California Welfare and Institutions Code ARTICLE 1.3 - Provider Enrollment, Application, and Participation

• Section 14043.
  In order to ensure the proper and efficient administration of the Medi-Cal program, every applicant, as defined in subdivision (b) of Section 14043.1, and every...
• Section 14043.1.
  As used in this article:(a) “Abuse” means either of the following:(1) Practices that are inconsistent with sound fiscal or business practices and result in unnecessary cost to...
• Section 14043.15.
  (a) The department may adopt regulations for certification of each applicant and each provider in the Medi-Cal program. No certification shall be required for natural persons...
• Section 14043.17.
  (a) Notwithstanding any other law, within 30 calendar days of receiving confirmation of certification for enrollment as a Medi-Cal provider for an affiliate primary care clinic...
• Section 14043.2.
  (a) Whether or not regulations for certification are adopted under Section 14043.15, in order to be enrolled as a provider, or for enrollment as a provider...
• Section 14043.25.
  (a) The application form for enrollment, the provider agreement, and all attachments or changes to either, shall be signed under penalty of perjury.(b) The department may require...
• Section 14043.26.
  (a) (1) On and after January 1, 2004, an applicant that currently is not enrolled in the Medi-Cal program, or a provider applying for continued enrollment, upon...
• Section 14043.27.
  (a) If an applicant or provider is granted provisional provider status or preferred provisional provider status pursuant to Section 14043.26 and, if at any time during...
• Section 14043.28.
  (a) (1) If an application package is denied under Section 14043.26 or provisional provider status or preferred provisional provider status is terminated under Section 14043.27, the applicant...
• Section 14043.29.
  (a) If, at the end of the period for which provisional provider status or preferred provisional provider status was granted under Section 14043.26, all of the...
• Section 14043.3.
  A provider shall be required to reimburse those Medi-Cal funds received during any period for which material information was not reported, or reported falsely, to...
• Section 14043.34.
  (a) As a condition of a pharmacy’s participation in the Medi-Cal program, the pharmacy shall have in stock and regularly dispense prescription drugs.(b) For purposes of this...
• Section 14043.341.
  (a) Each provider that dispenses, as defined in Section 4024 of the Business and Professions Code, or that furnishes, as defined in Section 4026 of the...
• Section 14043.35.
  Sections 14043.2, 14043.25, and 14043.3 shall not limit the authority granted the director and the rights granted providers in Section 14123. Action taken under the...
• Section 14043.36.
  (a) The department shall not enroll any applicant that has been convicted of any felony or misdemeanor involving fraud or abuse in any government program, or...
• Section 14043.37.
  The department may complete a background check on applicants for the purpose of verifying the accuracy of the information provided to the department for purposes...
• Section 14043.38.
  (a) Provider types are designated as “limited,” “moderate,” or “high” categorical risk by the federal government in Section 424.518 of Title 42 of the Code of...
• Section 14043.4.
  If discrepancies are found to exist during the preenrollment period, the department may conduct additional inspections prior to enrollment. Failure of a provider to remediate...
• Section 14043.45.
  (a) Notwithstanding whether a National Provider Identification (NPI) number is required by the rules issued by the Centers for Medicare and Medicaid Services implementing the Health...
• Section 14043.46.
  (a) Notwithstanding any other provision of law, on the effective date of the act adding this section, the department may implement a one-year moratorium on the...
• Section 14043.47.
  (a) A provider doing business as a sole proprietorship, partnership, or professional corporation under Part 4 (commencing with Section 13400) of Division 3 of the Corporations...
• Section 14043.5.
  Subject to Article 4 (commencing with Section 19130) of Chapter 5 of Division 5 of Title 2 of the Government Code, the department may enter...
• Section 14043.55.
  (a)  The department may implement a 180-day moratorium on the enrollment of providers in a specific provider of service category, on a statewide basis or...
• Section 14043.6.
  The department shall automatically suspend, as a provider in the Medi-Cal program, any individual who, or any entity that, has a license, certificate, or other...
• Section 14043.61.
  (a) A provider shall be subject to suspension if claims for payment are submitted for the services, goods, supplies, or merchandise provided, directly or indirectly, to...
• Section 14043.62.
  (a) The department shall deactivate, immediately and without prior notice, the provider’s number, including all business addresses used by a provider to obtain reimbursement from the...
• Section 14043.65.
  (a) Notwithstanding any other law, any applicant whose application for enrollment as a provider or whose certification is denied; or any provider who is denied continued...
• Section 14043.7.
  (a) The department may make unannounced visits to an applicant or to a provider for the purpose of determining whether enrollment, continued enrollment, or certification is...
• Section 14043.75.
  (a) The director may, in consultation with interested parties, by regulation, adopt, readopt, repeal, or amend additional measures to prevent or curtail fraud and abuse. Regulations...
• Section 14044.
  (a) The department may limit, for 18 months or less, the American Medical Association’s Current Procedural Terminology Fourth Edition (CPT-4) codes, the National Drug Codes (NDC),...
• Section 14045.
  (a) A provider shall not submit a reimbursement request to the Medi-Cal program containing a beneficiary’s social security number if the department has issued that beneficiary...

Last modified: October 22, 2018