(a) Reimbursement shall not be denied to any qualified health care provider for care rendered to an eligible Medi-Cal beneficiary for the sole reason that a proof of eligibility label does not accompany the bill.
Proof of eligibility labels may, however, continue to be used as such and shall be made available to an eligible Medi-Cal beneficiary through the local office which has determined the person’s eligibility or through the department. The provider may submit machine-reproduced copies of the beneficiary Medi-Cal card for billing purposes as long as the copy is made from the original unaltered Medi-Cal card under circumstances controlled by the provider, for example, on the premises of the provider with copying equipment controlled by the provider.
(b) It shall remain the responsibility of a Medi-Cal beneficiary to provide information and evidence of Medi-Cal eligibility, restrictions on the eligibility, and non-Medi-Cal health coverage, to that person’s health care providers, if this information is requested by those providers prior to rendering services to that beneficiary.
(c) It shall be the responsibility of the provider prior to rendering Medi-Cal reimbursable services to persons presenting themselves as Medi-Cal beneficiaries to make a good faith effort to verify the person’s identity, if the person is not known to the provider, by matching the name and signature on his or her Medi-Cal card against the signature on a valid California driver’s license, or California identification card issued by the Department of Motor Vehicles, or another type of picture identification card or other credible document of identification. When the provider verifies the beneficiary’s identity with a signed Medi-Cal card and one of the documents described above, the state will deem this to be a good faith effort. If the provider does not make a good faith effort of reasonable identification prior to rendering Medi-Cal reimbursable services and renders services to a presenting person who is ineligible for those Medi-Cal services, payment for those services may later be disallowed.
This provision shall not apply to:
(1) Persons 17 years of age and under.
(2) Persons in long-term care.
(3) Persons receiving emergency services.
(d) Notwithstanding subdivision (b) of this section, county welfare departments may provide Medi-Cal eligibility information to other governmental agencies and their designated agents as necessary for proper administration of the Medi-Cal program.
(e) If a hospital obtains proof of Medi-Cal eligibility for a patient subsequent to the date of service, it shall be the responsibility of the hospital to provide all information regarding that person’s Medi-Cal eligibility to all hospital-based providers, ambulance transportation services providers, providers that provide ambulance transportation services through the “911” emergency response system, and other hospital-based providers of professional services that bill separately for all services associated with the person’s treatment in the hospital rendered during the same time period for which the hospital is submitting a claim. The hospital may inform the provider that the person’s Medi-Cal eligibility is pending, before a final determination is made on the patient’s Medi-Cal application, to satisfy the requirements of this subdivision. If the provider or the provider’s agent obtains this information from the hospital, the requirement has been satisfied.
(f) For purposes of this section, the following definitions apply:
(1) “Hospital-based provider” means an anesthesiologist, radiologist, pathologist, emergency room physician, or other physician or a group of physicians providing medical services at the hospital.
(2) “Hospital-based professional services” means services performed for a patient while at a hospital, related to the patient’s hospital stay, and known to the hospital, including, but not limited to, diagnostic, laboratory, therapeutic, and radiologic services.
(Amended by Stats. 2009, Ch. 511, Sec. 1. (AB 1142) Effective January 1, 2010.)
Last modified: October 25, 2018