Independent Diagnotic Testing Facility (IDTF) Application Package Instructions
In accordance with Title 42, CFR, Section 410.33, Centers for Medicare and Medicaid Services, and the State Medicaid Manual, Section 3490 through 3490.14, Independent Diagnostic Testing Facility (IDTF) providers are only eligible to enroll into the Medi-Cal program as "Medicare Crossover Only" providers in order to receive reimbursement for Medicare Part B services.
"This provider type can only be authorized for Medicare Crossover reimbursement and must use the "Crossover Only Provider Form" (MC0804) to request such authorization from Medi-Cal."
Required Documents When Submitting the Crossover Only Provider Form (MC0804) are listed below.
1. Federal Employer Identification Number (FEIN) or Individual Taxpayer Identification Number (ITIN) verification, 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.
2. Copy of approval letter as an Independent Diagnostic Testing Facility (IDTF) provider from the Centers of Medicare and Medicaid Services (CMS).