of Regulations, Title 22, Section 51008.5 for usage restrictions and time limits)
Reason Code 1: Patient or legal representative's failure to present Medi-Cal beneficiary identification.
Reason Code 2: Initiation of legal proceedings to obtain payment of a liable third party pursuant to Section 14115 of the Welfare and Institution Code.
Reason Code 4: Determination by the Director of the DHCS, or the Director’s delegate, that the provider was prevented from submitting the claims on time due to circumstances beyond the provider’s control, where the circumstance is
either delay in the certification or recertification of the provider to participate in the DMC program by the State or delay by DHCS in enrolling a provider.
Reason Code 7: Billing involving other coverage, including/not limited to Medi-Care, Kaiser, Ross-Loos, or Champus.
Reason Code 10: Special circumstances that cause a billing delay such as a court decision or fair hearing decision.
Reason Code 11: Determination by the Director of DHCS, or the Director’s delegate, that the provider was prevented from submitting the claims on time due to circumstances beyond the provider’s control, specifically due to:
• Damage to or destruction of the provider’s business office or records by a natural disaster; includes fire, flood or earthquake, or
• Circumstances resulting from such a disaster have substantially interfered with processing bills in a timely manner;
• Theft, sabotage or other deliberate, willful acts by an employee;
• Other circumstances which may be clearly beyond the provider and/or county's control and have been reported to the appropriate law enforcement or fire agency when applicable.
HEADING INSTRUCTIONS
a. COUNTY/DIRECT PROVIDER: if submitter is a county, enter the county name; if submitter is a direct provider, enter the direct provider name.
b. DELAY REASON CODE: enter the appropriate delay reason code
c. EDI FILE NAME: enter the name of the ITWS 837P file.
COLUMN INSTRUCTIONS
a. SUBMITTER'S CLAIM ID NUMBER: for each claim listed, enter the unique claim ID number.
b. CLAIM FOR MO/YEAR: for each claim listed, enter the month and year of the claim.
c. DELAY REASON CODE: for each claim listed, enter the appropriate delay reason code.
d. STATE USE ONLY: submitters should not enter any information in this area. It is for State use only.
SIGNATURE BLOCK INSTRUCTIONS
a. SIGNATURE: only authorized county or direct provider representatives should sign.
b. PHONE NUMBER: enter the area and code and phone number of the representative signing the form.
c. DATE: enter the date the form was signed by the authorized representative.
d. STATE USE ONLY: submitters should not enter any information in this area. It is for State use only.
DHCS 6065A (rev 02/15)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
COMPLETION INSTRUCTIONS FOR GOOD CAUSE CERTIFICATION 6065A
GENERAL
The DHCS Good Cause Certification form is used by a Drug Medi-Cal provider to request a waiver of the 30-day Drug Medi-Cal billing limitation.
* A Good Cause Certification form must be completed for each Delay Reason Code used.
* Do not send this form to DHCS unless the specified claims require pre-approval for Delay Reason Codes 4 and 11.
* Retain a copy of the form at the provider site for auditing or monitoring purposes. Note: For county-contracted providers, send the original form to the county.
* Prior approval from DHCS is required prior to submitting this form for Delay Reason Codes 4 and 11. See the DMC Provider Billing Manual for details.
DELAY REASON CODES (see California Code of Regulations, Title 22, Section 51008.5 for usage restrictions and time limits)
Reason Code 1: Patient or legal representative's failure to present Medi-Cal beneficiary identification.
Reason Code 2: Initiation of legal proceedings to obtain payment of a liable third party pursuant to Section 14115 of the Welfare and Institution Code.
Reason Code 4: Determination by the Director of the DHCS, or the Director’s delegate, that the provider was prevented from submitting the claims on time due to circumstances beyond the provider’s control, where the circumstance is
either delay in the certification or recertification of the provider to participate in the DMC program by the State or delay by DHCS in enrolling a provider.
Reason Code 7: Billing involving other coverage, including/not limited to Medi-Care, Kaiser, Ross-Loos, or Champus.
Reason Code 10: Special circumstances that cause a billing delay such as a court decision or fair hearing decision.
Reason Code 11: Determination by the Director of DHCS, or the Director’s delegate, that the provider was prevented from submitting the claims on time due to circumstances beyond the provider’s control, specifically due to:
• Damage to or destruction of the provider’s business office or records by a natural disaster; includes fire, flood or earthquake, or
• Circumstances resulting from such a disaster have substantially interfered with processing bills in a timely manner;
• Theft, sabotage or other deliberate, willful acts by an employee;
• Other circumstances which may be clearly beyond the provider and/or county's control and have been reported to the appropriate law enforcement or fire agency when applicable.
HEADING INSTRUCTIONS
a. COUNTY/DIRECT PROVIDER: if submitter is a county, enter the county name; if submitter is a direct provider, enter the direct provider name.
b. DELAY REASON CODE: enter the appropriate delay reason code
c. EDI FILE NAME: enter the name of the ITWS 837P file.
COLUMN INSTRUCTIONS
a. SUBMITTER'S CLAIM ID NUMBER: for each claim listed, enter the unique claim ID number.
b. CLAIM FOR MO/YEAR: for each claim listed, enter the month and year of the claim.
c. DELAY REASON CODE: for each claim listed, enter the appropriate delay reason code.
d. STATE USE ONLY: submitters should not enter any information in this area. It is for State use only.
SIGNATURE BLOCK INSTRUCTIONS
a. SIGNATURE: only authorized county or direct provider representatives should sign.
b. PHONE NUMBER: enter the area and code and phone number of the representative signing the form.
c. DATE: enter the date the form was signed by the authorized representative.
d. STATE USE ONLY: submitters should not enter any information in this area. It is for State use only.
DHCS 6065A (rev 02/15)