Clinic-Based Physician Application Instructions and Requirements
Kev tsim nyog
This enrollment type is only for individual physicians who provide medical services exclusively at Medi-Cal enrolled, licensed primary care clinics, have no other established place of business (i.e. a medical office) where they provide services and who need to bill for inpatient services provided to beneficiaries in a general acute care hospital or acute psychiatric hospital setting. Groups are not eligible for this type of enrollment.
Pursuant to the regulatory Provider Bulletin published in the December 2005 Medi-Cal Update, DHCS has established procedures for the enrollment of physicians who are solely employed by or provide services pursuant to a contract with licensed primary care clinics, except for services provided as part of a graduate medical education program, and who do not have any active Medi-Cal provider number issued to them individually to bill for clinical services to Medi-Cal beneficiaries at another location and as such, use the licensed primary care clinic as their established place of business. This type of enrollment allows the physician to bill for inpatient services only and not for services provided at the Licensed Primary Care Clinic. In order to determine whether or not you qualify for this type of enrollment, please read the detailed Provider Bulletin: “Requirements and Procedures for ‘Clinic-Based Provider’ Enrollment”.
If you qualify to enroll as a Clinic-Based Physician: Clinic-Based Physicians are required to submit their individual and/or group applications via PAVE (Provider Application and Validation for Enrollment).
Daim ntawv tso cai
Ua ntej koj thov Medi-Cal, ua ntej tshaj, mus saib Medical Board of California lossis Osteopathic Medical Board of California kom paub tseeb tias koj ua tau raws li txhua yam kev cai ntawm daim ntawv tso cai.
Cov ntaub ntawv xav tau
Tom ntej no, sau cov ntaub ntawv xav tau hauv qab no, raws li tsim nyog, txhawm rau muab lawv tso rau hauv PAVE thaum koj ua tiav koj daim ntawv thov PAVE. Thov xyuas kom meej tias cov ntaub ntawv uas tau muab tso tawm yog pom tseeb.
- Current California Medical License or Osteopathic Physician and Surgeon’s License of applicant or provider. Please include DEA Certificate, if applicable.
- Driver’s License or state-issued identification card (issued within the 50 United States or the District of Columbia) of the provider who is signing the application. The signature must be that of the physician applicant.
- Federal Employer Identification Number (FEIN) or Individual Taxpayer Identification Number (ITIN) verification of the physician applicant, 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 the application 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 visit the IRS or call them at (800) 829-4933.
- Licensed Primary Care Clinic Cover Letter from at least one Medi-Cal-enrolled clinic at which you provide services. This letter should include the required information as described on page three of the Clinic-Based Provider Bulletin.
- Physician Cover Letter (at least one) that includes the required information as described on page four of the Clinic-Based Provider Bulletin.
- Fictitious Name Permit (FNP) issued by the Medical Board of California or the Osteopathic Medical Board of California, if using a fictitious name for your medical practice, as defined by the Board. Note: The business name of the applicant or provider on the application, all local business licenses/permits, and the FNP must exactly match.
- Yog tias koj lub lag luam yog ib lub koom haum, kev ncua sijhawm ua tiav yuav raug zam los ntawm kev muab daim ntawv theej ntawm Cov Lus Cog Tseg ntawm Lub Koom Haum los ntawm Tus Tuav Ntaub Ntawv ntawm Lub Xeev, thiab daim ntawv teev cov thawj coj thiab cov tub ceev xwm lub npe thiab lub npe, nrog rau feem pua ntawm kev muaj thiab kev tswj hwm rau txhua tus. Txhawm rau txheeb xyuas lossis hloov lub npe lossis txoj cai ntawm koj lub koom haum, lossis kom paub ntxiv, thov mus saib Tus Tuav Ntaub Ntawv ntawm Lub Xeev California Business Portal xaiv qhov txuas "California Business Search" lossis lwm qhov txuas tsim nyog.
- Certificate of Professional Liability Insurance nyob rau hauv ib tug npaum li cas ntawm tsis tsawg tshaj li $100,000 ib daim ntawv thov thiab ib tug yam tsawg kawg nkaus txhua xyoo ntawm $300,000. Kev lees paub lees paub yog daim ntawv pov thawj ntawm kev tuav pov hwm lossis daim ntawv tshaj tawm uas muab los ntawm lub tuam txhab pov hwm uas muaj lub npe ntawm lub tuam txhab pov hwm, lub npe ntawm cov ntawv pov hwm, hnub siv tau, thiab kev txwv ntawm kev pov hwm. Nco tseg: Tus kws kho mob lub npe, raws li nws tshwm sim hauv California Daim Ntawv Tso Cai Kho Mob, yuav tsum tau qhia txog kev txheeb xyuas ntawm kev pov hwm kev lav phib xaub.
PAUB Portal
Nkag mus rau PAVE portal.