DHCS Holds Follow-Up Stakeholder Meeting to Discuss Forthcoming Changes to Medi-Cal Provider Regulations

This Monday, June 25, 2012, the Provider Enrollment Division (PED) of the California Department of Health Care Services (DHCS) held stakeholder workgroup meetings to discuss pending changes to the application and revalidation processes for Medi-Cal providers who order, refer, or prescribe services. These issues are central to California’s implementation of a federal regulation passed in February of 2011 that requires states to enact new requirements for Medicaid provider enrollment and screening.

For Local Educational Agencies (LEAs) participating in the LEA Billing Option program, two important pieces of information were discussed at the stakeholder meetings:

  1. DHCS has maintained their position that a ‘referral’ in the LEA Billing Option program may actually be more akin to a request for services in the broader arena of health care services coordination. They have requested an official definition of ‘referral’ from CMS in writing. As a reminder, one requirement of the new federal regulations states, in broad terms, that all ordering, referring, and prescribing Medicaid providers must be enrolled in Medicaid with an individual National Provider Identification (NPI) number. The extent to which this regulation affects LEA practitioners in California will largely depend on CMS’ response.
  2. The PED confirmed that LEAs’ annual Provider Participation Agreement (PPA) may be used to satisfy new enrollment and revalidation requirements for LEAs.  Revalidation is the process by which Medi-Cal providers will be screened and reauthorized at least every five years for continuing participation in the Medi-Cal program.  Unlike initial enrollment, there is no fee associated with revalidation. As the agency that oversees the LEA Billing Option program, the Safety Net Financing Division (SNFD) of DHCS will assume responsibility for enrolling and screening LEA providers. The PED will only enroll and screen those Medi-Cal providers who are not monitored by any other federal or state governmental agency.


Once changes for Medi-Cal provider screening and enrollment have been finalized, DHCS plans to codify them through two measures: 1) issuing an amendment to California’s state Medicaid plan and 2) proposed legislation (SB 1529, Alquist) to be amended and take effect by January 2013. The PED within DHCS will also publish advance notice of these events in its Provider Bulletins.

As schools continue to increasingly interact with outside health care providers and agencies, such as community clinics, it may eventually serve individually licensed practitioners working in school districts to obtain an NPI and enroll in Medi-Cal for the purposes of ordering and referring. Whether this will be a requirement in California remains to be seen and is contingent on issues yet to be finalized. California’s implementation of ACA provider screening and enrollment requirements is expected to unfold over the next three to five years.

Paradigm will continue to post updates to the Policy Center as information becomes available on this issue.

Read More

Read the proposed text of SB 1529, Alquist…

Read the final federal regulation, CMS 6028-FC…