Medi-Cal Enrollment FAQ for Newly Onboarding Providers
1. What is the source of this requirement?
Answer: This requirement is the result of the California Department of Health Care Services (DHCS) coming into compliance with federal regulations designed to reduce the incidence of fraud and abuse by ensuring that providers are individually identified and screened for licensure and certification. CMS-6028-FC enhanced the enrollment and screening processes for Medicaid Fee-For-Service providers pursuant to the Affordable Care Act.
2. How is credentialing different from enrollment?
Answer: In November of 2017, DHCS published new requirements for MCPs in line with the CMS requirements above. These new requirements (CMS & DHCS) make it clear that credentialing and screening/enrollment are two completely separate processes, and both are required. We are hearing many different terms being used interchangeably and understand that terminology is one of the most challenging aspects of this requirement. Consider these definitions:
Credentialing is the process of verifying that providers have the education, training, and licensure/certification to deem them qualified to provide covered medical services to our members. It also includes monitoring for various occurrences that may indicate a potential risk of harm to our members, such as disciplinary actions against a license or serious/excessive malpractice suits. The credentialing process CenCal Health has followed for many years already meets DHCS requirements and is not changed by the requirements for Medi-Cal enrollment.
Enrollment is the process to identify providers who are providing covered medical services to our members and ensure they understand the requirements of being a Medi-Cal provider. It also includes the processes designed to limit the potential for fraud and abuse, such as risk-based screening requirements, and disclosure of ownership and control of practices and entities who submit claims for medical services rendered to Medi-Cal members.
3. What is the screening process?
Answer: The screening process is also designed to limit the potential for fraud and abuse in the Medi-Cal system. Providers are deemed limited, moderate, or high risk based on provider type. Most providers are in the limited risk category, and that screening process is already accomplished through routine credentialing (such as verifying a medical license and that a provider has not been excluded from any State or Federal programs). Screening for moderate and high risk providers may include site visits, fingerprinting, and background checks. DHCS is retaining responsibility for screening of moderate and high risk providers. The screening requirements have been in place for years and are not changed by the requirements for Medi-Cal enrollment.
4. Which providers must enroll and what is the deadline to complete the enrollment process?
Answer: Effective January 1, 2018, all providers who render medical services to Medi-Cal members are required to enroll, with the exception of providers with no enrollment pathway such as registered dieticians and ABA providers
5. I’m not sure whether I’m enrolled – how can I find out?
Answer: DHCS has made an “Open Data Portal” available that can be searched using NPI (preferred) or other identifiers, such as name. These lists are refreshed monthly despite the date in the links. But, don’t try to download them, they are very large files! Most provider types can search the list at the link below (enter the NPI in the search field on the Data Table):
Enrolled Medi-Cal Fee For Service Provider - CSV - California Health and Human Services Open Data Portal
6. How do I begin the enrollment process?
Answer: DHCS’s Provider Enrollment Division (PED) has worked to expand the online enrollment process to most provider types. We recommend this method which can be accessed at the following link:
PAVE - Provider Application and Validation for Enrollment
7. Can CenCal Health help me enroll with DHCS?
Answer: Unfortunately, we have no control over the DHCS enrollment process and are only able to offer information and links to DHCS’s online resources.
8. What if I still have questions, or need guidance for more complicated or unique situations?
Answer: CenCal Health is here to help! Some of our core values include commitment to the community and collaboration with our provider partners, and we take that very seriously. We appreciate our providers and our goal is to assist you in this process. Please reach out to our Quality Liaison Specialist at firstname.lastname@example.org with any questions.