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Subdivision 1 California Medical Assistance Program Chapter 3 Health Care Services Article 3 Standards for Participation Basic Requirement for Program Participation   

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(a) In addition to any other statutory or regulatory conditions for participation in the Medi-Cal program and any federal requirements for participation in Medicaid, as a condition for enrollment, or continued enrollment, an applicant or provider also shall meet the standards specified in this Article, applicable to their provider type, and the requirements specified in Sections 51000.30 through 51000.55. Failure to meet applicable standards for participation shall result in the denial of the applicant's or provider's application for enrollment, or continued enrollment, as specified in Section 51000.50.

(b) Any provider who violates any provision of law or regulation that governs the Medi-Cal program shall be subject to temporary or permanent suspension from the Medi-Cal program, as permitted by Section 14123, Welfare and Institutions (W&I) Code.

(c) All providers shall be subject to temporary suspension, including temporary deactivation of all provider numbers used by the provider to obtain reimbursement from the Medi-Cal program, under any of the following circumstances:

(1) The provider has failed to disclose all information required in federal Medicaid regulations or any other information required by the Department, or has disclosed false information, as specified in Section 14043.2, W&I Code.

(2) The provider is discovered to be under investigation for fraud or abuse, as specified in Section 14043.36.

(3) The provider has failed to remediate discrepancies that are discovered as a result of an unannounced visit to the provider, as specified in Section 14043.7, W&I Code.

(d) All applicants applying for enrollment, or providers applying for continued enrollment, in the Medi-Cal program shall be certified for participation in the Medicare program of the Federal Social Security Act (Title XVIII), if they provide services that are included in the Medicare scope of benefits and if they provide those services to persons who are eligible beneficiaries of the Medicare program.

(e) Any provider who requests the performance of a clinical laboratory test or examination for a Medi-Cal beneficiary, or upon a biological specimen derived from a Medi-Cal beneficiary, shall provide with the request to the clinical laboratory diagnostic information relevant to the test or examination for which the request is made, including the latest International Classification of Diseases, 9th Revision, or the latest published editions or amendments thereto, Clinical Modification (ICD-9-CM) code numbers, to the highest level of specificity indicating medical necessity for all laboratory tests as required under the Medicare program pursuant to 42, U.S.C., Section 1395u(p) and 42, CFR, Section 424.32.

(f) In addition to meeting and complying with all applicable requirements specified in Articles 1, 2, and 3, any place where a provider, as defined in Section 51051(a), renders laboratory or clinical laboratory services as defined in Section 51137.2 and any person performing, supervising, consulting on, or directing such laboratory or clinical laboratory services shall meet and maintain compliance with the requirements of Section 51211.2.

(g) Medi-Cal provider applicants or providers shall meet and maintain compliance with the requirements of Section 51200.01.

Authority cited:

Welfare and Institutions Code 10725

Welfare and Institutions Code 14105

Welfare and Institutions Code 14124.5

Section 78, Chapter 146, Statutes of 1999


Welfare and Institutions Code 14043.1

Welfare and Institutions Code 14043.36

Welfare and Institutions Code 14043.75

Welfare and Institutions Code 14123

Welfare and Institutions Code 14132

Health and Safety Code 101150-101160

Business and Professions Code 1200-1327

(Amended by Register 2004, No. 6)