Cal. Code Regs. Tit. 22, § 51242 - EPSDT Diagnosis and Treatment Provider and EPSDT Supplemental Services Provider
(a) An EPSDT
diagnosis and treatment provider shall meet the requirements for participation
in the Medi-Cal program as specified in this chapter, excepting the
requirements specified in subsection (b).
(b) A provider seeking to provide EPSDT
supplemental services, who is not enrolled as a provider pursuant to subsection
(a), shall first submit a provider enrollment application to the department to
become an EPSDT supplemental services provider. The application shall be
accompanied by a request for prior authorization, pursuant to Section
51340(c), for the
initial service the provider seeks to provide.
(c) An EPSDT case manager, defined in Section
51184(h)(4),
seeking to provide EPSDT case management services shall be considered to be an
EPSDT supplemental services provider and shall comply with the requirements of
this section.
(d) In order to be
approved as an EPSDT supplemental services provider for the particular service
sought, the provider shall supply documentation or other evidence which the
Department determines establishes that both of the following conditions are
met:
(1) The services to be provided meet the
standard of medical necessity set forth in Section
51340(e).
(2) The provider is licensed, certified, or
otherwise recognized or authorized under state law governing the healing arts
to provide the service pursuant to Division 2 (commencing with section
500)
of the Business and Professions Code or is a licensed pediatric day health and
respite care facility pursuant to Section
1760
of the Health and Safety Code, and meets any applicable requirements in federal
Medicaid law to provide the particular service requested.
(e) Notwithstanding the provisions of
paragraph (d)(1), an entity or individual seeking to provide EPSDT case
management services pursuant to Section
51340(j)(3) shall
supply documentation enabling the Department to determine that both of the
following requirements are met:
(1) The
criteria specified in Section
51340(f) are
met.
(2) The entity or individual
is qualified by education, training, or experience to provide EPSDT case
management services to the beneficiary.
(f) The Department shall not approve an
application pursuant to subsection (b) or (c) of this section if the Department
determines that the service to be provided is accessible and available in an
appropriate and timely manner through existing Medi-Cal certified provider
types or other Medi-Cal programs.
(g) Once enrolled as an EPSDT supplemental
services provider, the provider shall remain enrolled only for the purpose of
providing subsequent EPSDT supplemental services within his or her scope of
practice, or within the scope of the facility's license, unless disenrolled by
provider choice or the Department's administrative action, pursuant to Chapter
3, Division 3, Title 22, California Code of Regulations.
(h) A provider who is currently enrolled as a
Medi-Cal services provider shall not be required to enroll as an EPSDT
supplemental services provider.
(i)
Notwithstanding subsections (a) and (d), a local health department as defined
in Section
101185
of the Health and Safety Code or a comprehensive environmental agency as
referenced in Section
101275
of the Health and Safety Code may provide onsite investigations to detect the
source of lead contamination as an EPSDT supplemental service, as specified in
51340.1(d). To be eligible for payment, the service must be rendered by an
individual who is a Registered Environmental Health Specialist registered in
accordance with Article 1 of Chapter 4 of Part 1 of Division 104 of the
California Health and Safety Code (commencing with Section 106600) and who has
been certified in accordance with Section
of Title
1735005 of Title 17 of the California Code of
Regulations as a Certified Lead Inspector/Assessor of the Department.
Notes
2. New section refiled 8-1-94 as an emergency; operative 8-1-94 (Register 94, No. 31). A Certificate of Compliance must be transmitted to OAL by 11-29-94 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 10-24-94 as an emergency; operative 10-24-94 (Register 94, No. 43). A Certificate of Compliance must be transmitted to OAL by 2-21-95 or emergency language will be repealed by operation of law on the following day.
4. New section refiled 2-22-95; operative 2-22-95 (Register 95, No. 8). A Certificate of Compliance must be transmitted to OAL by 6-22-95 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 2-22-95 order including amendment of section heading and section transmitted to OAL 3-16-95 and filed 4-27-95 (Register 95, No. 17).
6. New subsection (i) and amendment of NOTE filed 4-13-99 as an emergency; operative 4-13-99 (Register 99, No. 16). A Certificate of Compliance must be transmitted to OAL by 8-11-99 or emergency language will be repealed by operation of law on the following day.
7. New subsection (i) and amendment of NOTE refiled 8-5-99 as an emergency; operative 8-5-99 (Register 99, No. 32). A Certificate of Compliance must be transmitted to OAL by 12-3-99 or emergency language will be repealed by operation of law on the following day.
8. Amendment of subsections (d)(1), (d)(2) and (g) and amendment of NOTE filed 11-10-99 as an emergency; operative 11-10-99 (Register 99, No. 46). A Certificate of Compliance must be transmitted to OAL by 3-9-2000 or emergency language will be repealed by operation of law on the following day.
9. Certificate of Compliance as to 8-5-99 order transmitted to OAL 12-1-99 and filed 1-12-2000 (Register 2000, No. 2).
10. Certificate of Compliance as to 11-10-99 order transmitted to OAL 3-8-2000 and filed 4-19-2000 (Register 2000, No. 16).
Note: Authority cited: Sections 10725, 14124.5 and 14195, Welfare and Institutions Code. Reference: Sections 14059, 14132 and 14132.10, Welfare and Institutions Code.
2. New section refiled 8-1-94 as an emergency; operative 8-1-94 (Register 94, No. 31). A Certificate of Compliance must be transmitted to OAL by 11-29-94 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 10-24-94 as an emergency; operative 10-24-94 (Register 94, No. 43). A Certificate of Compliance must be transmitted to OAL by 2-21-95 or emergency language will be repealed by operation of law on the following day.
4. New section refiled 2-22-95; operative 2-22-95 (Register 95, No. 8). A Certificate of Compliance must be transmitted to OAL by 6-22-95 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 2-22-95 order including amendment of section heading and section transmitted to OAL 3-16-95 and filed 4-27-95 (Register 95, No. 17).
6. New subsection (i) and amendment of Note filed 4-13-99 as an emergency; operative 4-13-99 (Register 99, No. 16). A Certificate of Compliance must be transmitted to OAL by 8-11-99 or emergency language will be repealed by operation of law on the following day.
7. New subsection (i) and amendment of Note refiled 8-5-99 as an emergency; operative 8-5-99 (Register 99, No. 32). A Certificate of Compliance must be transmitted to OAL by 12-3-99 or emergency language will be repealed by operation of law on the following day.
8. Amendment of subsections (d)(1), (d)(2) and (g) and amendment of Note filed 11-10-99 as an emergency; operative 11-10-99 (Register 99, No. 46). A Certificate of Compliance must be transmitted to OAL by 3-9-2000 or emergency language will be repealed by operation of law on the following day.
9. Certificate of Compliance as to 8-5-99 order transmitted to OAL 12-1-99 and filed 1-12-2000 (Register 2000, No. 2).
10. Certificate of Compliance as to 11-10-99 order transmitted to OAL 3-8-2000 and filed 4-19-2000 (Register 2000, No. 16).
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