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Medi-Cal Pharmacy Provider Application DSH-6205 - California
| Medi-Cal Pharmacy Provider Application Form. This is a California form and can be used in Medi Cal Statewide . |
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State of California--Health and Human Services Agency Department of Health Care Services TOBY DOUGLAS DIRECTOR EDMUND G. BROWN JR. GOVERNOR Dear Pharmacy Applicant: Thank you for your recent inquiry regarding participation in the Medi-Cal program. This letter addresses information about the enrollment application process for a specific provider type. PLEASE NOTE: Applicants and providers are required to submit their National Provider Identifier (NPI) with each Medi-Cal provider application package. Applicants are required to attach a copy of the CMS/National Plan and Provider Enumeration System (NPPES) confirmation for each NPI listed in the application package. If providers are not eligible to receive an NPI, they should instead enter the word "atypical" in any NPI fields. These "atypical providers" will receive a unique Medi-Cal provider number once the application is approved. An application package must be submitted for all pharmacy providers new to the Medi-Cal program as well as all currently enrolled pharmacies subject to continued enrollment under California Code of Regulations (CCR), Title 22, Section 51000.55 or required to submit a new application package under CCR, Title 22, Section 51000.30, subsections (a) through (b). Due to the current 180-day moratorium, the Department of Health Care Services (DHCS) is not accepting enrollment applications from non-chain, non-pharmacist owned pharmacies located in Los Angeles County, except for those eligible for an exemption. This moratorium ends on April 9, 2013, and is in accordance with the California Welfare and Institutions Code (W&I Code), Section 14043.55. As stated in the W&I Code, this moratorium may be continued when the DHCS Director determines this action is necessary to safeguard public funds or to maintain the fiscal integrity of the program. If your business is a non-chain, non-pharmacist owned pharmacy located in Los Angeles County, and is eligible for an exemption according to the criteria outlined in the moratorium (located on the Provider Enrollment Division [PED] website at www.dhcs.ca.gov/provgovpart/Pages/PED.aspx), please complete a new application package consisting of a Medi-Cal Pharmacy Provider Application (DHCS 6205, rev. 2/08), a Medi-Cal Disclosure Statement (DHCS 6207, rev. 11/11), a Medi-Cal Provider Agreement (DHCS 6208, rev. 11/11), and a cover letter specifically stating the moratorium exemption that you qualify under, including information relating how you qualify for the exemption. A change of ownership application must include a copy of the sale agreement. Provider Enrollment Division MS 4704 P.O. Box 997412, Sacramento, CA 95899-7412 Phone: (916) 323-1945 Internet Address: http://www.DHCS.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com Return the completed application package to: Department of Health Care Services Provider Enrollment Division MS 4704 P.O. Box 997412 Sacramento, CA 95899-7412 Please read all the instructions included in the application package carefully and complete each item requested. Incomplete application packages will be returned. It is your responsibility to report to DHCS any modifications to information previously submitted within 35 days from the date of the change. Most changes can be reported on a Medi-Cal Supplemental Changes form (DHCS 6209, rev. 2/08). However, you must complete a new application package if you are reporting a change of business ownership of 50 percent or more, a change of business address, or one of the other changes identified in CCR, Title 22, Section 51000.30, subsections (a) through (b). If you are planning to sell your business or buy an existing business, the PED website contains information about enrollment options available to you whenever there is a sale or purchase of a Medi-Cal enrolled pharmacy, including the option to submit a Successor Liability with Joint and Several Liability Agreement. Enrollment forms are available on the PED website or by contacting the Medi-Cal Telephone Service Center (TSC) at (800) 541-5555. For more information about the forms, form completion, and the regulatory requirements for participation in the Medi-Cal program, please visit the PED Website. For additional enrollment questions, you may contact the PED Message Center at (916) 323-1945, ext. 4522, or submit your question(s) to the address above or via email to PEDCorr@dhcs.ca.gov. Providers or provider representatives who intend to use the Medi-Cal Point of Service (POS) Network or Medi-Cal website applications must complete the Medi-Cal Point of Service Network/Internet Agreement, also available on the PED website, under the Forms heading, then select Billing. Providers must request a submitter number in order to submit claims electronically by completing a Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153, rev. 03/12), which is available at the same Billing location on the PED website. A submitter number for an existing pharmacy is not transferable. A new submitter number must be obtained each time a new Medi-Cal pharmacy provider number/NPI is issued. If you have any questions about completing the Medi-Cal Telecommunications Provider and Biller Application/Agreement, call the TSC at (800) 541-5555 and select the option for Computer Media Claims. Provider Enrollment Division Enclosures (Revised 10/2012) American LegalNet, Inc. www.FormsWorkFlow.com State of California--Health and Human Services Agency Department of Health Care Services INSTRUCTIONS FOR COMPLETION OF THE MEDI-CAL PHARMACY PROVIDER APPLICATION DO NOT USE staples on this form or on any attachments. DO NOT USE correction tape, white out, or highlighter pen or ink of a similar type on this form. If you must make corrections, please line through, date, and initial in ink. DO NOT LEAVE any questions, boxes, lines, etc. blank. Enter N/A if not applicable to you. This form is part of an application for enrollment or continued enrollment as a provider in the Medi-Cal program. Applicants and providers must also provide additional information and documentation. Applicants and providers may be subject to an on-site inspection and to unannounced visits prior to enrollment or approval for continued enrollment in a program. In addition to this form and requested documentation, a MEDI-CAL DISCLOSURE STATEMENT (DHCS 6207) and a MEDI-CAL PROVIDER AGREEMENT (DHCS 6208) must also be completed for enrollment or continued enrollment. Additional information can be f
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