STATE OF CALIFORNIA--HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF HEALTH CARE SERVICES MEDI-CAL TELECOMMUNICATIONS PROVIDER AND BILLER APPLICATION/AGREEMENT (For electronic claim submission) 1.0 IDENTIFICATION OF PARTIES This agreement is between the State of California, Department of Health Care Services, hereinafter referred to as the "Department," and: PROVIDER INFORMATION Provider name (full legal) DBA (if applicable) Provider number Last 4 digits of Tax Id Number or Social Security Number: Provider service address (number, street) City State ZIP code Contact person E-mail address Contact person address (number, street) City State ZIP code Contact telephone number Currently assigned submitter number (otherwise, leave blank to be assigned a new submitter number) ( ) BILLER INFORMATION (If other than the provider of service) Biller name (full legal) DBA (if applicable) E-mail address Biller telephone number ( ) Business address (number, street) City State Zip code Contact person Currently assigned submitter number (otherwise, leave blank to be assigned a new submitter number) Full legal name(s) required as well as any assumed (DBA) name(s), address(es), and Medi-Cal provider number(s). The parties identified above will be hereinafter referred to as the "Provider" and/or "Biller." 1.1 CMC Batch Submission Type: Dial-up Magnetic tape Internet* * Note: Requires a completed network agreement on file. Real Time Submission Type: Point of Service (POS) Internet* Leased Line or Dial-up INDICATE CLAIM TYPES WHICH WILL BE SUBMITTED ELECTRONICALLY NCPDP Version (indicate version): Pharmacy (01) ANSI X 12 837 Version (indicate version): Long-Term Care (02) Medical/Allied Health (05) Medicare Crossover Part A ANSI X 12 276/277 Version (indicate version): Claim Status Inquiry/Response ANSI X 12 278 Version (indicate version): Health Care Services and Review Inpatient (03) Vision (05) Medicare Crossover Part B Outpatient (04) CHDP (11) American LegalNet, Inc. www.FormsWorkFlow.com DHCS 6153 (Rev. 03/17) Page 1 of 4 1.2 BACKGROUND INFORMATION The Provider/Biller agrees to provide the Department with the above information requested in order to verify qualifications to act as a Medi-Cal electronic Biller. 2.0 DEFINITIONS The terms used in this agreement shall have their ordinary meaning, except those terms defined in regulations, Title 22, California Code of Regulations, Section 51502.1, shall have the meaning ascribed to them by that regulation as from time to time amended. The term "electronic" or "electronically," when used to describe a form of claims submission, shall mean any claim submitted through any electronic means such as: magnetic tape or modem communications. 3.0 CLAIMS ACCEPTANCE AND PROCESSING The Department agrees to accept from the enrolled Provider/Biller, electronic claims submitted to the Medi-Cal fiscal intermediary in accordance with the Medi-Cal provider manuals. The Provider hereby acknowledges that he has received, read, and understands the provider manual and its contents, and agrees to read and comply with all provider manual updates and provider bulletins relating to electronic billing. 3.1 CLAIMS CERTIFICATION The Provider agrees and shall certify under penalty of perjury that all claims for services submitted electronically have been personally provided to the patient by the Provider or under his direction by another person eligible under the Medi-Cal Program to provide to such services, and such person(s) are designated on the claim. The services were, to the best of the Provider's knowledge, medically indicated and necessary to the health of the patient. The Provider shall also certify that all information submitted electronically is accurate and complete. The Provider understands that payment of these claims will be from federal and/or state funds, and that any falsification or concealment of a material fact may be prosecuted under federal and/or state laws. The Provider/Biller agrees to keep for a minimum period of three years from the date of service an electronic archive of all records necessary to fully disclose the extent of services furnished to the patient. A printed representation of those records shall be produced upon request of the Department during that period of time. The Provider/Biller agrees to furnish these records and any information regarding payments claimed for providing the services, on request, within the State of California to the California Department of HealthCare Services; California Department of Justice; Office of the State Controller; U.S. Department of Health and Human Services; or their duly authorized representatives. The Provider also agrees that medical care services are offered and provided without discrimination based on race, religion, color, national or ethnic origin, sex, age, or physical or mental disability. The Provider/Biller agrees that using his Medi-Cal Submitter ID plus DHCS-issued password when submitting an electronic claim will identify the submitter and shall serve as acceptance to the terms and conditions of the Department's Telecommunications Provider and Biller Application/Agreement (DHCS 6153), paragraph 3.0. The Provider/Biller further acknowledges the necessity of maintaining the privacy of the DHCS-issued password and agrees to bear full responsibility for use or misuse of the Medi-Cal Submitter ID and password should privacy not be maintained. 3.2 VERIFICATION OF CLAIMS WITH SOURCE DOCUMENTS Regardless of whether the Provider employs a Biller, the Provider agrees to retain personal responsibility for the development, transcription, data entry, and transmittal of all claim information for payment. This includes usual and customary charges for services rendered. The Provider shall also assume personal responsibility for verification of submitted claims with source documents. The Provider/Biller agrees that no claim shall be submitted until the required source documentation is completed and made readily retrievable in accordance with Medi-Cal statutes and regulations. Failure to make, maintain, or produce source documents shall be cause for immediate suspension of electronic billing privileges. 3.3 ACCURACY AND CORRECTION OF CLAIMS OR PAYMENTS The Provider agrees to be responsible for the review and verification of the accuracy of claims payment information promptly upon the receipt of any payment. The Provider agrees to seek correction of any claim errors through the appropriate processes as designat