Department of Health & Human Services
Centers for Medicare & Medicaid Services
Division of Medicaid & Children's Health Operations
San Francisco Regional Office
90 Seventh Street, Suite 5-300 (5W)
San Francisco, CA 94103-6706
November 15, 2018
Chief Deputy Director, Health Care Programs
California Department of Health Care Services
P.O. Box 997413, MS 0000
Sacramento, CA 95899-7413
Dear Ms. Cantwell:
This letter is to grant the state flexibilities for provider enrollment under the section 1135 waiver authority.
California Medicaid Provider Enrollment Disaster Relief
California currently has the authority to rely upon screening that is performed by other SMAs and/or Medicare. California is not required to create a temporary provisional enrollment for providers who are enrolled with another SMA or Medicare.
With respect to providers not already enrolled with another SMA or Medicare, CMS will waive the following screening requirements so the state/territory may provisionally, temporarily, enroll the providers:
- Payment of the application fee - 42 C.F.R 455.460
- Criminal background checks associated with FCBC- 42 C.F.R Section 455.434
- Site visits - 42 C.F.R Section 455.432
- In-state/territory licensure requirements - 42 C.F.R Section 455.412
For those providers located out of state/territory and from which California Medicaid participants seek care, enrollment is not necessary if the following criteria are met:
- The item or service is furnished by an institutional provider, individual practitioner, or pharmacy at an out-of-state/territory practice location– i.e., located outside the geographical boundaries of the reimbursing state/territory’s Medicaid plan,
- The NPI of the furnishing provider is represented on the claim,
- The furnishing provider is enrolled and in an "approved" status in Medicare or in another state/territory’s Medicaid plan,
- The claim represents services furnished, and;
- The claim represents either: a. A single instance of care furnished over a 180 day period, or
- Multiple instances of care furnished to a single participant, over a 180 day period
If the Medicaid participant is enrolled with the Medicaid program from the disaster designated state, the final two criterion will be waived. Therefore, there is no limit to the instances of care furnished or to how many participants in a 180 day period.
In the instance that a certified provider is enrolled in Medicare or with a state/territory’s Medicaid program other than California, California may perform an expedited enrollment, as described above, of an out-of-state/territory facility in order to accommodate participants who were displaced by the disaster.
CMS is granting waiver authority to allow California to enroll providers who are not currently enrolled by meeting the following minimum requirements:
- Must collect minimum data requirements in order to file claims and process, including, but not limited to NPI
- Must collect SSN/EIN/TIN in order to perform the following screening requirements:
- OIG exclusion list
- State/territory licensure – provider must be licensed, and legally authorized, in any state/territory to practice or deliver the services for which they intend to file claims
- California may grant a provisional temporary enrollment that meets the following requirements:
- Must cease approving temporary provisional enrollments no later than the date that the disaster designation is lifted.
- Must cease payment to providers who are temporarily enrolled within six months from the date that the disaster designation is lifted, unless a provider has submitted an application that meets all requirements for Medicaid participation and that application was subsequently reviewed and approved by California.
- California must allow a retroactive effective date for provisional temporary enrollments that is no earlier than November 13, 2018.
California may temporarily cease revalidation of providers who are located in California or are otherwise directly impacted by the disaster.
These provider enrollment disaster relief efforts also apply to the Children’s Health Insurance Program (CHIP).
If you have any questions or concerns with what is outlined in this letter, please contact Dzung Hoang at (415) 744-3589 or Dzung.Hoang@cms.hhs.gov.
Acting Associate Regional Administrator
Division of Medicaid & Children’s Health Operations
cc: Steven Chickering, CMS Region IX Division of Survey & Certification (DSC)
Jackie Glaze, Senior Policy Advisor, CMS Consortium for Medicaid & Children’s Health Operations (CMCHO)
Alisha Sanders, CMS Center for Program Integrity (CPI)