Clinic-Based Physician Application Instructions and Requirements
Eligibility: This enrollment type is only for individual physicians who provide medical services exclusively at Medi-Cal enrolled, licensed primary care clinic(s), have no other established place of business (i.e. a medical office) where they provide services and who need to bill for inpatient services provided to beneficiaries in a general acute care hospital or acute psychiatric hospital setting. Groups are not eligible for this type of enrollment.
Pursuant to the regulatory Provider Bulletin published in the December 2005 Medi-Cal Update, DHCS has established procedures for the enrollment of physicians who are solely employed by or provide services pursuant to a contract with licensed primary care clinics, except for services provided as part of a graduate medical education program, and who do not have any active Medi-Cal provider number issued to them individually to bill for clinical services to Medi-Cal beneficiaries at another location and as such, use the licensed primary care clinic as their established place of business. This type of enrollment allows the physician to bill for inpatient services only and not for services provided at the Licensed Primary Care Clinic. In order to determine whether or not you qualify for this type of enrollment, please read the detailed Provider Bulletin "Requirements and Procedures for 'Clinic-Based Provider' Enrollment".
If you qualify to enroll as a Clinic-Based Physician...
You need to complete two separate Medi-Cal forms, and attach a number of required documents and two cover letters, as verification of information provided in the Medi-Cal forms. All questions and blanks on the forms must be completed. Also, legible and current copies of all required documents must be submitted in order for the application package to be considered complete. An incomplete application package will prolong your enrollment process because it will be returned to you for correction and/or completion. The Provider Enrollment staff can not make any changes to your documents.
Prior to applying to Medi-Cal, first check the Medical Board of California Web site at www.mbc.ca.gov or the Osteopathic Medical Board of California Web site at www.ombc.ca.gov to ensure you meet all the licensing requirements.
Next, make legible copies of current documents that are required to be submitted with your Medi-Cal application forms, as listed below.
1. Current California Medical License or Osteopathic Physician and Surgeon's License of applicant or provider. Please include DEA Certificate, if applicable.
2. Driver’s License or state-issued identification card (issued within the 50 United States or the District of Columbia) of the provider who is signing the form. The signature must be that of the physician applicant.
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3. National Plan and Provider Enumeration System (NPPES) confirmation for each National Provider Identifier (NPI) you list in the application package. Acceptable NPI documentation is one of the following: 1) NPI notification letter from the NPPES, 2) NPI notification e-mail from NPPES, or 3) NPI notification letter or e-mail from the Electronic File Interchange Organization (EFIO). Note: The name and business address of the applicant or provider on all forms must exactly match the name and practice location on the NPPES or EFIO notification. For information on how to apply for an NPI or update your information in NPPES, visit the Medi-Cal Web site at www.medi-cal.ca.gov, and click on the "NPI" link, or go to https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart.
4. Federal Employer Identification Number (FEIN) or Individual Taxpayer Identification Number (ITIN) verification of the physician applicant, if a social security number is not used, by submitting a current Internal Revenue Service (IRS) generated document. The only acceptable documents include an IRS-generated Letter 147-C, IRS-generated Form 941 (Employer’s Quarterly Federal Tax Return), IRS-generated Form 8109-C (Deposit Coupon), or IRS-generated Form SS-4 (only the official Confirmation Notification of FEIN/ITIN assignment). Note: The legal name of the applicant or provider on all forms must exactly match the name on the IRS-generated document; and the applicant/provider must be an owner or officer of the entity listed on the IRS document. For further information, please contact the IRS at (800) 829-4933 or www.irs.gov.
5. Licensed Primary Care Clinic Cover Letter from at least one Medi-Cal-enrolled clinic at which you provide services. This letter should include the required information as described on page three of the Clinic-Based Provider Bulletin.
6. Physician Cover Letter (at least one) that includes the required information as described on page four of the Clinic-Based Provider Bulletin.
7. Fictitious Name Permit (FNP) issued by the Medical Board of California or the Osteopathic Medical Board of California, if using a fictitious name for your medical practice, as defined by the Board. Note: The business name of the applicant or provider on all forms, all local business licenses/permits, and the FNP must exactly match.
8. If your business is a corporation, processing delays may be avoided by attaching a copy of the filed Articles of Incorporation from the Secretary of State, and a list of directors’ and officers’ names and titles, with percent of ownership and control interest for each.
To verify or change the name or status of your corporation, or for further information, please visit the Secretary of State California Business Portal Web page at www.sos.ca.gov/business/business.htm, and click on the "California Business Search" link or other appropriate link.
12. Certificate of Professional Liability Insurance in an amount of not less than $100,000 per claim and a minimum annual aggregate of $300,000. Acceptable verification is a certificate of insurance or declaration sheet issued by the insurance company that contains the name of the insurance company, the name of the insured, effective dates, and limits of coverage. Note: The provider’s name, as it appears on the California Medical License, must also show on the verification of the professional liability insurance.
You may need to submit additional documents depending upon answers to certain questions on the Medi-Cal Disclosure Statement (DHCS 6207). The document requirements are subject to change depending upon future changes in enrollment regulations and/or state law.
PROCEED TO THE 2 APPLICATION FORMS NEEDED AND BE SURE TO COMPLETE SECTION (4.b) OF THE MEDI-CAL PHYSICIAN APPLICATION/AGREEMENT (DHCS 6210).
1. Medi-Cal Physician Application/Agreement Form (DHCS 6210)
2. Medi-Cal Disclosure Statement Form (DHCS 6207)