Instructions for Form DHCS100186 "Drug Medi-Cal (Dmc) Claim Submission Certification - County Contracted Provider" - California

This document contains official instructions for Form DHCS100186, Drug Medi-Cal (Dmc) Claim Submission Certification - County Contracted Provider - a form released and collected by the California Department of Health Care Services. An up-to-date fillable Form DHCS100186 is available for download through this link.

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Download Instructions for Form DHCS100186 "Drug Medi-Cal (Dmc) Claim Submission Certification - County Contracted Provider" - California

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STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
COMPLETION INSTRUCTIONS FOR DRUG MEDI-CAL (DMC) CLAIM SUBMISSION CERTIFICATION - COUNTY CONTRACTED PROVIDER
(DHCS 100186)
GENERAL
The DMC Claim Submission Certification form for County Contracted Providers (DHCS 100186) is used by a Drug Medi-Cal provider to certify the submission of
Drug Medi-Cal claim files to a County. The county must have certification of all claim files prior to submission for processing to the State. The County must retain
and make available the DMC Claim Submission Certification form to DHCS on demand.
HEADING INSTRUCTIONS
a. COUNTY NAME: enter the name of county of where services are being provided.
b. PROVIDER NAME (LEGAL ENTITY): enter the name of provider performing the service.
c. DMC NUMBER(S): enter the DMC number(s) of the provider performing the service.
d. SERVICE FACILITY LOCATION NPI(S): enter the service facility NPI(s) of the provider performing the service.
e. DMC SUBMISSION IDENTIFIER: enter the filename, tracking number, or other identifier agreed to between the county and provider which uniquely
identifies the claim file or group of claim files being certified on this form.
SIGNATURE BLOCK INSTRUCTIONS
One original signature is required on the DHCS 100186, that of the authorized claim submitter.
a. PRINTED NAME: AUTHORIZED SERVICE PROVIDER: print the name of the authorized service provider.
b. SIGNATURE: AUTHORIZED SERVICE PROVIDER: signature line for the authorized service provider.
c. PHONE NUMBER: enter the area code and phone number of the authorized service provider.
d. DATE SIGNED: enter the date the form was signed by the authorized service provider.
COUNTY USE ONLY HEADING INSTRUCTIONS
a. RECEIPT DATE: enter the date the form was received by the county from the provider.
b. EDI File Name: Enter the name of the EDI file in which the claims certified on this form were submitted to DHCS by the county.
c. EDI File Submission Date: Enter the date in which the EDI file was submitted for processing.
DHCS 100186 (Revised 6/2014)
STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
COMPLETION INSTRUCTIONS FOR DRUG MEDI-CAL (DMC) CLAIM SUBMISSION CERTIFICATION - COUNTY CONTRACTED PROVIDER
(DHCS 100186)
GENERAL
The DMC Claim Submission Certification form for County Contracted Providers (DHCS 100186) is used by a Drug Medi-Cal provider to certify the submission of
Drug Medi-Cal claim files to a County. The county must have certification of all claim files prior to submission for processing to the State. The County must retain
and make available the DMC Claim Submission Certification form to DHCS on demand.
HEADING INSTRUCTIONS
a. COUNTY NAME: enter the name of county of where services are being provided.
b. PROVIDER NAME (LEGAL ENTITY): enter the name of provider performing the service.
c. DMC NUMBER(S): enter the DMC number(s) of the provider performing the service.
d. SERVICE FACILITY LOCATION NPI(S): enter the service facility NPI(s) of the provider performing the service.
e. DMC SUBMISSION IDENTIFIER: enter the filename, tracking number, or other identifier agreed to between the county and provider which uniquely
identifies the claim file or group of claim files being certified on this form.
SIGNATURE BLOCK INSTRUCTIONS
One original signature is required on the DHCS 100186, that of the authorized claim submitter.
a. PRINTED NAME: AUTHORIZED SERVICE PROVIDER: print the name of the authorized service provider.
b. SIGNATURE: AUTHORIZED SERVICE PROVIDER: signature line for the authorized service provider.
c. PHONE NUMBER: enter the area code and phone number of the authorized service provider.
d. DATE SIGNED: enter the date the form was signed by the authorized service provider.
COUNTY USE ONLY HEADING INSTRUCTIONS
a. RECEIPT DATE: enter the date the form was received by the county from the provider.
b. EDI File Name: Enter the name of the EDI file in which the claims certified on this form were submitted to DHCS by the county.
c. EDI File Submission Date: Enter the date in which the EDI file was submitted for processing.
DHCS 100186 (Revised 6/2014)