Form DHCS9098 "Medi-Cal Provider Agreement (Institutional Provider)" - California

What Is Form DHCS9098?

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, 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 DHCS9098 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 DHCS9098 "Medi-Cal Provider Agreement (Institutional Provider)" - California

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State of California
Department of Health Care Services
Health and Human Services Agency
INSTRUCTIONS FOR THE COMPLETION OF THE MEDI-CAL PROVIDER AGREEMENT
(Institutional Provider)
• Type or print clearly.
• Return original and maintain a copy for your records.
• The Legal name and Business name must be consistent throughout the Medi-Cal Provider
Agreement and any of its attachments.
• DO NOT LEAVE any questions, boxes, lines, etc. blank. Enter N/A if not applicable to you. If this
document is incomplete, it will be returned to you.
Page 2 (Please enter the date)
Legal name is the name listed with the Internal Revenue Service (IRS).
Business name is the facility, hospital, agency, or clinic name (name of business/DBA)
Provider Number (NPI) is the ten-digit National Provider Identifier for the business address, as
registered with the National Plan and Provider Enumeration System (NPPES).
Business telephone number is the primary business telephone number used at the business
address.
Business address is the actual business location including the street name and number, room or
suite number or letter, city, state, and nine-digit ZIP code. A post office box or commercial box is
not acceptable.
Mailing address is the location at which the applicant or provider wishes to receive general
Medi-Cal correspondence. General Medi-Cal correspondence includes bulletin updates and
Provider Manual updates.
Pay-to address is the address at which the applicant or provider wishes to receive payment.
Previous business address is the address where the applicant or provider was previously
enrolled. If the applicant or provider is not submitting an application for a change of location, enter
N/A.
Taxpayer Identification Number is the Taxpayer Identification Number (TIN) issued by the IRS
under the name of the applicant or provider.
Page 12
1. Legal name is the name listed with the IRS.
2. Printed name of the person signing this agreement.
3. Original signature of the person signing this agreement.
4. Title of the person signing this agreement.
5. Notary Public box is for Certificate of Acknowledgment, signature and seal of Notary Public.
(See California Civil Code Section 1189).
DHCS 9098 (Rev. 7/17)
Page 1 of 13
State of California
Department of Health Care Services
Health and Human Services Agency
INSTRUCTIONS FOR THE COMPLETION OF THE MEDI-CAL PROVIDER AGREEMENT
(Institutional Provider)
• Type or print clearly.
• Return original and maintain a copy for your records.
• The Legal name and Business name must be consistent throughout the Medi-Cal Provider
Agreement and any of its attachments.
• DO NOT LEAVE any questions, boxes, lines, etc. blank. Enter N/A if not applicable to you. If this
document is incomplete, it will be returned to you.
Page 2 (Please enter the date)
Legal name is the name listed with the Internal Revenue Service (IRS).
Business name is the facility, hospital, agency, or clinic name (name of business/DBA)
Provider Number (NPI) is the ten-digit National Provider Identifier for the business address, as
registered with the National Plan and Provider Enumeration System (NPPES).
Business telephone number is the primary business telephone number used at the business
address.
Business address is the actual business location including the street name and number, room or
suite number or letter, city, state, and nine-digit ZIP code. A post office box or commercial box is
not acceptable.
Mailing address is the location at which the applicant or provider wishes to receive general
Medi-Cal correspondence. General Medi-Cal correspondence includes bulletin updates and
Provider Manual updates.
Pay-to address is the address at which the applicant or provider wishes to receive payment.
Previous business address is the address where the applicant or provider was previously
enrolled. If the applicant or provider is not submitting an application for a change of location, enter
N/A.
Taxpayer Identification Number is the Taxpayer Identification Number (TIN) issued by the IRS
under the name of the applicant or provider.
Page 12
1. Legal name is the name listed with the IRS.
2. Printed name of the person signing this agreement.
3. Original signature of the person signing this agreement.
4. Title of the person signing this agreement.
5. Notary Public box is for Certificate of Acknowledgment, signature and seal of Notary Public.
(See California Civil Code Section 1189).
DHCS 9098 (Rev. 7/17)
Page 1 of 13
State of California
Department of Health Care Services
Health and Human Services Agency
MEDI-CAL PROVIDER AGREEMENT
(Institutional Provider)
(To Accompany Applications for 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 (as listed with
Business name (if different than legal name)
the IRS)
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.
** The taxpayer identification number may be a Taxpayer Identification Number (TIN) or a social security
number for sole proprietors.
DHCS 9098 (Rev. 7/17)
Page 2 of 13
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
Procedure Act) from further participation in the Medi-Cal program, including deactivation of any provider
agreement, 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 25(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.
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 treatment authorization requests
(TARs) or claims to DHCS using an NPI unless that NPI is appropriately registered for this provider 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 Title 22, California Code of Regulations, Section 51000.40 and
51000.52(b).
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 any Medi-Cal patient 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.
In addition, Provider shall not discriminate against Medi-Cal beneficiaries in any manner, including, but
not limited to, admission practices, room selection and placement, meals provision and waiting time for
surgical procedures. Without exception, Provider shall provide to Medi-Cal patients their specific Medi-
Cal benefit Inpatient Services in the same manner as Provider also directly, or indirectly, renders those
same services to non-Medi-Cal patients, regardless of payor source.
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.
DHCS 9098 (Rev. 7/17)
Page 3 of 13
State of California
Department of Health Care Services
Health and Human Services Agency
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
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 it shall be automatically suspended 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. 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 or a claim was submitted.
Providers using billing agents shall assure that the billing agents maintain and submit documents
required.
9. DHCS, CDP H, 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, CDPH, the California Attorney General's
Medi-Cal Fraud Unit ("AG") or the Health, Education and Welfare Unit, 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 or its billing agent from participation in the Medi-Cal program. Provider will be reimbursed for
reasonable copy costs as determined by DHCS, CDPH, AG or Secretary.
10. Confidentiality of Beneficiary Information. Provider agrees that all documents, whether paper,
electronic or in any media, that contain protected health information as defined under the Health
Information Portability and Accountability Act or personal, confidential information 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. Provider agrees to
enter into a business associate agreement with any billing agents to assure that they comply with these
requirements.
DHCS 9098 (Rev. 7/17)
Page 4 of 13
State of California
Department of Health Care Services
Health and Human Services Agency
11. 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
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.
12. 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.
13. 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. Pursuant to Welfare and
Institutions Code Section 14043.7(b), such unannounced visits are authorized should the department
have reason to believe that the provider will defraud or abuse the Medi-Cal program or lacks the
organizational or administrative capacity to provide services under the program. 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.
14. 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.
15. 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 Federal, state or local law enforcement agency, including the Medicaid investigation units
of DHCS and the Office of the Inspector General for the Federal Department of Health and Human
Services. Provider further agrees to notify DHCS within ten business days of learning that it is under
DHCS 9098 (Rev. 7/17)
Page 5 of 13
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