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Medi-Cal Enrollment of Non-Physician Medical Practitioners

NMP = Non-physician Medical Practitioner, sometimes referred to as mid-level providers.

Title 22, CCR Section 51240 addresses enrollment and supervision requirements for NMPs. This regulation stipulates the requirements of the Physician-Practitioner Interface Agreement for the various NMP types and also stipulates that they must be enrolled pursuant to Section 51000.30. Physician-Practitioner Interface documents include the specific standardized procedures and supervisory guidelines required by Title 16, CCR Sections 1399.540, 1399.545(e) and 1470.

Physician Assistants, Nurse Practitioners and Certified Nurse Midwives are all considered to be NMPs for purposes of Medi-Cal provider enrollment.

1. PHYSICIAN ASSISTANT (PA) Physician Assistants must be supervised by a physician. PA's enroll in Medi-Cal using the DHCS 6248, 6207 and 6208 forms and their information is added to a "trailer screen" in the Provider Master File under the file of the physician or physician group for whom they work. PA's may not enroll as groups and may not enroll as stand-alone providers.

2. NURSE PRACTITIONER (NP) NPs who work for physicians or physician groups use the DHCS 6248, 6207 and 6208 forms to enroll. In these types of enrollments, the NP's information is added to a "trailer screen" in the Provider Master File under the file of the physician or physician group for whom they work.

NPs enrolling as stand-alone providers use the DHCS 6204, 6207 and 6208 forms to enroll. "Stand-alone NPs" are enrolled into the Provider Master File under their own NPI and the RN number from their license.

In order to enroll in Medi-Cal as a "stand-alone NP", a Nurse Practitioner must have completed a clinical and didactic educational program of at least six months in the field of Pediatrics or Family Care. The program must have been completed in a college or university that offers a baccalaureate or higher degree, or in a health care agency that has an academic affiliation with such a college or university.

(Assembly Bill 1591 enacted on September 29, 2006, amended the Welfare and Institutions Code Section 14132.41 to allow Nurse Practitioners to bill Medi-Cal independently for their services. This state legislation allowed for NPs of any specialty to enroll in Medi-Cal as stand-alone providers. Subsequently, DHCS developed a State Plan Amendment to give DHCS the legal authority to make payments directly to all specialty areas of certified nurse practitioners. The Medi-Cal payment system is currently undergoing the system changes needed in order to process claims for payment to NPs specializing in areas other than Pediatrics or Family Care.)

In addition to enrolling with a physician or physician group or enrolling as stand-alone providers, NPs may also enroll as groups, and as rendering provider members of NP Groups. Currently, to enroll as a Nurse Practitioner Group, all of the rendering NPs in the group must specialize in either Family Care or Pediatrics. NP Groups use the Group Provider Package, DHCS 6203, 6207 and 6208 forms to enroll. The NPs who are rendering members of an NP group use the DHCS 6216 form to enroll in the NP group.

Stand-alone NPs and NP groups may also qualify to enroll as Facility-Based Providers.                                                    Back to Top

3. CERTIFIED NURSE MIDWIFE (CNM) CNMs working for obstetric physicians or physician groups use the DHCS 6248, 6207 and 6208 forms to enroll. When enrolling this way, using the 6248, the CNM's information is added to a "trailer screen" in the Provider Master File under the file of the physician or physician group for whom they work.

CNMs enrolling as stand-alone providers, including enrollment as stand-alone "Clinic Based Certified Nurse Midwife" providers, use the DHCS 6204, 6207 and 6208 forms to enroll. "Stand-alone CNMs" are enrolled using their own NPI and the RN number from their license.

CNMs may enroll as groups and as rendering members of CNM groups. CNM groups enroll using the Group Provider Package, DHCS 6203, 6207, 6208. CNMs who are group members rendering to a CNM group, use the DHCS 6216 to enroll as such.

Stand-alone CNMs and CNM groups may also qualify to enroll as Facility-Based Providers.

 

Last modified on: 7/3/2015 5:39 PM