クリニックベースの医師のアプリケーションの説明と要件
合格
この登録タイプは、Medi-Calに登録され、認可されたプライマリケアクリニックでのみ医療サービスを提供し、サービスを提供する他の確立された事業所(つまり、診療所)がなく、一般急性期病院または急性精神病院の受益者に提供される入院サービスに対して請求する必要がある個々の医師のみを対象としています。 グループは、このタイプの登録の対象外です。
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).
ライセンス
Prior to applying to Medi-Cal, first check the Medical Board of California or the Osteopathic Medical Board of California to ensure you meet all the licensing requirements.
必要書類
次に、必要に応じて以下に示す必要書類を収集し、PAVEアプリケーションの完了時にPAVEにアップロードします。 アップロードした書類が判読可能であることを確認してください。
- 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.
- If your business is a corporation, processing delays may be avoided by attaching a copy of the filed Articles of Incorporation from the Secretary of State, and a list of directors’ and officers’ names and titles, with percent of ownership and control interest for each. To verify or change the name or status of your corporation, or for further information, please visit the Secretary of State California Business Portal select the “California Business Search” link or other appropriate link.
- 請求ごとに100,000ドル以上、最低年間総額300,000ドルの専門職賠償責任保険の証明書。許容される検証は、保険会社の名前、被保険者の名前、発効日、および補償限度額が記載された保険会社が発行する保険証書または申告書です。 注:カリフォルニア州の医師免許に記載されているプロバイダーの名前は、専門職賠償責任保険の確認にも表示する必要があります。
舗装ポータル
PAVEポータルに進みます。