Form DHCS6208 "Medi-Cal Provider Agreement (To Accompany Applications for Enrollment or Continued Enrollment)" - California

What Is Form DHCS6208?

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 February 1, 2017;
  • 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 DHCS6208 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 DHCS6208 "Medi-Cal Provider Agreement (To Accompany Applications for Enrollment or Continued Enrollment)" - California

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State of California
Department of Health Care Services
Health and Human Services Agency
MEDI-CAL PROVIDER AGREEMENT
(To Accompany Applications for Enrollment or Continued Enrollment)*
Do not use staples on this form or any attachments.
For State Use Only
Type or print clearly in ink. If you must make corrections, please
line through, date, and initial in ink.
Do not leave any questions, lines, etc. blank. Enter N/A if not
applicable to you.
Date:
Legal name of applicant or provider (hereinafter
Business name (if different than legal name)
jointly referred to as “Provider”)
Provider number (NPI)
Business Telephone Number
Business address (number, street)
City
State
ZIP code (9-digit)
Mailing address (number, street, P.O. Box number)
City
State
ZIP code (9-digit)
Pay-to address (number, street, P.O. Box number)
City
State
ZIP code (9-digit)
Previous business address (number, street)
City
State
ZIP code (9-digit)
Taxpayer Identification Number (TIN)**
EXECUTION OF THIS PROVIDER AGREEMENT BETWEEN AN APPLICANT OR PROVIDER
(HEREINAFTER JOINTLY REFERRED TO AS “PROVIDER”) AND THE DEPARTMENT OF HEALTH
CARE SERVICES (HEREINAFTER “DHCS”), IS MANDATORY FOR PARTICIPATION OR CONTINUED
PARTICIPATION AS A PROVIDER IN THE MEDI-CAL PROGRAM PURSUANT TO 42 UNITED STATES
CODE, SECTION 1396a(a)(27), TITLE 42, CODE OF FEDERAL REGULATIONS, SECTION 431.107,
WELFARE AND INSTITUTIONS CODE, SECTION 14043.2, AND TITLE 22, CALIFORNIA CODE OF
REGULATIONS, SECTION 51000.30(a)(2).
AS A CONDITION FOR PARTICIPATION OR CONTINUED PARTICIPATION AS A PROVIDER IN THE
MEDI-CAL PROGRAM, PROVIDER AGREES TO COMPLY WITH ALL OF THE FOLLOWING TERMS
AND CONDITIONS, AND WITH ALL OF THE TERMS AND CONDITIONS INCLUDED ON ANY
ATTACHMENT(S) HERETO, WHICH IS/ARE INCORPORATED HEREIN BY REFERENCE:
* Every applicant and provider must execute this Provider Agreement, except physicians, who must
execute the “Medi-Cal Physician Application/Agreement,” DHCS 6210.
** The taxpayer identification number may be a Taxpayer Identification Number (TIN) or a social security
number for sole proprietors.
DHCS 6208 (Rev. 2/17)
Page 1 of 12
State of California
Department of Health Care Services
Health and Human Services Agency
MEDI-CAL PROVIDER AGREEMENT
(To Accompany Applications for Enrollment or Continued Enrollment)*
Do not use staples on this form or any attachments.
For State Use Only
Type or print clearly in ink. If you must make corrections, please
line through, date, and initial in ink.
Do not leave any questions, lines, etc. blank. Enter N/A if not
applicable to you.
Date:
Legal name of applicant or provider (hereinafter
Business name (if different than legal name)
jointly referred to as “Provider”)
Provider number (NPI)
Business Telephone Number
Business address (number, street)
City
State
ZIP code (9-digit)
Mailing address (number, street, P.O. Box number)
City
State
ZIP code (9-digit)
Pay-to address (number, street, P.O. Box number)
City
State
ZIP code (9-digit)
Previous business address (number, street)
City
State
ZIP code (9-digit)
Taxpayer Identification Number (TIN)**
EXECUTION OF THIS PROVIDER AGREEMENT BETWEEN AN APPLICANT OR PROVIDER
(HEREINAFTER JOINTLY REFERRED TO AS “PROVIDER”) AND THE DEPARTMENT OF HEALTH
CARE SERVICES (HEREINAFTER “DHCS”), IS MANDATORY FOR PARTICIPATION OR CONTINUED
PARTICIPATION AS A PROVIDER IN THE MEDI-CAL PROGRAM PURSUANT TO 42 UNITED STATES
CODE, SECTION 1396a(a)(27), TITLE 42, CODE OF FEDERAL REGULATIONS, SECTION 431.107,
WELFARE AND INSTITUTIONS CODE, SECTION 14043.2, AND TITLE 22, CALIFORNIA CODE OF
REGULATIONS, SECTION 51000.30(a)(2).
AS A CONDITION FOR PARTICIPATION OR CONTINUED PARTICIPATION AS A PROVIDER IN THE
MEDI-CAL PROGRAM, PROVIDER AGREES TO COMPLY WITH ALL OF THE FOLLOWING TERMS
AND CONDITIONS, AND WITH ALL OF THE TERMS AND CONDITIONS INCLUDED ON ANY
ATTACHMENT(S) HERETO, WHICH IS/ARE INCORPORATED HEREIN BY REFERENCE:
* Every applicant and provider must execute this Provider Agreement, except physicians, who must
execute the “Medi-Cal Physician Application/Agreement,” DHCS 6210.
** The taxpayer identification number may be a Taxpayer Identification Number (TIN) or a social security
number for sole proprietors.
DHCS 6208 (Rev. 2/17)
Page 1 of 12
State of California
Department of Health Care Services
Health and Human Services Agency
1. Term and Termination. This Agreement will be effective from the date applicant is enrolled as a provider
by DHCS, or, from the date provider is approved for continued enrollment. Provider may terminate this
Agreement by providing DHCS with written notice of intent to terminate, which termination shall result in
Provider’s immediate disenrollment and exclusion (without formal hearing under the Administrative
Procedures Act) from further participation in the Medi-Cal program unless and until such time as Provider
is re-enrolled by DHCS in the Medi-Cal program. DHCS may immediately terminate this Agreement for
cause if Provider is suspended/excluded for any of the reasons set forth in Paragraph 26(a) below, which
termination will result in Provider’s immediate disenrollment and exclusion (without formal hearing under
the Administrative Procedures Act) from further participation in the Medi-Cal program. During any period
in which the provider is on provisional provider status or preferred provisional provider status, DHCS
may terminate this agreement for any of the grounds stated in Welfare and Institutions Code Section
14043.27(c).
2. Compliance With Laws and Regulations. Provider agrees to comply with all applicable provisions of
Chapters 7 and 8 of the Welfare and Institutions Code (commencing with Sections 14000 and 14200),
and any applicable rules or regulations promulgated by DHCS pursuant to these Chapters. Provider
further agrees that if it violates any of the provisions of Chapters 7 and 8 of the Welfare and Institutions
Code, or any other regulations promulgated by DHCS pursuant to these Chapters, it may be subject to
all sanctions or other remedies available to DHCS. Provider further agrees to comply with all federal
laws and regulations governing and regulating Medicaid providers.
3. National Provider Identifier (NPI). Provider agrees not to submit any claims to DHCS using an NPI
unless that NPI is appropriately registered with the Centers for Medicare and Medicaid Services (CMS)
and is in compliance with all NPI requirements established by CMS as of the date the claim is submitted.
Provider agrees that submission of an NPI to DHCS as part of an application to use that NPI to obtain
payment constitutes an implied representation that the NPI submitted is appropriately registered and in
compliance with all CMS requirements at the time of submission. Provider also agrees that any
subsequent defect in registration or compliance of the NPI constitutes an “addition or change in the
information previously submitted” which must be reported to DHCS under the requirements of California
Code of Regulations, title 22, section 51000.40.
4. Forbidden Conduct. Provider agrees that it shall not engage in conduct inimical to the public health,
morals, welfare and safety of any Medi-Cal beneficiary, or the fiscal integrity of the Medi-Cal program.
5. Nondiscrimination. Provider agrees that it shall not exclude or deny aid, care, service or other benefits
available under Medi-Cal or in any other way discriminate against a person because of that person’s
race, color, ancestry, marital status, national origin, gender, age, economic status, physical or mental
disability, political or religious affiliation or beliefs in accordance with California and federal laws.
Provider further agrees that it shall provide aid, care, service, or other benefits available under Medi-Cal
to Medi-Cal beneficiaries in the same manner, by the same methods, and at the same scope, level, and
quality as provided to the general public.
6. Scope of Health and Medical Care. Provider agrees that the health care services it provides may
include diagnostic, preventive, corrective, and curative services, goods, supplies, and merchandise
essential thereto, provided by qualified personnel for conditions that cause suffering, endanger life, result
in illness or infirmity, interfere with capacity for normal activity, including employment, or for conditions
which may develop into some significant handicap or disability. Provider further agrees such health care
services may be subject to prior authorization to determine medical necessity.
7. Licensing. Provider agrees to possess at the time this Agreement becomes effective, and to maintain
in good standing throughout the term of this Agreement, valid and unexpired license(s), certificate(s), or
DHCS 6208 (Rev. 2/17)
Page 2 of 12
State of California
Department of Health Care Services
Health and Human Services Agency
other approval(s) to provide health care services, which is appropriate to the services, goods, supplies,
and merchandise being provided, if required by the state or locality in which Provider is located, or by
the Federal Government. Provider further agrees that DHCS shall automatically suspend Provider as a
provider in the Medi-Cal program pursuant to Welfare and Institutions Code, Section 14043.6, if Provider
has license(s), certificate(s), or other approval(s) to provide health care services, which are revoked or
suspended by a federal, California, or another state’s licensing, certification, or approval authority, has
otherwise lost that/those license(s), certificate(s), or approval(s), or has surrendered that/those
license(s), certificate(s), or approval(s) while a disciplinary hearing on that/those license(s), certificate(s),
or approval(s) was pending. Such suspension shall be effective on the date that Provider’s license,
certificate, or approval was revoked, suspended, lost, or surrendered. Provider further agrees to notify
DHCS within ten business days of learning that any restriction has been placed on, or of a suspension
of Provider’s license, certificate, or other approval to provide health care. Provider further agrees to
provide DHCS complete information related to any restriction to, or revocation or loss of, Provider’s
license, certificate, or other approval to provide health care services.
8. Insurance. Provider agrees to possess at the time this Agreement becomes effective, and to maintain
in good standing throughout the term of this Agreement, liability insurance for the business address and,
if a licensed practitioner, professional liability (malpractice) insurance coverage from an authorized
insurer pursuant to Section 700 of the Insurance Code.
9. Record Keeping and Retention. Provider agrees to make, keep and maintain in a systematic and
orderly manner, and have readily retrievable, such records as are necessary to fully disclose the type
and extent of all services, goods, supplies, and merchandise provided to Medi-Cal beneficiaries,
including, but not limited to, the records described in Section 51476 of Title 22, California Code of
Regulations, and the records described in Section 431.107 of Title 42 of the Code of Federal
Regulations. Provider further agrees that such records shall be made at or near the time at which the
services, goods, supplies, and merchandise are delivered or rendered, and that such records shall be
retained by Provider in the form in which they are regularly kept for a period of three years from the date
the goods, supplies, or merchandise were delivered or the services rendered.
10.
DHCS, AG and Secretary Access to Records; Copies of Records. Provider agrees to make
available, during regular business hours, all pertinent financial records, all records of the requisite
insurance coverage, and all records concerning the provision of health care services to Medi-Cal
beneficiaries to any duly authorized representative of DHCS, the California Attorney General’s Medi-Cal
Fraud Unit (“AG”), and the Secretary of the United States Centers for Medicare and Medicaid Services
(Secretary). Provider further agrees to provide, if requested by any of the above, copies of the records
and documentation, and that failure to comply with any request to examine or receive copies of such
records shall be grounds for immediate suspension of Provider from participation in the Medi-Cal
program. Provider will be reimbursed for reasonable copy costs as determined by DHCS, AG or
Secretary.
11. Confidentiality of Beneficiary Information. Provider agrees that all medical records of beneficiaries
made or acquired by Provider shall be confidential and shall not be released without the written consent
of the beneficiary or his/her personal representative, or as otherwise authorized by law.
12. Disclosure of Information to DHCS. Provider agrees to disclose all information as required in Federal
Medicaid laws and regulations and any other information required by DHCS, and to respond to all
requests from DHCS for information. Provider further agrees that the failure of Provider to disclose the
required information, or the disclosure of false information shall, prior to any hearing, result in the denial
of the application for enrollment or shall be grounds for termination of enrollment status or suspension
DHCS 6208 (Rev. 2/17)
Page 3 of 12
State of California
Department of Health Care Services
Health and Human Services Agency
from the Medi-Cal program, which shall include deactivation of all provider numbers used by Provider to
obtain reimbursement from the Medi-Cal program. Provider further agrees that all bills or claims for
payment to DHCS by Provider shall not be due and owing to Provider for any period(s) for which
information was not reported or was reported falsely to DHCS. Provider further agrees to reimburse
those Medi-Cal funds received during any period for which information was not reported, or reported
falsely, to DHCS.
13. Information Regarding Subcontractors and Suppliers. Provider agrees to submit, within 35 days of
the date on a request by the Secretary or the Medicaid agency, full and complete information about the
ownership of any subcontractor with whom the provider has had business transactions totaling more
than $25,000 during the 12-month period ending on the date of the request; and any significant business
transactions between the provider and any wholly owned supplier, or between the provider and any
subcontractor, during the 5-month period ending on the date of the request.
14. Background Check. Provider agrees that DHCS may conduct a background check on Provider for the
purpose of verifying the accuracy of the information provided in the application and in order to prevent
fraud or abuse. The background check may include, but not be limited to, the following: (1) on-site
inspection prior to enrollment; (2) review of medical and business records; and, (3) data searches.
15. Unannounced Visits By DHCS, AG and Secretary. Provider agrees that DHCS, AG and/or Secretary
may make unannounced visits to Provider, at any of Provider’s business locations, before, during or after
enrollment, for the purpose of determining whether enrollment, continued enrollment, or certification is
warranted, to investigate and prosecute fraud against the Medi-Cal program, to investigate complaints
of abuse and neglect of patients in health care facilities receiving payment under the Medi-Cal program,
and/or as necessary for the administration of the Medi-Cal program and/or the fulfillment of the AG’s
powers and duties under Government Code Section 12528. Premises subject to inspection include billing
agents, as defined in Welfare and Institutions Code Section 14040.1. Failure to permit inspection by
DHCS, AG or Secretary or any agent, investigator or auditor thereof, shall be grounds for immediate
suspension of provider from participation in the Medi-Cal program.
16. Provider Fraud and Abuse. Provider agrees that it shall not engage in or commit fraud or abuse.
“Fraud” means an intentional deception or misrepresentation made by a person with the knowledge that
the deception could result in some unauthorized benefit to himself or herself or some other person. It
includes any act that constitutes fraud under applicable federal or state law. “Abuse” means either: (1)
practices that are inconsistent with sound fiscal or business practices and result in unnecessary cost to
the Medicare program, the Medi-Cal program, another state’s Medicaid program, or other health care
programs operated, or financed in whole or in part, by the Federal Government or any state or local
agency in this state or any other state; (2) practices that are inconsistent with sound medical practices
and result in reimbursement by the Medi-Cal program or other health care programs operated, or
financed in whole or in part, by the Federal Government or any state or local agency in this state or any
other state, for services that are unnecessary or for substandard items or services that fail to meet
professionally recognized standards for health care.
17. Investigations of Provider for Fraud or Abuse. Provider certifies that, at the time this Agreement was
signed, it was not under investigation for fraud or abuse pursuant to Subpart A (commencing with Section
455.12) of Part 455 of Title 42 of the Code of Federal Regulations or under investigation for fraud or
abuse by any other government entity. Provider further agrees to notify DHCS within ten business days
of learning that it is under investigation for fraud or abuse. Provider further agrees that it shall be subject
to temporary suspension pursuant to Welfare and Institutions Code, Section 14043.36(a), which shall
include temporary deactivation of all provider numbers used by Provider to obtain reimbursement from
DHCS 6208 (Rev. 2/17)
Page 4 of 12
State of California
Department of Health Care Services
Health and Human Services Agency
the Medi-Cal program, if it is discovered by DHCS that Provider is under investigation for fraud or abuse.
Provider further agrees to cooperate with and assist DHCS and any state or federal agency charged with
the duty of identifying, investigating, sanctioning, or prosecuting suspected fraud and abuse.
18. Provider Fraud or Abuse Convictions and/or Civil Fraud or Abuse Liability. Provider certifies that
it and its owners, officers, directors, employees, and agents, has not: (1) been convicted of any felony
or misdemeanor involving fraud or abuse in any government program, within the last ten years; or (2)
been convicted of any felony or misdemeanor involving the abuse of any patient; or (3) been convicted
of any felony or misdemeanor substantially related to the qualifications, functions, or duties of a provider;
or (4) entered into a settlement in lieu of conviction for fraud or abuse, within the last ten years; or, (5)
been found liable for fraud or abuse in any civil proceeding, within the last ten years. Provider further
agrees that DHCS shall not enroll Provider if within the last ten years, Provider has been convicted of
any felony or any misdemeanor involving fraud or abuse in any government program, has entered into
a settlement in lieu of conviction for fraud or abuse, or has been found liable for fraud or abuse in any
civil proceeding.
19. Changes to Provider Information. Provider agrees to keep its application for enrollment in the Medi-
Cal program current by informing DHCS, Provider Enrollment Division, in writing on a form or forms to
be specified by DHCS, within 35 days of any changes to the information contained in its application for
enrollment, its disclosure statement, this Agreement, and/or any attachments to these documents.
20. Prohibition of Rebate, Refund, or Discount. Provider agrees that it shall not offer, give, furnish, or
deliver any rebate, refund, commission preference, patronage dividend, discount, or any other gratuitous
consideration, in connection with the rendering of health care services to any Medi-Cal beneficiary.
Provider further agrees that it shall not solicit, request, accept, or receive, any rebate, refund, commission
preference, patronage dividend, discount, or any other gratuitous consideration, in connection with the
rendering of health care services to any Medi-Cal beneficiary. Provider further agrees that it will not take
any other action or receive any other benefit prohibited by state or federal law.
21. Payment From Other Health Coverage Prerequisite to Claim Submission. Provider agrees that it
shall first seek to obtain payment for services provided to Medi-Cal beneficiaries from any private or
public health insurance coverage to which the beneficiary is entitled, where Provider is aware of this
coverage and to the extent the coverage extends to these services, prior to submitting a claim to DHCS
for the payment of any unpaid balance for these services. In the event that a claim submitted to a private
or public health insurer has not been paid within 90 days of billing by Provider, Provider may submit a
claim to DHCS.
22. Beneficiary Billing. Provider agrees that it shall not submit claims to or demand or otherwise collect
reimbursement from a Medi-Cal beneficiary, or from other persons on behalf of the beneficiary, for any
service included in the Medi-Cal program’s scope of benefits in addition to a claim submitted to the Medi-
Cal program for that service, except to: (1) collect payments due under a contractual or legal entitlement
pursuant to Welfare and Institutions Code, Section 14000(b); (2) bill a long-term care patient for the
amount of his/her liability; and, (3) collect a co-payment pursuant to Welfare and Institutions Code,
Sections 14134 and 14134.1. Provider further agrees that, in the event that a beneficiary willfully
refuses to provide current other health care coverage billing information as described in Section
50763(a)(5) of Title 22, California Code of Regulations, Provider may, upon giving the beneficiary written
notice of intent, bill the beneficiary as a private pay patient.
23. Payment From Medi-Cal Program Shall Constitute Full Payment. Provider agrees that payment
received from DHCS in accordance with Medi-Cal fee structures shall constitute payment in full, except
that Provider, after making a full refund to DHCS of any Medi-Cal payments received for services, goods,
DHCS 6208 (Rev. 2/17)
Page 5 of 12