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Facility-Based Providers Application Instructions

Eligibility: This type of enrollment is for individual healthcare providers and groups of healthcare providers who provide medical services exclusively in one or more Licensed Health Facilities that are also actively-enrolled in Medi-Cal.

Licensed Health Facilities that are included in this type of enrollment are those defined in the California Health & Safety Code Sections 1250 -1250.3.

Pursuant to the regulatory Provider Bulletin published in the February 2005 Medi-Cal Update, DHCS has established procedures for the enrollment of licensed or certificated healthcare providers, or applicants who are professional corporations, who render services to Medi-Cal beneficiaries exclusively in one or more licensed health facilities that are enrolled in the Medi-Cal program. This bulletin refers to such persons or professional corporations as "facility-based providers". In order to determine whether or not you qualify for this type of enrollment, please read the detailed Provider Bulletin"Requirements and Procedures for Enrollment as a Facility-Based Provider".If you qualify to enroll as a Facility-Based Provider or Provider Group…

You must complete a Medi-Cal provider application package according to your provider type or a Group Application, if you are a provider group. The specific application package you need to submit, including required documentation, can be found in the list of application packages by provider type.  In addition, you need to submit the specified cover letters as described below. Your application package will not be processed without the required cover letters.

*Be sure to indicate in Section four on the application forms that you are applying as a Facility-Based Provider and check all options that apply to you or your group.

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.

 

Cover Letters Required for Facility-Based Provider Enrollment:

1. Health Care Facility Cover Letter…must be on facility letterhead, from each Medi-Cal enrolled and licensed health facility at which you render services to Medi-Cal beneficiaries. The requirements for the information needed and a suggested format for this letter can be found on pages two and four of the "Facility-Based Provider Bulletin".  N.B. This letter is not required for facility-based anesthesiologists who do not have a contract with a licensed health facility/facilities.

2. Provider Cover Letter…a letter from you, the provider or provider group, that lists each Medi-Cal enrolled and licensed health facility at which you render services to Medi-Cal beneficiaries. The requirements for this letter and a suggested format for this letter can be found on pages two and five of the "Facility-Based Provider Bulletin".  N.B. This letter is not required for facility-based anesthesiologists who do not have a contract with a licensed health facility/facilities.

3. Provider Cover Letter for an anesthesiologist or group of anesthesiologists who don’t have a contract with a licensed health facility(ies) …a letter which lists all of the Medi-Cal enrolled and licensed health facilities at which you render services to Medi-Cal beneficiaries. The requirements for this letter and a suggested format for this letter can be found on pages three and six of the"Facility-Based Provider Bulletin".  

Last modified on: 7/3/2015 5:21 PM