Tsev Cov Ntawv, Cov Cai, thiab Cov Ntawv Tshaj Tawm  Cov Ntawv Cov Ntawv Qhia Txog Tus Nqi thiab Cov Ntaub Ntawv ​​ 

Daim Ntawv Qhia Tus Nqi thiab Cov Ntaub Ntawv​​ 

Rov qab mus rau Kev Tshawb Xyuas Nyiaj Txiag Inpatient Division Homepage​​ 
Rov qab mus rau Kev Tshawb Fawb Txog Nyiaj Txiag Sab Nraud thiab Tus Cwj Pwm Kev Noj Qab Haus Huv Hauv Tsev​​ 

Department of Health Care Services (DHCS) cov ntaub ntawv qhia txog tus nqi muaj nyob rau download. Tus Nqi Them Nqi Tshaj Lij Tshaj Lij (CRTS) tau txais cov ntaub ntawv qhia txog Tus Nqi Them Nqi. CRTS yuav hloov kho cov ntawv thiab cov ntaub ntawv raws li lawv muaj.​​    

The forms are Adobe Acrobat PDF files and Microsoft Excel files. If you are unable to access a form and would like to request a copy, please send an email to FRDaudits.Questions@dhcs.ca.gov or contact CRTS at (916) 650-6696.​​ 

Ceev faj - Txhua daim ntawv yuav raug kho dua. Thaum npaj Daim Ntawv Qhia Tus Nqi Tshiab, nkag mus rau cov ntaub ntawv los ntawm lub vev xaib no kom ntseeg tau tias siv cov qauv tam sim no. Kev xa tawm ntawm cov ntaub ntawv dhau los yuav raug tsis lees paub los ntawm CRTS thiab yuav xav tau kev xa rov qab nrog cov ntaub ntawv tshiab.​​ 

Nco tseg - Koj yuav tsum xa daim ntawv pov thawj DocuSign sib thooj nrog txhua Daim Ntawv Qhia Tus Nqi kom tsis txhob raug tso tseg.​​ 

Kev Pabcuam Tus Neeg Mob​​ 

Cov ntawv tu ncua sij hawm ntev thiab cov ntaub ntawv​​ 

Individual Intermediate Care Facility – Provider​​ 

Ib Lub Chaw Kho Mob Nruab Nrab Nruab Nrab rau Kev Txhim Kho Cov Neeg Tsis Muaj Peev Xwm / Kev Saib Xyuas Neeg Mob (ICF-DDH/N) yuav tsum ua kom tiav thiab xa DHCS 3076 Tus Nqi Tshaj Tawm txhua xyoo. Daim Ntawv Qhia Tus Nqi yuav tsum muaj qee cov ntaub ntawv nthuav tawm thiab cov nqi khiav lag luam nyiaj txiag rau lub chaw thiab Medi-Cal qhov kev pab cuam.​​ 

Individual Intermediate Care Facility – Home Office​​ 

ICF-DDH/N Cov Chaw Ua Haujlwm Hauv Tsev yuav tsum ua kom tiav thiab xa DHCS 3099 Daim Ntawv Qhia Tus Nqi Hauv Tsev nyob rau ib xyoos. Daim Ntawv Qhia Tus Nqi yog rau cov koom haum saw hlau ua haujlwm lossis tswj ob (2) lossis ntau dua ICF-DDH/N cov chaw. Daim Ntawv Qhia Tus Nqi yuav tsum muaj qee cov ntaub ntawv nthuav tawm ntawm Lub Tsev Haujlwm Hauv Tsev thiab kev faib cov nqi tsev hauv tsev rau ntau yam ICF-DDH/N cov chaw.​​  

If you have any questions regarding these forms, please send an email to ICFDDHN.Questions@dhcs.ca.gov or contact CRTS at (916) 650-6696.​​ 

Qhov Kev Pab Kho Mob Sab Nraud​​ 

Federally Qualified Health Center/Rural Health Clinic (FQHC/RHC) Cov ntawv thiab cov ntaub ntawv​​ 

FQHC/RHC/Indian Health Services Memorandum of Agreement (IHS-MOA) cov chaw muab kev pab thiab FQHC/RHC Cov Chaw Ua Haujlwm Hauv Tsev yuav tsum ua kom tiav thiab xa DHCS 3088 Medi-Cal Worksheets Electronic Submission Protocol.​​ 

Home Office – Six (6) or Less​​ 

Freestanding FQHC/RHC cov chaw muab kev pab uas muaj rau (6) lossis tsawg dua FQHC/RHC cov chaw kho mob yuav tsum ua kom tiav thiab xa DHCS 3089 Daim Ntawv Qhia Txog Tus Nqi Hauv Tsev rau Kev Npaj Them Nqi (PPS) Rate Setting (xav txog lossis qhov tseeb) thiab Hloov Hauv Kev Thov Kev Pabcuam (CSOSR). Cov chaw zov me nyuam no yog ib feem ntawm lub koom haum saw lossis ntau lub koom haum kho mob uas ua haujlwm tsawg kawg yog ob (2) lossis ntau lub tsev kho mob lossis ib qho (1) FQHC/RHC thiab ib lub koom haum tsis yog kev kho mob/kev lag luam.​​  

Home Office – Seven (7) or More​​ 

Freestanding FQHC/RHC cov chaw muab kev pab uas muaj xya (7) lossis ntau dua FQHC/RHC cov chaw kho mob yuav tsum ua kom tiav thiab xa DHCS 3089.1 Daim Ntawv Qhia Tus Nqi Hauv Tsev rau PPS Rate Setting (xav txog lossis qhov tseeb) thiab CSOSR. Cov chaw zov me nyuam no yog ib feem ntawm lub koom haum saw lossis ntau lub koom haum kho mob uas ua haujlwm tsawg kawg yog ob (2) lossis ntau lub tsev kho mob lossis ib qho (1) FQHC/RHC thiab ib lub koom haum tsis yog kev kho mob/kev lag luam.​​  

Rate Setting ua ntej Lub Ib Hlis 1, 2021​​ 

FQHC thiab RHC cov chaw muab kev pabcuam nrog Lub Sijhawm Kawg (FPE) hnub ua ntej Lub Ib Hlis 1, 2021 yuav tsum ua kom tiav thiab xa DHCS 3090 Tus Nqi Tshaj Tawm los txiav txim siab nws tus nqi PPS.​​ 

Rate Setting tom qab Lub Ib Hlis 1, 2021​​ 

FQHC thiab RHC cov chaw muab kev pabcuam nrog FPE hnub tom qab Lub Ib Hlis 1, 2021 yuav tsum ua kom tiav thiab xa DHCS 3090 (Post FPE Lub Ib Hlis 1, 2021) Daim Ntawv Qhia Tus Nqi los txiav txim nws tus nqi PPS.​​ 

Hloov hauv Scope-of-Service Thov ua ntej Lub Ib Hlis 1, 2021​​ 

FQHC thiab RHC cov chaw muab kev pabcuam nrog FPE hnub ua ntej Lub Ib Hlis 1, 2021 yuav tsum ua kom tiav thiab xa DHCS 3096 CSOSR Daim Ntawv Thov kom hloov PPS tus nqi yog tias muaj cov qauv tshwj xeeb.​​ 

Hloov hauv Scope-of-Service Thov tom qab Lub Ib Hlis 1, 2021​​ 

FQHC thiab RHC cov chaw muab kev pabcuam nrog FPE hnub tom qab Lub Ib Hlis 1, 2021 yuav tsum ua kom tiav thiab xa DHCS 3096 (Post FPE Lub Ib Hlis 1, 2021) CSOSR Daim Ntawv Thov kom hloov PPS tus nqi yog tias muaj cov qauv tshwj xeeb.​​ 

Kev Thov Kev Pom Zoo (hloov kho Lub Kaum Hli 31, 2024)​​ 

FQHC thiab RHC cov kws kho mob yuav tsum ua kom tiav thiab xa DHCS 3097 Daim Ntawv Thov Kev Sib Tham Txhua Xyoo rau DHCS los ua kev sib haum xeeb rau Managed Care Plans (MCPs) thiab Medicare crossover mus ntsib kom ntseeg tau tias cov chaw kho mob tau them tus nqi sib npaug ntawm nws tus nqi PPS.​​ 

Pursuant to Welfare & Institutions (W&I) Code section 14105.201, DHCS developed targeted rate increases (TRI) for providers in Medi-Cal effective for dates of service on or after January 1, 2024. More information about TRI can be found at Medi-Cal Targeted Provider Rate Increases and Investments.​​  

W&I Code Tshooj 14087.325(d) xav kom MCPs them rov qab cov kev cog lus FQHC thiab RHC cov chaw muab kev pab raws li qhov tsis tsawg dua li qib thiab cov nyiaj them uas MCP yuav ua rau tib qhov kev pabcuam yog tias cov kev pabcuam tau muab los ntawm tus kws khomob uas tsis yog FQHC lossis RHC. Txawm hais tias tus nqi TRI tsis cuam tshuam ncaj qha rau FQHC lossis RHC cov chaw muab kev pabcuam, DHCS lees paub tias qee lub sijhawm, qhov nce ntawm MCP tus nqi them rau cov neeg tsis yog FQHC thiab RHC yuav ua rau MCPs nce cov nqi cog lus them rau FQHC thiab RHC cov chaw muab kev pabcuam. FQHC thiab RHC cov chaw muab kev pabcuam yuav tsum suav tag nrho cov nyiaj them MCP hauv kev thov kom rov sib haum, suav nrog cov nyiaj tau los ntawm TRI.​​  

Based on the TRI implementation timeline, DHCS is extending the Fiscal Year Ending (FYE) 2024 DHCS 3097 Reconciliation Request due date for FQHC and RHC providers with a Fiscal Year End (FYE) between January 31st and September 30th. The extension is designed to allow sufficient time for FQHC and RHC providers to receive and record all MCP payments, including any resulting from TRI. FYE 2024 DHCS 3097 Reconciliation Request for FQHC and RHC providers with a FYE between January 31st and September 30th will be due by March 31, 2025. ​​ 

  • DHCS 3097 Reconciliation Request can only be accessed through the new web-based portal Enterprise Cost Reporting Settlement System (ECRS).​​  
  • Each clinic must have an administrator added to the system. If you do not have an administrator assigned, email CRTS at Reconciliation.clinics@dhcs.ca.gov and provide the following: National Provider Identifier (NPI) number, Legal Name (clinic), Service Address, Administrator’s First and Last Name, and email (please use a company email).​​  
  • If you have any technical issues, please email ECRS@dhcs.ca.gov.​​ 

Indian Health Services Memorandum of Agreement Reconciliation​​ 

Txhua lub tsev kho mob IHS-MOA, 638 Lub Tsev Kho Mob thiab Pab Pawg Pab Pawg Saib Xyuas Kev Noj Qab Haus Huv (TRIBAL-FQHC) yuav tsum ua kom tiav thiab xa DHCS 3098 Daim Ntawv Thov Kev Sib Koom Ua Ke txhua xyoo rau DHCS los ua kev sib haum xeeb rau Managed Care Plans thiab Medicare crossover mus xyuas kom ntseeg tau tias cov chaw kho mob tau them tus nqi sib npaug.​​ 

  • DHCS 3098 IHS Reconciliation Request tuaj yeem nkag tau los ntawm lub vev xaib tshiab ECRS.​​  
  • Txhua lub tsev kho mob yuav tsum muaj tus thawj tswj hwm ntxiv rau hauv qhov system. Yog tias koj tsis muaj tus thawj tswj hwm, xa email rau CRTS ntawm Reconciliation.clinics@dhcs.ca.gov thiab muab cov hauv qab no: NPI tus lej, Lub Npe Raws Cai (lub tsev kho mob), Chaw Pabcuam, Tus Thawj Saib Xyuas Lub Npe thiab Lub Xeem, thiab email (thov siv a tuam txhab email).​​  
  • If you have any technical issues, please email ECRS@dhcs.ca.gov.​​  

Kev thov tus nqi sib txawv​​ 

FQHC thiab RHC cov kws kho mob yuav tsum ua kom tiav thiab xa DHCS 3100 Daim Ntawv Thov Kev Sib Nrauj Sib txawv los tsim lossis hloov Tus Txheej Txheem Kev Pabcuam Kev Tswjhwm Sib txawv, tus lej 521 T1015 SE (yav dhau los code 18). Daim foos no yog tsim los txiav txim siab tus nqi ib ntus rau cov neeg muab kev pab them rov qab rau qhov sib txawv ntawm lawv tus nqi PPS thiab lawv cov Medi-Cal Managed Care Plan them.​​ 

Medicare Advantage Plan Code 529​​ 

FQHC thiab RHC cov kws kho mob yuav tsum ua kom tiav thiab xa daim ntawv thov DHCS 3104 los tsim lossis hloov Medicare Advantage Plan tus nqi, code 529 G0466-G0470 (yav dhau los code 20). Daim foos no yog tsim los txiav txim siab tus nqi ib ntus los them rov qab cov neeg muab kev pabcuam rau qhov sib txawv ntawm lawv tus nqi PPS thiab lawv cov Capitated Medicare Advantage Plan them.​​ 

Thawj Tus Nqi Them Daim Ntawv Thov Pob​​ 

FQHC/RHC Thawj Tus Nqi Them Daim Ntawv Thov pob, DHCS 3106, suav nrog:​​  

  • Cov lus qhia rau kev thov (nplooj 1-4),​​  
  • Daim Ntawv Pov Thawj Them Nqi Xaiv Tsa (nplooj 5-6),​​  
  • Kev xaiv tsa (nplooj 7-8),​​  
  • Cov ntsiab lus ntawm cov kev pabcuam tam sim no muab los ntawm Clinic (nplooj 9), thiab​​  
  • Cov ntsiab lus ntawm Cov Kws Kho Mob (nplooj 10).​​  

These forms will be used to establish the initial PPS rate for newly approved FQHC and RHC. If you have any questions regarding this package, please send an email to clinics@dhcs.ca.gov or contact CRTS at (916) 650-6696.​​