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Medi-Cal Durable Medical Equipment Provider Application DSH-6201 - California
| Medi-Cal Durable Medical Equipment 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 Durable Medical Equipment 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 Durable Medical Equipment (DME) providers new to the Medi-Cal program as well as all currently enrolled DME 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, DHCS is not accepting enrollment applications from DME providers located outside of California and in the California counties of Los Angeles, Orange, Riverside, or San Bernardino, except for those eligible for an exemption as indicated below. This moratorium expires on March 26, 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 or repeated when the DHCS Director determines this action is necessary to safeguard public funds or to maintain the fiscal integrity of the program. This moratorium does not apply to: 1. DME applicants who for the purpose of the Medi-Cal program choose to be enrolled exclusively for medically necessary lactation aids and shall only be reimbursed for items mentioned in the Medi-Cal Provider Manual for Lactation Management Aids (found in Durable Medical Equipment [DME]: Bill for DME [dura bil dme]). 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 2. DME applicants who for the purpose of the Medi-Cal program choose to be enrolled exclusively as Customized Wheelchair DME (CWDME) providers and/or Oxygen and Respiratory Equipment DME (OREDME) providers. a) CWDME providers shall sell, service and/or repair customized wheelchairs as medically necessary for Medi-Cal beneficiaries. An enrolled CWDME provider shall only be reimbursed for items authorized in the Medi-Cal Provider Manual for wheelchairs, modifications and accessories. OREDME providers shall sell, service and/or repair Oxygen and Respiratory Equipment. An enrolled provider shall only be reimbursed for items authorized in the Medi-Cal Provider Manual, under the Oxygen and Respiratory Equipment Group and deemed medically necessary for Medi-Cal beneficiaries. b) 3. Current Medi-Cal enrolled DME providers seeking to add a new business location so long as a provider enrolled in the program after October 12, 1999, is not adding new business activities, categories of service, or billing codes, other than those approved for enrollment at its existing location and the new business location is in the same county as the previous location. Applicants who will be enrolled solely for reimbursement of Medicare cost sharing amounts. An application that is submitted because an existing Medi-Cal enrolled DME provider, which is part of a group of affiliated corporations (as defined by California Corporations Code, Section 150), is transferring its assets to another affiliated corporation that is a part of the same group of affiliated corporations. An application that is submitted because an existing Medi-Cal enrolled DME provider, who is an individual operating as an unincorporated sole proprietorship, has incorporated that sole proprietorship, with all of the existing issued shares of the new corporation being owned by that individual who is also the president of the new corporation. An application that is submitted because there has been a cumulative change of 50 percent or more in the person(s) with an ownership or control interest in an existing Medi-Cal enrolled DME provider, provided that the change only consists of a reorganization or consolidation among existing person(s) previously identified in the last complete application package that was approved for enrollment as having an ownership interest in the provider totaling 5 percent or greater. Applications submitted pursuant to CCR, Title 22, Section 51000.55 or Section 51006, Subparts (a)(1), (a)(2), (a)(3) or (a)(5). 4. 5. 6. 7. 8. American LegalNet, Inc. www.FormsWorkFlow.com 9. Applications submitted pursuant to CCR, Title 22, Section 51000.30(b)(3) provided that there is no change in the person(s) previously identified in the last complete application package that was approved for enrollment as having a control or ownership interest in the provider totaling 5 percent or greater. 10. Applications submitted pursuant to CCR, Title 22, Section 51000.30(a) only because an existing Medi-Cal enrolled DME provider has changed its location provided that its previous business was located in either of the following counties: Los Angeles, Orange, Riverside, or San Bernardino; or 11. Applicants that are the only person or entity in the United States that provides a specific product or service that is a Medi-Cal covered benefit. 12. Any applicant offering services or replacement parts, not available from an enrolled Medi-Cal provider on the date of application, for a Medi-Cal covered medical device. If providers are eligible according to the criteria outlined above, they should complete a new application package consisting of a Medi-Cal Durable Medical Equipment Provider Application (DHCS 6201, rev. 2/08), a Medi-Cal Disclosure Statement (DHCS 6207, rev. 11/11), a Medi-Cal Provider Agreement (DHCS 6208, rev. 11/11), and any required attachments. Return the completed application package to: Department of Health Care Services Provider Enrollment Division MS 4704 P.O. Box 997412 Sacramento, CA 95899-7412 Providers shoul
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