Form DHCS100224A "Drug Medi-Cal Certification for Federal Reimbursement" - California

What Is Form DHCS100224A?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2014;
  • 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 DHCS100224A 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 DHCS100224A "Drug Medi-Cal Certification for Federal Reimbursement" - California

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STATE OF CALIFORNIA – Health and Human Services Agency
Department of Health Care Services
DRUG MEDI-CAL CERTIFICATION FOR FEDERAL REIMBURSEMENT
Date
(mm/dd/yyyy)
County Code
County
Claim EDI Filename
TOTAL
Total Actual Expenditures
$
CERTIFICATION FOR SERVICES RENDERED:
I HEREBY CERTIFY under penalty of perjury that—
1.
I am the official responsible for the administration of the Drug Medi-Cal services for the above-named agency, and that I have not violated
any of the provisions of Section 1090 et. seq. of the Government Code.
2.
To the best of my knowledge and belief, each claim file is in all respects true, correct, and in accordance with state and federal law and
regulations, including Section 1903(a) of the Social Security Act and 42 C.F.R. Section 433.51, and any falsification or concealment of a
material fact may be prosecuted under federal and/or state laws.
3.
This certification is based on actual, total-fund expenditures of public funds necessary for claiming Federal Financial Participation (FFP)
pursuant to all applicable requirements of federal law, including 42 C.F.R. Section 433.51 and that the expenditures claimed have not
previously been, nor will they be, claimed at any other time as claims to receive FFP funds under Medicaid or any other program (except
those claims, if any, that are being submitted as Void and/or Replacement claims). I also understand that misrepresentation of any
information constitutes a violation of federal and state law.
4.
Pursuant to 42 C.F.R. Section 433.32, the County agrees to keep for a minimum of three years after the final determination of costs are
made through the California Department of Health Care Services (DHCS) reconciled Cost Report settlement process and retained beyond
the three-year period if audit findings have not been resolved, a printed representation of all records which are necessary to disclose fully
the extent of services furnished to the client. The County also agrees to furnish these records and any information regarding payments
claimed for providing the services, on request, within the State of California, to the Department of Health Care Services Medi-Cal Fraud
Unit; California Department of Justice; Office of the State Controller; U.S. Department of Health and Human Services, Managed Risk
Medical Insurance Board or their duly authorized representatives.
I understand that the State of California must deny payment of any claim file submitted if it determines the certification is not adequately
supported for purposes of claiming federal financial participation.
Date:
_________________________________________
Signature:
_______________________________________
County Representative
Executed at:
_____________________________________
, California
I HEREBY CERTIFY under penalty of perjury that—
1.
I am a duly qualified and authorized official of the herein claimant responsible for the examination and settlement of accounts, and that I
am authorized to sign this certification on behalf of the County, and that the information is to be used for filing a claim with the federal
government for federal funds pursuant to 42 C.F.R. Section 430.30, and that I have not violated any of the provisions of Section 1090 et.
seq. of the Government Code.
2.
This certification is based on actual, total-funds expenditures of public funds necessary for claiming FFP pursuant to all applicable
requirements of federal law, including 42 C.F.R. Section 433.51 and that the expenditures claimed have not previously been, nor will they
be, claimed at any other time as claims to receive FFP funds under Medicaid or any other program (except those claims, if any, that are
being submitted as Void and/or Replacement claims). I also understand that misrepresentation of any information constitutes a violation
of federal and state law.
3.
I acknowledge that all records of funds expended are subject to review and audit by DHCS and/or the federal government and that
pursuant to 42 C.F.R. Section 433.32, all records necessary to fully disclose the extent of services furnished to clients must be kept for a
minimum of three years after the final determination of costs are made through the DHCS reconciled Cost Report settlement process and
retained beyond the three-year period if audit findings have not been resolved.
I understand that the State of California must deny payment of any claim file submitted if it determines the certification is not adequately
supported for purposes of claiming federal financial participation.
Date:
_________________________________________
Signature:
________________________________________
Executed at:
_____________________________
, California
Title:
_________________________________________
(County Auditor-Controller, City Finance Officer,
or County Accounting Officer)
Please fax the completed form to DHCS, Fiscal Management and Accountability Branch, at (916) 322-1176. The original form is for your files.
If you have any questions, please call your assigned county analyst of the Fiscal Management and Accountability Branch.
DHCS 100224A (Revised 7/2014)
STATE OF CALIFORNIA – Health and Human Services Agency
Department of Health Care Services
DRUG MEDI-CAL CERTIFICATION FOR FEDERAL REIMBURSEMENT
Date
(mm/dd/yyyy)
County Code
County
Claim EDI Filename
TOTAL
Total Actual Expenditures
$
CERTIFICATION FOR SERVICES RENDERED:
I HEREBY CERTIFY under penalty of perjury that—
1.
I am the official responsible for the administration of the Drug Medi-Cal services for the above-named agency, and that I have not violated
any of the provisions of Section 1090 et. seq. of the Government Code.
2.
To the best of my knowledge and belief, each claim file is in all respects true, correct, and in accordance with state and federal law and
regulations, including Section 1903(a) of the Social Security Act and 42 C.F.R. Section 433.51, and any falsification or concealment of a
material fact may be prosecuted under federal and/or state laws.
3.
This certification is based on actual, total-fund expenditures of public funds necessary for claiming Federal Financial Participation (FFP)
pursuant to all applicable requirements of federal law, including 42 C.F.R. Section 433.51 and that the expenditures claimed have not
previously been, nor will they be, claimed at any other time as claims to receive FFP funds under Medicaid or any other program (except
those claims, if any, that are being submitted as Void and/or Replacement claims). I also understand that misrepresentation of any
information constitutes a violation of federal and state law.
4.
Pursuant to 42 C.F.R. Section 433.32, the County agrees to keep for a minimum of three years after the final determination of costs are
made through the California Department of Health Care Services (DHCS) reconciled Cost Report settlement process and retained beyond
the three-year period if audit findings have not been resolved, a printed representation of all records which are necessary to disclose fully
the extent of services furnished to the client. The County also agrees to furnish these records and any information regarding payments
claimed for providing the services, on request, within the State of California, to the Department of Health Care Services Medi-Cal Fraud
Unit; California Department of Justice; Office of the State Controller; U.S. Department of Health and Human Services, Managed Risk
Medical Insurance Board or their duly authorized representatives.
I understand that the State of California must deny payment of any claim file submitted if it determines the certification is not adequately
supported for purposes of claiming federal financial participation.
Date:
_________________________________________
Signature:
_______________________________________
County Representative
Executed at:
_____________________________________
, California
I HEREBY CERTIFY under penalty of perjury that—
1.
I am a duly qualified and authorized official of the herein claimant responsible for the examination and settlement of accounts, and that I
am authorized to sign this certification on behalf of the County, and that the information is to be used for filing a claim with the federal
government for federal funds pursuant to 42 C.F.R. Section 430.30, and that I have not violated any of the provisions of Section 1090 et.
seq. of the Government Code.
2.
This certification is based on actual, total-funds expenditures of public funds necessary for claiming FFP pursuant to all applicable
requirements of federal law, including 42 C.F.R. Section 433.51 and that the expenditures claimed have not previously been, nor will they
be, claimed at any other time as claims to receive FFP funds under Medicaid or any other program (except those claims, if any, that are
being submitted as Void and/or Replacement claims). I also understand that misrepresentation of any information constitutes a violation
of federal and state law.
3.
I acknowledge that all records of funds expended are subject to review and audit by DHCS and/or the federal government and that
pursuant to 42 C.F.R. Section 433.32, all records necessary to fully disclose the extent of services furnished to clients must be kept for a
minimum of three years after the final determination of costs are made through the DHCS reconciled Cost Report settlement process and
retained beyond the three-year period if audit findings have not been resolved.
I understand that the State of California must deny payment of any claim file submitted if it determines the certification is not adequately
supported for purposes of claiming federal financial participation.
Date:
_________________________________________
Signature:
________________________________________
Executed at:
_____________________________
, California
Title:
_________________________________________
(County Auditor-Controller, City Finance Officer,
or County Accounting Officer)
Please fax the completed form to DHCS, Fiscal Management and Accountability Branch, at (916) 322-1176. The original form is for your files.
If you have any questions, please call your assigned county analyst of the Fiscal Management and Accountability Branch.
DHCS 100224A (Revised 7/2014)