California Administrative Code

(a) Medi-Cal Special Treatment Programs beneficiary means a person who is either a Medi-Cal Special Treatment Programs--Only beneficiary or a Medi-Cal Special Treatment Programs--Supplement beneficiary. (1) Medi-Cal Special Treatment Programs--Only beneficiary means a person who …

“Heir” means a person who survives the decedent and is designated to receive some or all of the decedent's property.

Gross income means adjusted annual gross income as used for purposes of federal income tax reporting.

Annual net worth means the total market value of all property and gross income received for a 12-month period by the applicant or beneficiary, in accordance with Section 50825.

Percentage obligation means the percent of the cost of dialysis or parenteral hyperalimentation and related services for which a Medi-Cal Special Treatment Programs beneficiary must either pay or assume full legal responsibility.

“Equity interest” means the fair market value of the property to which the decedent held legal title or interest at the time of death (to the extent of such interest), less the amount owed in deeds of trust, mortgages, and liens on record at the time of death.

(a) The Department shall claim against the estate of a decedent, or against any recipient of the decedent's property by distribution or survival, an amount equal to the lesser of: (1) All payments made by the Medi-Cal program on behalf of the decedent, except for those payments s…

(a) The Department shall withdraw its claim against the estate of a deceased Medi-Cal beneficiary when the surviving child or his or her representative provides the following documentary evidence to the Department of Health Care Services, Estate Recovery Section, Mail Stop 4720, …

(a) Whenever it appears that other parties shall be joined in order to dispose of all issues, the board shall so order. The board may remand the case for hearing by an administrative law judge on behalf of the board or for hearing and decision by an administrative law judge. (b) …

“Provider Group” means two or more rendering providers doing business together under a provider number at the same business location.

“Provider Identification Number or PIN” means the unique identification number assigned to a provider to: (a) Submit electronic claims for reimbursement. (b) Verify a beneficiary's eligibility. (c) Determine whether the beneficiary has met his/her share of cost, if applicable. (d…

“Beneficiary” means any person certified as eligible for services under the Medi-Cal program.

“Substance Use Disorder Medical Director” means a physician who is licensed by the Medical Board of California or the Osteopathic Medical Board of California and who meets requirements set forth in Sections 51000.70 and 51341.1(b)(28).

“Substance use disorder nonphysician medical practitioner” means an individual that provides medically necessary, clinical services prescribed for beneficiaries admitted, registered, or accepted for care by the substance use disorder clinic and is either: (a) A registered nurse p…

“Business telephone” means the telephone number at the business address of the applicant or provider. A beeper number, answering service, biller or billing service, pager, facsimile machine, answering machine, or a cellular telephone shall not be used as the primary business tele…

“Capital” means the total of all money invested in, and property or services contributed to, an applicant's or provider's business enterprise for the purpose of starting, acquiring, equipping, and operating the applicant's or provider's business enterprise.

(a) The Department shall review the applicant's or provider's completed application package for enrollment, continued enrollment, enrollment at a new, additional, or change in location, or enrollment pursuant to Section 51000.30(b) in the Medi-Cal program. The applicant or provid…

(a) All Medi-Cal covered services not included in the PCCM plan contract as part of the capitated services provided to a PCCM plan member are subject to prior authorization by the member's PCCM plan except: (1) Dental Services. (2) Emergency services as defined in section 51056(a…

(a) Copayment as used in these regulations refers to a specified amount of money which a beneficiary must expend for an outpatient visit to or by a provider, for each prescribed drug and for nonemergency services received in an emergency room as set forth in Welfare and Instituti…

(a) Wherever beneficiaries eligible for benefits under this program are also eligible for the same benefits, either full or partial, under any other State or Federal medical care program or under other contractual or legal entitlement, including but not limited to a private group…

(a) The following definitions shall be used throughout this article unless otherwise noted. (1) Audits or Examination Report. “Audit or examination report” means a document that presents the final audit or examination findings and is formally issued to the provider by the Departm…

A provider may request a hearing under the provisions of this article to examine any disputed audit or examination finding which results in an adjustment to Medi-Cal program reimbursement or reimbursement rates by submitting a Statement of Disputed Issues to the Department in acc…

(a) The Department may impose a remedy other than or in addition to termination of a provider as provided in Section 1919(h)(2) of the Social Security Act. (Section 1396r(h)(2) of Title 42 of the United States Code). (b) In deciding what remedy to impose, the Department shall sel…

The home office of a chain organization has no separate right to an individual hearing under this article. Where a provider in a chain organization disputes an audit or examination finding concerning the allocation of home office costs, other related entity costs or any other mat…

(a) An amended cost report may be submitted by a provider and accepted by the Department for the fiscal period or periods for which proceedings are pending under this article. (b) The hearing officer may suspend the proceedings until identification of any additional disputes that…

(a) An amended audit report may be issued by or on behalf of the Department for the fiscal period or periods for which proceedings are pending under this article. (b) The hearing officer may suspend the proceedings until identification of any additional disputes that may result f…

(a) The provider shall be afforded a reasonable opportunity to participate in an exit conference after the conclusion of any field audit or examination of records or reports of a provider, by or on behalf of the Department, and prior to the issuance of the Audit Report. The purpo…

(a) An Institutional provider may request a hearing for any disputed audit or examination finding as follows: (1) A written request shall be filed with the Department within 60 calendar days of the receipt of the written notice of the audit or examination findings. (2) This reque…

(a) If the hearing officer determines that an informal level of review is appropriate, it shall be ordered and scheduled as soon as reasonably possible. The hearing officer, or a hearing auditor designated by the hearing officer, shall preside at this informal level of review. (b…

(a) The Department shall review each request for reconsideration that is filed in accordance with Section 51048.2. The Department shall reconsider the determination and the reasons on which it was based. The Department shall issue, within 30 days of the receipt of the request, a …

(a) A request for a full evidentiary hearing shall be made in writing and signed by the provider or authorized representative of the skilled nursing facility or intermediate care facility concerned. The request shall be filed: (1) With the Director, Department of Health Services,…

“Physicians' services” means professional services performed or provided by physicians, including, but not limited to, surgery, anesthesiology, radiology, consultations, and home, office and institutional calls.

(a) “Provider” means any individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents of any partnership, group association, corporation, institution, or entity, that provides services, goods,…

“Blood bank” means a facility that collects, stores, and distributes human blood and blood derivatives.

“Physician” means a doctor of medicine or osteopathy.

Chiropractic services means services a chiropractor may perform under California laws limited to treatment involving manual manipulation of the spine.

“Acupuncturist” means a person who is trained in the theory and method of acupuncture.

“Podiatrist” means a doctor of surgical chiropody (D.S.C.), doctor of podiatric medicine (D.P.M.), doctor of surgical podiatry (D.S.P.), or doctor of podiatry (D.P. or Pod. D.).

“Pharmacist” means a doctor of pharmacy (Pharm.D.), Bachelor of Science in Pharmacy (B.S.), or a person trained to practice pharmacy in an accredited college of pharmacy or an approved apprentice program prior to 1937.

“Pharmacy” is a facility where a pharmacist stores, compounds, and dispenses drugs.

(a) Skilled nursing facility services include: (1) Room and board. (2) Nursing and related care services. (3) Commonly used items of equipment, supplies and services used for the medical and nursing benefit of patients as set forth in 51511 (b). (b) Skilled nursing facility servi…

(a) “Skilled Nursing facility level of care” means that level of care provided by a skilled nursing facility meeting the standards for participation as a provider under the Medi-Cal program as set forth in Section 51215 of this division. (b) The skilled nursing facility level of …

“Medi-Cal Care Coordinator” means the designated Medi-Cal consultant who authorizes, reauthorizes, and coordinates, as required, medically necessary services for a beneficiary. The Medi-Cal Care Coordinator shall be a physician or registered nurse. The extent of the participation…

(a) Subacute level of care means a level of care needed by a patient who does not require hospital acute care but who requires more intensive licensed skilled nursing care than is provided to the majority of patients in a skilled nursing facility. (b) To be eligible for subacute …

“Provider of medical transportation” means an individual or organization furnishing medical transportation services as defined in Section 51151.

“Renal dialysis center” means a facility which provides chronic hemodialysis and evaluates and treats renal disease.

“Community hemodialysis unit” means a facility which provides chronic hemodialysis and supervision of patients undergoing chronic home hemodialysis.

Acute administrative days means those days approved in an acute inpatient facility which provides a higher level of medical care than that currently needed by the patient.

“In-home medical care waiver services and nursing facility waiver services” means those medical services provided in a beneficiary's place of residence to beneficiaries who would otherwise require acute hospital or nursing facility inpatient care for at least 90 consecutive days.…

Nurse midwife services means services provided by nurse midwives, acting within the scope of their practice.