Form DHCS6204 "Medi-Cal Clinical Medical Laboratory Application" - California

What Is Form DHCS6204?

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;
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Download Form DHCS6204 "Medi-Cal Clinical Medical Laboratory Application" - California

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State of California—Health and Human Services Agency
Department of Health Care Services
JENNIFER KENT
EDMUND G. BROWN JR.
DIRECTOR
GOVERNOR
Dear Clinical Laboratory Provider Applicant:
Thank you for your inquiry regarding participation in the Medi-Cal program. This letter addresses
information about the enrollment application process for a specific provider type.
PLEASE NOTE: Applicants and providers are required to submit their National Provider Identifier (NPI)
with each Medi-Cal provider application package. Current Medi-Cal providers will be required to submit
both the NPI and any Medi-Cal provider numbers issued previously on any application forms submitted to
the Department of Health Care Services (DHCS). Applicants are required to attach a copy of the
CMS/National Plan and Provider Enumeration System (NPPES) confirmation letter for each NPI listed in
the application package. If providers are not eligible to receive an NPI, they should instead enter the word
“atypical” in any NPI fields. These “atypical providers” will receive a unique Medi-Cal provider number
once the application is approved.
Applicants and providers may be required to submit an application fee or proof of payment to or
enrollment with Medicare or other state Medicaid programs. Effective January 1, 2013, DHCS requires
certain applicants and providers to submit an application fee when requesting an enrollment action. The
application fee collected is used to offset the cost of conducting the required screening as specified in Title
42 Code of Federal Regulations (CFR), Section 455 Subpart E. Please reference the Medi-Cal
Regulatory Provider Bulletin, “Medi-Cal Application Fee Requirements for Compliance with 42 Code of
Federal Regulations Section 455.460,” for further information.
The moratorium on the enrollment of clinical laboratory providers expired October 3, 2015. This letter
provides information for clinical laboratory applicants applying for enrollment in the Medi-Cal
Fee-for-Service Program during the six-month period following the expiration of the moratorium.
State Medicaid Agencies are required to collect fingerprints and conduct criminal background checks from
applicants or providers screened at the “high” categorical risk level. (42 CFR §§ 424.518, 455.434, and
455.450)
Title 42, CFR, Section 455.450(e)(2) and Welfare and Institutions Code (W&I Code), Section
14043.38(b)(4) specify that a provider that would have been prevented from applying for enrollment due to
a moratorium that has been lifted in the past six months, be screened at the “high” categorical risk level.
Provider Enrollment Division
MS 4704
P.O. Box 997412, Sacramento, CA 95899-7412
Phone: (916) 323-1945
Internet Address: www.dhcs.ca.gov/provgovpart/Pages/PED.aspx
State of California—Health and Human Services Agency
Department of Health Care Services
JENNIFER KENT
EDMUND G. BROWN JR.
DIRECTOR
GOVERNOR
Dear Clinical Laboratory Provider Applicant:
Thank you for your inquiry regarding participation in the Medi-Cal program. This letter addresses
information about the enrollment application process for a specific provider type.
PLEASE NOTE: Applicants and providers are required to submit their National Provider Identifier (NPI)
with each Medi-Cal provider application package. Current Medi-Cal providers will be required to submit
both the NPI and any Medi-Cal provider numbers issued previously on any application forms submitted to
the Department of Health Care Services (DHCS). Applicants are required to attach a copy of the
CMS/National Plan and Provider Enumeration System (NPPES) confirmation letter for each NPI listed in
the application package. If providers are not eligible to receive an NPI, they should instead enter the word
“atypical” in any NPI fields. These “atypical providers” will receive a unique Medi-Cal provider number
once the application is approved.
Applicants and providers may be required to submit an application fee or proof of payment to or
enrollment with Medicare or other state Medicaid programs. Effective January 1, 2013, DHCS requires
certain applicants and providers to submit an application fee when requesting an enrollment action. The
application fee collected is used to offset the cost of conducting the required screening as specified in Title
42 Code of Federal Regulations (CFR), Section 455 Subpart E. Please reference the Medi-Cal
Regulatory Provider Bulletin, “Medi-Cal Application Fee Requirements for Compliance with 42 Code of
Federal Regulations Section 455.460,” for further information.
The moratorium on the enrollment of clinical laboratory providers expired October 3, 2015. This letter
provides information for clinical laboratory applicants applying for enrollment in the Medi-Cal
Fee-for-Service Program during the six-month period following the expiration of the moratorium.
State Medicaid Agencies are required to collect fingerprints and conduct criminal background checks from
applicants or providers screened at the “high” categorical risk level. (42 CFR §§ 424.518, 455.434, and
455.450)
Title 42, CFR, Section 455.450(e)(2) and Welfare and Institutions Code (W&I Code), Section
14043.38(b)(4) specify that a provider that would have been prevented from applying for enrollment due to
a moratorium that has been lifted in the past six months, be screened at the “high” categorical risk level.
Provider Enrollment Division
MS 4704
P.O. Box 997412, Sacramento, CA 95899-7412
Phone: (916) 323-1945
Internet Address: www.dhcs.ca.gov/provgovpart/Pages/PED.aspx
A “high” risk screening requires a provider or applicant to submit proof that fingerprints for all the required
individuals have been submitted to an authorized State Identification Bureau (Bureau of Criminal
Information and Analysis, Department of Justice [DOJ] in California). Providers and applicants must
attach a copy of a prefilled DOJ Request for Live Scan Service (BCIA 8016) form for each required
individual with their application, date stamped and show verification that all fees have been paid by either
a “PAID” stamp from the public Live Scan operator or a receipt of payment.
If you would have met one of the exemptions listed below, you do not need to be screened as “high” risk
but you must submit a cover letter with your application advising which exemption you meet and include
any necessary supporting documentation.
1. A clinical laboratory owned and operated by a physician or physician group so long as the physician
or physician group only performs Provider-Performed Microscopy Procedures (PPMP) and/or waived
clinical laboratory tests or examinations;
2. Current Medi-Cal enrolled clinical laboratory providers that have at least six actively enrolled
locations, and seek to add a new business location, so long as the provider does not add new
business activities, categories of service or billing codes other than those approved for enrollment at
its existing locations; this exemption is only applicable to clinical laboratory providers who meet this
criteria and all six locations are continuously and actively enrolled and in good standing with
Medi-Cal, from February 12, 2007, through the date of application;
3. A clinical laboratory that is owned and operated by a general acute care hospital or psychiatric
hospital licensed pursuant to Health and Safety Code (H&S Code), Section 1250, et seq.;
4. A clinical laboratory that is owned and operated by a clinic licensed pursuant to H&S Code, Section
1200, et seq.;
5. A public health laboratory as defined in Business and Professions Code, Section 1206(a) and certified
pursuant to H&S Code Section 101160;
6. The purchase of an existing clinical laboratory that is currently enrolled in the Medi-Cal program as a
clinical laboratory, whether it constitutes a change of ownership or not; unless it is being sold by a
laboratory provider who has expanded their location(s) and/or services, under Exemption #13;
7. An out-of-state clinical laboratory requesting enrollment for the sole purpose of providing services to a
Medi-Cal beneficiary on an emergency basis, in accordance with the California Code of Regulations
(CCR), Title 22, Section 51006;
8. The change of location of an existing clinical laboratory that is currently enrolled in the Medi-Cal
program as a clinical laboratory, so long as it neither constitutes a change of ownership nor involves
the change or addition of specialty codes;
9. A clinical laboratory that only seeks reimbursement for Medicare cost sharing amounts;
10. Currently enrolled clinical laboratory providers that DHCS requires to submit an application for
continued enrollment pursuant to CCR, Title 22, Section 51000.55;
11. A clinical laboratory that performs a test or examination that is a Medi-Cal covered benefit and the
clinical laboratory is the only Clinical Laboratory Improvement Amendments (CLIA) approved clinical
laboratory in the United States to perform that test or examination;
12. Applicants whose sole business is, and continues to be throughout the existence of this moratorium, a
clinical laboratory performing only anatomic pathology services that has a laboratory director certified
in anatomic pathology by the American Board of Pathology or the American Osteopathic Board of
Pathology;
13. A clinical laboratory that is owned and operated by a professional medical corporation or partnership
of professional medical corporations, comprised of physicians that are certified by the American
Board of Pathology or the American Osteopathic Board of Pathology in clinical or anatomic pathology,
who can provide evidence of a current contract to provide pathology services at a licensed and
Medi-Cal certified acute care hospital in California, that currently is enrolled as a clinical laboratory
provider and seeks to obtain a provider number for an additional location that will also perform clinical
laboratory services, whether anatomic or clinical pathology services, and/or seeks to add new
business activities, categories of service or billing codes other than those approved at its initial
enrollment at its current business location. Exemption #13 only applies to those clinical lab providers
who remain under the same common ownership and directorship, as defined above, for all of their
business locations, throughout the period of this Moratorium;
14. A clinical laboratory that performs a test or examination that is a Medi-Cal covered benefit and, as of
the date of application denial or approval, no Medi-Cal provider offers a test or examination that fills
the same functional role. Multiple applications from providers asserting this exception will be granted
or denied in the order they were submitted;
15. A clinical laboratory, that is licensed by the California Department of Public Health (CDPH) as a
clinical laboratory that will be providing services exclusively to California Medi-Cal beneficiaries
placed through the Interstate Compact Placement of Children program (ICPC) in an out-of-state
residential care facility approved by the California Department of Social Services, and for whom the
residential care facility has provided a “letter of certification” that the facility is using the laboratory to
provide services for ICPC placed Medi-Cal beneficiaries.
16. A CLIA approved clinical laboratory that, as of the date of the application, performs a test or
examination that is not performed or available through an existing Medi-Cal provider.
Reimbursement shall be limited to the tests and examinations that form the basis of this exemption
and that have been prior authorized by the Department.
If DHCS determines that you do not meet an exemption or if you do not want to go through an exemption
review, you are required to be screened at the “high” categorical risk level and submit fingerprints for a
criminal background check.
Failure to submit fingerprints for a criminal background check when required will result in the denial of the
application package. (42 CFR § 455.416; W&I Code § 14043.26[f][4][E])
Additional information about the Medi-Cal requirements for submitting fingerprints is available in the
“Medi-Cal Requirement to Submit Fingerprints for a Criminal Background Check” provider bulletin.
If you wish to enroll as a Medi-Cal clinical laboratory provider, please complete a new application package
consisting of a Medi-Cal Provider Application (DHCS 6204, Rev. 2/17), a Medi-Cal Provider Agreement
(DHCS 6208, Rev. 2/17), a Medi-Cal Disclosure Statement (DHCS 6207, Rev. 2/17) and any required
attachments.
Return the completed application package to:
Department of Health Care Services
Provider Enrollment Division
MS 4704
P.O. Box 997412
Sacramento, CA 95899-7412
Please read all the instructions included in the application package carefully and complete each item
requested. Incomplete application packages will be returned.
It is your responsibility to report to DHCS any modifications to information previously submitted,
within 35 days from the date of the change. Most changes may be reported on a Medi-Cal
Supplemental Changes form (DHCS 6209, Rev. 10/16). However, if you are reporting a change of
ownership of 50 percent or more, a change of business address, or one of the other changes
identified in the CCR, Title 22, Section 51000.30, subsections (a) through (b), you must complete a
new application package.
If you are planning to sell your business or buy an existing business, you may find it helpful to refer to the
Medi-Cal Provider Enrollment page at www.medi-cal.ca.gov. The Provider Enrollment page contains
information about enrollment options available to you whenever there is a sale or purchase of a Medi-Cal
enrolled clinical laboratory, including the option to submit a Successor Liability with Joint and Several
Liability Agreement (DHCS 6217, Rev. 2/08).
Enrollment forms are available at www.medi-cal.ca.gov or by contacting the Telephone Service Center
(TSC) at 1-800-541-5555. For more information about the forms, form completion and the regulatory
requirements for participation in the Medi-Cal program, please visit our website at www.medi-cal.ca.gov
and click the “Provider Enrollment” link.
If you have any additional enrollment questions, please contact the Provider Enrollment Message Center
at (916) 323-1945, or submit your question, in writing, to the address on the front page or via email at
PEDCorr@dhcs.ca.gov.
In order to submit claims electronically, providers must request a submitter number by completing a
Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153, Rev. 3/17),
available on the Medi-Cal website at www.medi-cal.ca.gov, under “Provider Resources”, “Forms”, then
“Billing”.
A submitter billing number for an existing clinical laboratory provider is not transferable. A new DHCS
6153 form must be submitted each time a new enrolled location is approved.
If you have any questions about completing the DHCS 6153 form, call the TSC at 1-800-541-5555 and
select the option for Computer Media Claims (CMC).
Provider Enrollment Division
Enclosures
(Rev. 6/17)
State of California
Department of Health Care Services
Health and Human Services Agency
INSTRUCTIONS FOR COMPLETION OF THE
MEDI-CAL PROVIDER APPLICATION
DO NOT USE staples on this form or on any attachments.
DO NOT USE correction tape, white out, or highlighter pen or ink of a similar type on this form. If you
must make corrections, please line through, date, and initial in ink.
DO NOT LEAVE any questions, boxes, lines, etc. blank. Enter N/A if not applicable to you.
This form is part of an application for enrollment or continued enrollment as a provider in the Medi-Cal
program. Applicants and providers must also provide additional information and documentation.
Applicants and providers may be subject to an on-site inspection and to unannounced visits prior to
enrollment or approval for continued enrollment in a program. In addition to this form and requested
documentation, a MEDI-CAL DISCLOSURE STATEMENT (DHCS 6207) and a MEDI-CAL PROVIDER
AGREEMENT (DHCS 6208) must also be completed for enrollment or continued enrollment. Additional
information can be found on the Medi-Cal Web site (www.medi-cal.ca.gov) by clicking the “Provider
Enrollment” link.
Omission of any information or documentation on this form or failure to sign any of these
documents may result in any of the denial actions identified in California Code of Regulations
(CCR), Title 22, Section 51000.50.
You must attach copies of Centers for Medicare and Medicaid Services/National Plan and Provider
Enumeration System (CMS/NPPES) confirmation for each National Provider Identifier (NPI)
submitted with your application package. You may not submit an NPI for use in Medi-Cal billing
unless that NPI is appropriately registered with CMS and is in compliance with all NPI
requirements established by CMS at the time of submission.
You must submit an application fee and/or fee waiver request unless you are exempt from paying
the fee. DHCS will only accept a cashier’s check made payable to the State of California,
Department of Health Care Services, in the amount required for the calendar year in which DHCS
receives your application. Information regarding the current fee is available on the DHCS Web
site at www.dhcs.ca.gov. Failure to submit a cashier’s check when required may result in denial
of your application.
Enrollment action requested - check all that apply. Enter the date you are completing the application.
“New provider” —check if the applicant is not currently enrolled in the Medi-Cal program as a provider
with an active provider number. Include the NPI for the business address indicated in item 4.
“Change of business address”—check if the applicant is currently enrolled in the Medi-Cal program and is
requesting to relocate to a new business address and vacate the old location. Indicate the business
address applicant is moving from.
“Additional business address”—check if the applicant is currently enrolled in the Medi-Cal program and is
requesting enrollment for an additional business location.
“New Taxpayer ID Number”—check if a new Taxpayer Identification Number (TIN) has been issued by
the IRS.
DHCS 6204 (Rev. 2/17)
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