Cal. Code Regs. Tit. 22, § 51000.50 - Application Review Criteria and Notice of Department Action

(a) The Department shall review the applicant's or provider's completed application package for enrollment, continued enrollment, enrollment at a new, additional, or change in location, or enrollment pursuant to Section 51000.30(b) in the Medi-Cal program. The applicant or provider shall meet the following requirements for enrollment in the Medi-Cal program:

(1) The application package shall be signed and notarized if required by Section 51000.30(a)(2).

(2) The information specified in Sections 51000.30, 51000.35, and 51000.45, and all required submittals and attachments to the application package have been received by the Department.

(3) The applicant or provider has a valid license, certificate, or other approval necessary to perform the healthcare services or to provide the goods, supplies, or merchandise within the applicable provider of service category or subgroup of that category.

(4) The applicant or provider meets all applicable standards for participation in the Medi-Cal program specified in Chapter 7 (commencing with section 14000) and Chapter 8 (commencing with 14200) of Part 3 of Division 9 of the Welfare and Institutions Code, and Division 3, Title 22, California Code of Regulations.

(5) The applicant or provider has obtained all state and local licenses, permits, or authorizations necessary to operate a business at the business address for which the application package is submitted and to perform the health care services or to provide the goods, supplies, or merchandise with the applicable provider of service category or subgroup of that category.

(6) All fines, and debts due and owing, including overpayments and penalty assessments, to any federal, state, or local government entity that relates to Medicare, Medicaid, Medi-Cal, or any other federal and state health care program, have been paid, or satisfactory arrangements have been made to fulfill the obligation or the fine or debt has been excused by legal proceedings.

(7) No applicant, provider, person with an ownership or control interest in the applicant or provider, or person who is a director, officer, or managing employee of an applicant or provider, has been convicted of any felony, or convicted of any misdemeanor involving fraud or abuse in any government program, related to neglect or abuse of a patient in connection with the delivery of a healthcare item or service, or in connection with the interference with, or obstruction of, any investigation into health care related fraud or abuse, or has been found liable for fraud or abuse in any civil proceeding, or has entered into a settlement in lieu of conviction for fraud or abuse in any government program within ten years of the date of the application package.

(8) No applicant, provider, person with an ownership or control interest in the applicant or provider, or person who is a director, officer, or managing employee of an applicant or provider shall be under investigation for any healthcare related fraud or abuse at the time of the application for enrollment, continued enrollment, enrollment at a new, additional, or change in location, enrollment pursuant to Section 51000.30(b), or during the preenrollment period.

(9) The applicant or provider has satisfactorily corrected any discrepancies in the application package or identified in a background check, preenrollment inspection or unannounced visit within the time limit specified by the Department. If the applicant or provider cannot satisfactorily correct one or more discrepancies because they occurred in the past, then the application shall be denied.

(10) The applicant or provider has satisfactorily demonstrated to the Department that the business address for which the application package was submitted is an established place of business as specified in Section 51000.60, at the time of application and at the time of any background check, preenrollment inspection or unannounced visit.

(11) If applicable, the period of time during which an applicant or provider has been barred from reapplying has passed.

(12) The information submitted by the applicant or provider is accurate and complete.

(b) Except as provided in subsection (c), within 30 days of receipt of an application package, the Department shall provide written notice to inform the applicant or provider that either:

(1) A moratorium has been imposed pursuant to Welfare and Institutions Code, Section 14043.55 or 14125.8, on the enrollment of providers in the specific provider of service category for which the applicant or provider has applied. If a moratorium has been imposed, the Department shall return the application package to the applicant or provider with the notice.

(2) The Department has received the applicant's or provider's application package and shall evaluate the application package based upon the criteria contained in this Chapter and its governing statutes.

(c) Within 15 days of receipt of an application package from a physician, or a group of physicians, licensed by the Medical Board of California or the Osteopathic Medical Board of California, the Department shall provide written notice to inform the applicant or provider that the Department has received the applicant's or provider's application package.

(d) An applicant or provider who requests consideration as a preferred provider shall be notified within 60 days whether the applicant or provider meets or does not meet all of the criteria listed in the Provider Bulletin, titled "Preferred Provider Status", dated February 2004, accessible on the Medi-Cal Web site at www.medi-cal.ca.gov at the Provider Enrollment link, under Statute, Regulations, and Provider Bulletins. If an applicant or provider is notified that the applicant or provider does not meet the criteria for a preferred provider, the application package submitted shall be processed in accordance with the remainder of this section.

(e) Except as provided in subsection (f) within 180 days of receipt by the Department of an application package, or within 180 days from the date of the notice to an applicant or provider that the applicant or provider does not qualify as a preferred provider, the Department shall give written notice to the applicant or provider of one of the following:

(1) The applicant or provider is granted provisional provider status for a period of 12 months, effective from the date on the notice; or

(2) The application package is incomplete, describing which information is required, or which attachments are outstanding and/or inadequate. The application package shall be returned at the time of this notice to the applicant, who may re-submit the application package at any future date. When an application package is re-submitted, it may include the materials previously submitted along with the materials necessary to correct the outstanding and/or inadequate information, provided the materials are current and valid at the time of re-submission; or

(3) The Department is exercising its authority under Welfare and Institutions Code Section 14043.37, 14043.4, or 14043.7 to conduct background checks, preenrollment inspections, or unannounced visits; or

(4) The application package is denied based on the applicant's or provider's failure to meet the criteria specified in subsection (a), or failure to comply with the requirements specified in this Chapter or its governing statutes.

(f) Notwithstanding subsection (e), within 90 days of receipt by the Department of an application package from a physician or group of physicians licensed by the Medical Board of California or the Osteopathic Medical Board of California, or within 90 days from the date of the notice to an applicant or provider that the applicant or provider does not qualify as a preferred provider, the Department shall give written notice to the applicant or provider that either paragraph (1), (2), (3) or (4) of subsection (e) applies, or shall on the 91st day grant the applicant or provider provisional provider status for a period no longer than 12 months, effective from the 91 day.

(g) If the re-submitted application package is received by the Department within 60 days of the date of the notice of an incomplete application pursuant to subsection (e)(2) above, the Department shall continue to process the application package and shall, within 60 days of the receipt of the re-submitted application package, send a notice indicating one of the following actions:

(1) The applicant or provider is granted provisional provider status for a period of 12 months, effective from the date on the notice; or

(2) The Department is exercising its authority under Welfare and Institutions Code, Section 14043.37, 14043.4, or 14043.7 to conduct background checks, preenrollment inspections, or unannounced visits; or

(3) The application package is denied based on the applicant's or provider's failure to meet the criteria specified in subsection (a), or failure to comply with the requirements specified in this Chapter or its governing statutes.

(h) If a re-submitted application package for enrollment, continued enrollment, enrollment at a new additional or change in location, or enrollment pursuant to Section 51000.30(b), is not received by the Department within 60 days of the date of the notice of an incomplete application pursuant to subsection (e)(2) above, the application package shall be denied by operation of law pursuant to Welfare and Institutions Code Section 14043.26. If the failure to re-submit an application package is by a provider applying for continued enrollment, the provider shall be subject to immediate deactivation of all provider numbers, pursuant to Welfare and Institutions Code Section 14043.26(h)(2)(B). Nothing in this subsection prevents the provider from reapplying as a new applicant by submitting a new application package, which shall receive a new application received date.

(i) If a background check is conducted pursuant to Welfare and Institutions Code, Section 14043.37, a preenrollment inspection is conducted pursuant to Welfare and Institutions Code Section 14043.4, or an unannounced visit is conducted pursuant to Welfare and Institutions Code, Section 14043.7, prior to enrollment, continued enrollment, enrollment at a new, additional or change in location, or enrollment pursuant to Section 51000.30(b), the Department shall provide written notice to the applicant or provider of the following:

(1) The applicant or provider is granted provisional provider status for a period of 12 months, effective from the date on the notice; or

(2) Discrepancies were found with the information provided by the applicant or provider on the application package that require remediation. The applicant or provider shall have 60 days from the date of the notice to provide the requested information and documentation to the Department in order to remediate the discrepancies. If no response is received or the discrepancies are not remediated within the 60 days, the application shall be denied by operation of law pursuant to Welfare and Institutions Code Section 14043.26; or

(3) Discrepancies were found with the information provided by the applicant or provider on the application package that cannot be remediated and the application shall be denied by operation of law pursuant to Welfare and Institutions Code Section 14043.26.

(4) The application is denied based on the applicant's or provider's failure to meet the criteria specified in subsection (a), or failure to comply with the requirements specified in this Chapter or its governing statutes.

(5) A provider whose application for continued enrollment has been denied pursuant to subsection (i)(2), (i)(3), or (i)(4) above, shall prior to any hearing be subject to temporary suspension and deactivation of all provider numbers pursuant to Welfare and Institutions Code, Section 14043.2, 14043.36, 14043.37 and 14043.7.

(j) Any notice by the Department of a denial of an application package shall specify the reason(s) for denial and the administrative remedies, if any, that may be pursued by the applicant or provider.

(k) An applicant or provider whose application package has been denied for enrollment, continued enrollment, enrollment at a new, additional, or change in location, or enrollment pursuant to Section 51000.30(b), may appeal the application package denial, in accordance with Welfare and Institutions Code, Section 14043.65.

(l) An applicant or provider whose application package has been denied for failure to submit to the Department requested information or documentation pursuant to Welfare and Institutions Code Section 14043.26(h)(2)(A) or failure to remediate discrepancies identified by the Department pursuant to Welfare and Institutions Code Section 14043.26(i)(2)(A) may reapply for enrollment in the Medi-Cal program by submitting a new application package that shall be reviewed anew.

(m) An applicant or provider whose application package has been denied for failing to disclose information or for providing false information pursuant to Welfare and Institutions Code Section 14043.2, or denied because it is under investigation pursuant to Welfare and Institutions Code Section 14043.36, shall be barred from reapplying for enrollment in the Medi-Cal program for a period of three years from the date of the denial notice. The Department shall not deny enrollment to an applicant or provider whose felony or misdemeanor charges did not result in a conviction.

(n) An applicant shall not apply for enrollment within 10 years from the date of the conviction for any offense or for any act included in Welfare and Institutions Code Section 14043.36. An applicant or provider whose application package has been denied based on a conviction for any offense or for any act included in Welfare and Institutions Code Section 14043.36, shall be barred from reapplying for enrollment in the Medi-Cal program for a period of 10 years from the date of the denial notice or from the date of the final decision following an appeal from that denial.

(o) An applicant or provider whose application package has been denied based on two or more convictions for any offense or two or more acts included in Welfare and Institutions Code Section 14043.36, shall be permanently barred from applying for enrollment in the Medi-Cal program.

Notes

Cal. Code Regs. Tit. 22, § 51000.50

1. New section filed 9-28-99 as an emergency; operative 9-28-99 (Register 99, No. 40). A Certificate of Compliance must be transmitted to OAL by 3-27-2000 or emergency language will be repealed by operation of law on the following day. Submitted to OAL for printing only pursuant to section 78, AB 1107 (Chapter 146, Statutes of 1999).
2. New section refiled 11-24-99 as an emergency; operative 11-24-99 (Register 99, No. 48). A Certificate of Compliance must be transmitted to OAL by 5-22-2000 or emergency language will be repealed by operation of law on the following day. Submitted to OAL for printing only pursuant to section 78, AB 1107 (Chapter 146, Statutes of 1999).
3. New section refiled 5-5-2000 as an emergency; operative 5-22-2000 (Register 2000, No. 18). A Certificate of Compliance must be transmitted to OAL by 9-19-2000 or emergency language will be repealed by operation of law on the following day.
4. New section refiled 8-28-2000 as an emergency; operative 9-6-2000 (Register 2000, No. 35). A Certificate of Compliance must be transmitted to OAL by 1-4-2001 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 8-28-2000 order, including amendment of section, transmitted to OAL 12-26-2000 and filed 2-8-2001 (Register 2001, No. 6).
6. Amendment of section and NOTE filed 2-3-2003 as an emergency; operative 2-3-2003 (Register 2003, No. 6). Emergency amendments exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75. Amendments to remain in effect for 180 days pursuant to section 78, chapter 146, Statutes of 1999 (AB 1107). A Certificate of Compliance must be transmitted to OAL by 8-4-2003 or emergency language will be repealed by operation of law on the following day.
7. Amendment of section and NOTE refiled 8-5-2003 as an emergency; operative 8-5-2003 (Register 2003, No. 32). Emergency amendments exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75. Amendments to remain in effect for 180 days pursuant to section 78, chapter 146, Statutes of 1999 (AB 1107). A Certificate of Compliance must be transmitted to OAL by 2-2-2004 or emergency language will be repealed by operation of law on the following day.
8. Amendment of section and NOTE refiled 2-3-2004 as an emergency; operative 2-3-2004 (Register 2004, No. 6). Emergency amendments exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75. A Certificate of Compliance must be transmitted to OAL by 6-2-2004 or emergency language will be repealed by operation of law on the following day.
9. Reinstatement of section and NOTE as they existed prior to 2-3-2004 emergency amendment by operation of Government Code section 11346.1(f) (Register 2004, No. 24).
10. Amendment of section and NOTE refiled 6-8-2004 as an emergency; operative 6-8-2004 (Register 2004, No. 24). A Certificate of Compliance must be transmitted to OAL by 10-6-2004 or emergency language will be repealed by operation of law on the following day.
11. Reinstatement of section as it existed prior to 6-8-2004 emergency amendment by operation of Government Code section 11346.1(f) (Register 2004, No. 41).
12. Amendment of section and NOTE filed 9-29-2004 as an emergency; operative 10-7-2004 (Register 2004, No. 41). A Certificate of Compliance must be transmitted to OAL by 2-4-2005 or emergency language will be repealed by operation of law on the following day. Deemed emergency exempt from OAL pursuant to Welfare and Institutions Code section 14043.75.
13. Amendment of section and NOTE refiled 1-27-2005 as an emergency; operative 2-5-2005 (Register 2005, No. 4). A Certificate of Compliance must be transmitted to OAL by 6-6-2005 or emergency language will be repealed by operation of law on the following day. Deemed emergency exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75.
14. Amendment of section and NOTE refiled 6-2-2005 as an emergency; operative 6-7-2005 (Register 2005, No. 22). A Certificate of Compliance must be transmitted to OAL by 10-5-2005 or emergency language will be repealed by operation of law on the following day. Deemed emergency exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75.
15. Certificate of Compliance as to 6-2-2005 order, including further amendment of section, transmitted to OAL 9-29-2005 and filed 11-10-2005 (Register 2005, No. 45).
16. Change without regulatory effect amending subsections (e), (f) and (g)(2) and amending NOTE filed 2-28-2008 pursuant to section 100, title 1, California Code of Regulations (Register 2008, No. 9).
17. Change without regulatory effect amending subsection (b), adopting new subsections (c) and (f), relettering subsections and amending newly designated subsections (d), (e), (g), (h), (i)(5) and (l) filed 1-23-2009 pursuant to section 100, title 1, California Code of Regulations (Register 2009, No. 4).

Note: Authority cited: Section 20, Health and Safety Code; and Sections 10725, 14043.75 and 14124.5, Welfare and Institutions Code. Reference: Sections 14043.2, 14043.26. 14043.28, 14043.36, 14043.37, 14043.4, 14043.6, 14043.65 and 14043.7, Welfare and Institutions Code; 42 U.S.C. Sections 1320a-3, 1320a-7, 1396a(a)(38) and 1396b(i)(2); and Title 42, Code of Federal Regulations, Part 455.

1. New section filed 9-28-99 as an emergency; operative 9-28-99 (Register 99, No. 40). A Certificate of Compliance must be transmitted to OAL by 3-27-2000 or emergency language will be repealed by operation of law on the following day. Submitted to OAL for printing only pursuant to section 78, AB 1107 (Chapter 146, Statutes of 1999).
2. New section refiled 11-24-99 as an emergency; operative 11-24-99 (Register 99, No. 48). A Certificate of Compliance must be transmitted to OAL by 5-22-2000 or emergency language will be repealed by operation of law on the following day. Submitted to OAL for printing only pursuant to section 78, AB 1107 (Chapter 146, Statutes of 1999).
3. New section refiled 5-5-2000 as an emergency; operative 5-22-2000 (Register 2000, No. 18). A Certificate of Compliance must be transmitted to OAL by 9-19-2000 or emergency language will be repealed by operation of law on the following day.
4. New section refiled 8-28-2000 as an emergency; operative 9-6-2000 (Register 2000, No. 35). A Certificate of Compliance must be transmitted to OAL by 1-4-2001 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 8-28-2000 order, including amendment of section, transmitted to OAL 12-26-2000 and filed 2-8-2001 (Register 2001, No. 6).
6. Amendment of section and Note filed 2-3-2003 as an emergency; operative 2-3-2003 (Register 2003, No. 6). Emergency amendments exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75. Amendments to remain in effect for 180 days pursuant to section 78, chapter 146, Statutes of 1999 (AB 1107). A Certificate of Compliance must be transmitted to OAL by 8-4-2003 or emergency language will be repealed by operation of law on the following day.
7. Amendment of section and Note refiled 8-5-2003 as an emergency; operative 8-5-2003 (Register 2003, No. 32). Emergency amendments exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75. Amendments to remain in effect for 180 days pursuant to section 78, chapter 146, Statutes of 1999 (AB 1107). A Certificate of Compliance must be transmitted to OAL by 2-2-2004 or emergency language will be repealed by operation of law on the following day.
8. Amendment of section and Note refiled 2-3-2004 as an emergency; operative 2-3-2004 (Register 2004, No. 6). Emergency amendments exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75. A Certificate of Compliance must be transmitted to OAL by 6-2-2004 or emergency language will be repealed by operation of law on the following day.
9. Reinstatement of section and Noteas they existed prior to 2-3-2004 emergency amendment by operation of Government Code section 11346.1(f) (Register 2004, No. 24).
10. Amendment of section and Note refiled 6-8-2004 as an emergency; operative 6-8-2004 (Register 2004, No. 24). A Certificate of Compliance must be transmitted to OAL by 10-6-2004 or emergency language will be repealed by operation of law on the following day.
11. Reinstatement of section as it existed prior to 6-8-2004 emergency amendment by operation of Government Code section 11346.1(f) (Register 2004, No. 41).
12. Amendment of section and Note filed 9-29-2004 as an emergency; operative 10-7-2004 (Register 2004, No. 41). A Certificate of Compliance must be transmitted to OAL by 2-4-2005 or emergency language will be repealed by operation of law on the following day. Deemed emergency exempt from OAL pursuant to Welfare and Institutions Code section 14043.75.
13. Amendment of section and Note refiled 1-27-2005 as an emergency; operative 2-5-2005 (Register 2005, No. 4). A Certificate of Compliance must be transmitted to OAL by 6-6-2005 or emergency language will be repealed by operation of law on the following day. Deemed emergency exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75.
14. Amendment of section and Note refiled 6-2-2005 as an emergency; operative 6-7-2005 (Register 2005, No. 22). A Certificate of Compliance must be transmitted to OAL by 10-5-2005 or emergency language will be repealed by operation of law on the following day. Deemed emergency exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75.
15. Certificate of Compliance as to 6-2-2005 order, including further amendment of section, transmitted to OAL 9-29-2005 and filed 11-10-2005 (Register 2005, No. 45).
16. Change without regulatory effect amending subsections (e), (f) and (g)(2) and amending Note filed 2-28-2008 pursuant to section 100, title 1, California Code of Regulations (Register 2008, No. 9).
17. Change without regulatory effect amending subsection (b), adopting new subsections (c) and (f), relettering subsections and amending newly designated subsections (d), (e), (g), (h), (i)(5) and (l) filed 1-23-2009 pursuant to section 100, title 1, California Code of Regulations (Register 2009, No. 4).