Instructions for Form DHCS6065B "Good Cause Certification" - California

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This document contains official instructions for Form DHCS6065B, Good Cause Certification - a form released and collected by the California Department of Health Care Services. An up-to-date fillable Form DHCS6065B is available for download through this link.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
COMPLETION INSTRUCTIONS FOR GOOD CAUSE CERTIFICATION 6065B
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.
* 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.
DELAY REASON CODE 8 (see California Code of Regulations, Title 22, Section 51008.5 for usage restrictions and time limits)
Determination by the DHCS Director, or the Director's delegate, that the provider was prevented from submitting the claims on time due to circumstances beyond the control of the county/provider regarding delay or error in the
certification of Medi-Cal eligibility of the beneficiary by the state or county. This includes retroactive Medi-Cal eligibility.
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. EDI FILE NAME: enter the name of the ITWS 837P file.
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.
DHCS 6065B (rev 02/15)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
COMPLETION INSTRUCTIONS FOR GOOD CAUSE CERTIFICATION 6065B
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.
* 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.
DELAY REASON CODE 8 (see California Code of Regulations, Title 22, Section 51008.5 for usage restrictions and time limits)
Determination by the DHCS Director, or the Director's delegate, that the provider was prevented from submitting the claims on time due to circumstances beyond the control of the county/provider regarding delay or error in the
certification of Medi-Cal eligibility of the beneficiary by the state or county. This includes retroactive Medi-Cal eligibility.
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. EDI FILE NAME: enter the name of the ITWS 837P file.
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.
DHCS 6065B (rev 02/15)
California Department of Health Care Services California Legal Forms United States Legal Forms

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