​Section 4 - General Program Administration

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Sections and Attachments​​

4.1    Methods of Administration 

4.2    Hearings of Applicants and Recipients


4.3    Safeguarding Information on Applicants and Recipients


4.4    Medicaid Quality Control

Attachment 4.4-A   MMIS Alternative Claims Processing Assessment System

4.5   Medicaid Recovery Audit Contractor Program


4.6    Reports


4.7    Maintenance of Records


4.8    Availability of Agency Program Manuals


4.9    Reporting Provider Payments to Internal Revenue Service


4.10  Free Choice of Providers


4.11  Relations with Standard-Setting and Survey Agencies

Attachment 4.11-A  Standard Setting Authority for Institutions 

4.12  Consultation to Medical Facilities

4.13  Required Provider Agreement


4.14  Utilization/Quality Control


4.15  Inspections of Care in Skilled Nursing and Intermediate Care Facilities and Institutions for Mental Diseases


4.16  Relations with State Health and Vocation Rehabilitation Agencies and Title V Grantees

Attachment 4.16-A  Interagency Agreements of the Department of Health Services Regarding Medi-Cal Services 

4.17 Liens and Adjustments or Recoveries

Attachment 4.17-A IHSS Services from Estate Recovery & Clarify Estate Recovery Process 

4.18  Recipient Cost Sharing and Similar Charges


Attachment 4.18-A  Categorically Needy Services Other than those Provided Under Section 1905(a)(1) through (5) and (8)

Attachment 4.18-B  No attachment

Attachment 4.18-C  Services For Medically Needy

Attachment 4.18-D  Premiums Imposed on Low Income Pregnant Women and Infants

Attachment 4.18-E  Optional Sliding Scale Premiums Imposed on Qualified Disabled and Working Individuals

Attachment 4.18-F  Alternative Premiums and Cost-Sharing Changes 

4.19  Payment for Services

Attachments 4.19-A through F

4.20A Direct Payments to Certain Recipients for Physicians' or Dentists' Services

Attachment 4.20-A  Conditions for Direct Payment for Physician's & Dentists' Services

Attachment 4.20-B  Conditions for Direct Beneficiary Reimbursement 

4.21  Prohibition Against Reassignment of Provider Claims


4.22  Third Party Liability

Attachment 4.22-A  

Attachment 4.22-B

Attachment 4.22-C

Attachment 4.22-D 

4.23  Use of Contracts


4.24  Standards for Payments for Nursing Facility and Intermediate Care Facility for the Mentally Retarded Services


4.25  Program for Licensing Administrators for Nursing Homes


4.26  Drug Utilization Review Program


4.27  Disclosure of Survey Information and Provider or Contractor Evaluation


4.28  Appeals Process


4.29  Conflict of Interest Provisions


4.30  Exclusion of Providers and Suspension of Practitioners and Other Individuals

Attachment 4.30  Sanctions of Psychiatric Hospitals/ MCOs and PCCMs 

4.31  Disclosure of Information by Providers and Fiscal Agents


4.32  Attachment 4.32-A: Income and Eligibility Verification System Procedures Requests to Other State Agencies


4.33  Medicaid Eligibility Cards for Homeless Individuals

Attachment 4.33  Method of Issuance of Medicaid Eligibility Claims to Homeless Individuals 

4.34  Systematic Alien Verification for Entitlements

Attachment 4.34-A  Requirements for Advance Directives Under State Plans for Medical Assistance

Supplement 1 to Attachment 4.34-A  Implementation of Patient Self-Determination Provision of OBRA 90 

4.35  Remedies for Skilled Nursing and Intermediate Care Facilities that Do Not Meet Requirements of Participation

Attachment 4.35- A through H

4.36  Required Coordination Between the Medicaid and WIC Programs


4.38  Nurse Aide Training and Competency Evaluation for Nursing Facilities


4.39  Preadmission Screening and Resident Review in Nursing Facilities

Attachment 4.39    Definition of Specialized Services

Attachment 4.39-A Categorical Determinations 

4.40  Survey and Certification Process

Attachment 4.40- A through E 

4.41  Resident Assessment for Nursing Facilities


4.42  Employee Education About False Claims Recoveries

 Attachment 4.42-A  Methodologies for Compliance Oversight PDF

4.43  Employee Education About False Claims Recoveries


4.44  Medicaid Prohibition on Payments to Institutions Located Outside of the United States


4.46  Provider Screening and Enrollment



Last modified date: 10/16/2019 2:39 PM