Instructions for Form DHCS6700 "Multiple Billing Override Certification" - California

This document contains official instructions for Form DHCS6700, Multiple Billing Override Certification - a form released and collected by the California Department of Health Care Services. An up-to-date fillable Form DHCS6700 is available for download through this link.

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Download Instructions for Form DHCS6700 "Multiple Billing Override Certification" - California

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STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
COMPLETION INSTRUCTIONS FOR MULTIPLE BILLING OVERRIDE CERTIFICATION
GENERAL
The DHCS Multiple Billing Override Certification form is used by a Drug Medi-Cal Provider to certify that an additional, second unit of service for the same client was submitted for the same service date. This form documents that the additional
service was medically necessary and was not a hardship for the client's return.
* This form must be signed by a person authorized to represent the provider to certify that the client record was reviewed and that the multiple billing met the requirements of California Code of Regulations, Title 22, Section 51490.1.
* This form shall be prepared and retained in the client file to be produced for monitoring and/or auditing purposes.
HEADING INSTRUCTIONS
a. PROVIDER NAME: enter the provider name.
b. CLIENT NAME: enter the client's name for the claim.
c. MONTH/YEAR OF SERVICES CLAIMED: enter the month and year of the services provided.
d. CIN: enter client identification number.
COLUMN INSTRUCTIONS
a. SERVICE FACILITY/PROVIDER NPI CODE: enter the NPI code for the service facility.
b. ZIP CODE+4: FOR SOLE PROPRIETOR ONLY - enter the zip code + 4 (9-digits)
c. SERVICE DATE: enter the date the service was performed.
d. UNITS BILLED: enter the number of units being billed for this service.
e. SERVICE TYPE: enter the service provided.
f. OVERRIDE REASON: enter one of the following reasons:
1) The client could not receive all necessary services at one time. The client record clearly documents the date and time of day each visit was made and that the return visit was not a hardship on the client.
2) Crisis visit. Services are documented in client record.
3) Collateral services. Services are documented in client record.
SIGNATURE BLOCK INSTRUCTIONS
a. SIGNATURE - only authorized provider representatives should sign.
b. TITLE: enter the title of the representative signing the form.
c. DATE: enter the date the form was signed by the authorized representative.
DHCS MC 6700 Instructions (Revised 6/2014)
STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
COMPLETION INSTRUCTIONS FOR MULTIPLE BILLING OVERRIDE CERTIFICATION
GENERAL
The DHCS Multiple Billing Override Certification form is used by a Drug Medi-Cal Provider to certify that an additional, second unit of service for the same client was submitted for the same service date. This form documents that the additional
service was medically necessary and was not a hardship for the client's return.
* This form must be signed by a person authorized to represent the provider to certify that the client record was reviewed and that the multiple billing met the requirements of California Code of Regulations, Title 22, Section 51490.1.
* This form shall be prepared and retained in the client file to be produced for monitoring and/or auditing purposes.
HEADING INSTRUCTIONS
a. PROVIDER NAME: enter the provider name.
b. CLIENT NAME: enter the client's name for the claim.
c. MONTH/YEAR OF SERVICES CLAIMED: enter the month and year of the services provided.
d. CIN: enter client identification number.
COLUMN INSTRUCTIONS
a. SERVICE FACILITY/PROVIDER NPI CODE: enter the NPI code for the service facility.
b. ZIP CODE+4: FOR SOLE PROPRIETOR ONLY - enter the zip code + 4 (9-digits)
c. SERVICE DATE: enter the date the service was performed.
d. UNITS BILLED: enter the number of units being billed for this service.
e. SERVICE TYPE: enter the service provided.
f. OVERRIDE REASON: enter one of the following reasons:
1) The client could not receive all necessary services at one time. The client record clearly documents the date and time of day each visit was made and that the return visit was not a hardship on the client.
2) Crisis visit. Services are documented in client record.
3) Collateral services. Services are documented in client record.
SIGNATURE BLOCK INSTRUCTIONS
a. SIGNATURE - only authorized provider representatives should sign.
b. TITLE: enter the title of the representative signing the form.
c. DATE: enter the date the form was signed by the authorized representative.
DHCS MC 6700 Instructions (Revised 6/2014)