State of California227Health and Human Services Agency Department of Health Care Services JENNIFER KENT EDMUND G. BROWN JR. DIRECTOR GOVERNOR Provider Enrollment Division MS 4704 P.O. Box 997412, Sacramento, CA 95899-7412 Internet Address: www.dhcs.ca.gov/provgovpart/Pages/PED.aspx 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 Centers for Medicare & Medicaid Services (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 223atypical224 in any NPI fields. These 223atypical providers224 will receive a 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 Providers 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). Applicants and providers may be required to submit an application fee or proof of payment to or enrollment with Medicare or other state Medicaid programs. Effective January 1, 2013, the Department of Health Care Services (DHCS) requires certain applicants and providers to submit an application fee when requesting an enrollment action. The application fee collected is used to offset the cost of conducting the required screening as specified in Title 42 Code of Federal Regulations 455 Subpart E. Reference the Medi-Cal Regulatory Provider Bulletin, 223Medi-Cal Application Fee Requirements for Compliance with 42 Code of Federal Regulations Section 455.460,224 for further information. Currently, DME providers are designated as 223high224 categorical risk level. Federal law requires State Medicaid Agencies (Medi-Cal in California) to establish categorical risk levels for providers and provider categories who pose an increased financial risk of fraud, waste or abuse to the Medicaid program. Federal law mandates that Medi-Cal screen all initial applications, including applications for a new practice location and any applications received in response to a re-enrollment or a revalidation of enrollment request based on a categorical risk level of 223limited,224 223moderate224 or 223high.224 An applicant or provider is subject to the 223high224 risk level of screening if the provider category is designated by DHCS as 223high224 risk. If the DME Moratorium is lifted, DME providers will be subject to screening as a 223high224 risk level, in accordance with Title 42 Code of Federal Regulations Sections 424.518, 455.434, and 455.450; and California Welfare and Institutions Code (W&I Code), Section 14043.38. American LegalNet, Inc. www.FormsWorkFlow.com Due to the 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 February 23, 2019, and is in accordance with 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 for medically necessary lactation aids and shall be reimbursed for items mentioned in the Medi-Cal provider manual under the Breastfeeding: Lactation Management Aids heading (found in Durable Medical Equipment [DME]: Bill for DME [dura bil dme]) 2. DME applicants who, for the purpose of the Medi-Cal Program, choose to be enrolled 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 be reimbursed for items authorized in the Medi-Cal provider manual for wheelchairs, modifications and accessories b) OREDME providers shall sell, service and/or repair oxygen and respiratory equipment. An enrolled provider shall 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 3. Current Medi-Cal enrolled DME providers seeking to add a new business location in the same county, so long as the DME provider enrolled in the program after October 12, 1999, and is not adding new business activities, categories of service or billing codes, other than those approved for enrollment at its existing location; 4. Applicants who will be enrolled solely for reimbursement of Medicare cost sharing amounts; 5. 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 an affiliated corporation that is a part of the same group of affiliated corporations; 6. 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; 7. 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; 8. Applications submitted pursuant to CCR, Title 22, Section 51000.55 or Section 51006, Subparts (a)(1), (a)(2), (a)(3) or (a)(5); 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; 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 one of the following counties: Los Angeles, Orange, Riverside or San Bernardino and is not adding new business activities, categories of service or billing codes other than those approved for enrollment; 10. 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; or, 11. DME applicants who, for the purpose of the Medi-Cal program, choose to enroll to provide only the services and/or replacement parts for a Medi-Cal covered device for an enrolled Medi-Cal beneficiary, when those services and/or parts are not available from an enrolled Medi-Cal provider on the date of application. If you are eligible according to the criteria outlined above, complete a new application package consisting of a Medi-Cal Durable Medical Equipment Provider Application (DHCS 6201 Rev. 5/17), a Medi-Cal Disclosure Statement (DHCS 6207, Rev. 2/17), a Medi-Cal Provider Agreement (DHCS 6208, Rev. 2/17),