Form DHCS6065B "Good Cause Certification" - California

What Is Form DHCS6065B?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on February 1, 2015;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHCS6065B by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS6065B "Good Cause Certification" - California

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STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICE
GOOD CAUSE CERTIFICATION
Retroactive Eligibility - Delay Reason Code 8
___________________________________________________
requests a waiver of the 30-day Drug Medi-Cal billing limitation for the claims listed below.
COUNTY/DIRECT PROVIDER
EDI File Name:
______________________________________
By signing below, I certify that I have reviewed the claims in the above-named EDI file using the Attachment Control Number listed
above, and that each such claim is being submitted more than 30 days after the end of the month of service due to delay or error in
the certification or determination of the Medi-Cal eligibility by the State or county for the client to whom services identified on that
claim were provided. I also certify that each of those claim(s) are being submitted not later than 60 days after that delay or error
was resolved by the State or county, and that documentation substantiating those circumstances for each client are on file with the
above named county or direct provider and will be made available to the California Department of Health Care Services (DHCS) on
request for auditing and monitoring purposes. I further acknowledge that I understand that DHCS will rely on this certification in
determining that this late submission is acceptable under Title 22 of the California Code of Regulations, Section 51008.5.A14.
Phone Numbe
r
Signature: COUNTY/DIRECT PROVIDER REPRESENTATIVE
Date:
(
)
DHCS 6065B (rev 02/15)
STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICE
GOOD CAUSE CERTIFICATION
Retroactive Eligibility - Delay Reason Code 8
___________________________________________________
requests a waiver of the 30-day Drug Medi-Cal billing limitation for the claims listed below.
COUNTY/DIRECT PROVIDER
EDI File Name:
______________________________________
By signing below, I certify that I have reviewed the claims in the above-named EDI file using the Attachment Control Number listed
above, and that each such claim is being submitted more than 30 days after the end of the month of service due to delay or error in
the certification or determination of the Medi-Cal eligibility by the State or county for the client to whom services identified on that
claim were provided. I also certify that each of those claim(s) are being submitted not later than 60 days after that delay or error
was resolved by the State or county, and that documentation substantiating those circumstances for each client are on file with the
above named county or direct provider and will be made available to the California Department of Health Care Services (DHCS) on
request for auditing and monitoring purposes. I further acknowledge that I understand that DHCS will rely on this certification in
determining that this late submission is acceptable under Title 22 of the California Code of Regulations, Section 51008.5.A14.
Phone Numbe
r
Signature: COUNTY/DIRECT PROVIDER REPRESENTATIVE
Date:
(
)
DHCS 6065B (rev 02/15)