1. (a) When the share of cost has been met, the beneficiary shall return the signed form MC 177S to the county department. The county department shall review form MC 177S to ensure that:

   1. (1) The case description portion of the form is complete.
   2. (2) The services listed were provided to persons listed on form MC 177S.
   3. (3) The providers have completed the form in accordance with Section 50657(a)(4) through (6).
   4. (4) The beneficiary or the beneficiary's representative has signed the form.

2. (b) If the items specified above are not completed correctly, the following action shall be taken:

   1. (1) The county department shall attempt to obtain the information necessary for completion of form MC 177S verbally from either of the following:

      1. (A) The beneficiary.
      2. (B) The provider.

   2. (2) If the information necessary to correct form MC 177S cannot be obtained verbally the county department shall:

      1. (A) Identify the information needed.
      2. (B) Return the form to the beneficiary.

   3. (3) When the amount shown in the Billed Patient column is in excess of the share of cost amount, the county department shall:

      1. (A) Explain to the beneficiary that the amount shown in the Billed Patient column is the amount for which he has assumed legal responsibility.
      2. (B) Attempt to correct the error in accordance with (b) (1) and (2) if the beneficiary states that the assumption of legal responsibility for the cost of services in excess of the share of cost was not intentional.

3. (c) After form MC 177S has been determined to be correct and complete, the following action shall be taken, unless the conditions specified in (d) are met.

   1. (1) The first two pages of form MC 177S shall be submitted to Department of Health Services, Key Data Entry Unit. In addition a copy of form MC 176M shall be submitted with form MC 177S if an adjustment to the share of cost is being made pursuant to Section 50653.3.
   2. (2) Key Data Entry Unit will certify that the share of cost has been met.
   3. (3) The Department will issue Medi-Cal cards to the persons included in the MFBU.

4. (d) If the beneficiary signs a Certification of Medical Need/Request for Medi-Cal Card, MC 113, which indicates a need for medical services prior to normal anticipated receipt of a Department issued Medi-Cal card, the county department shall:

   1. (1) Enter the date of certification for claims clearance on form MC 177S.
   2. (2) Issue a Medi-Cal card to each person who has been listed on form MC 113 as having an immediate need. Card issuance procedures specified in Article 14 shall be followed.
   3. (3) Indicate on form MC 177S and form MC 176M, if required, the persons who have been issued a card.
   4. (4) Forward form MC 177S and form MC 176M, if required, to the Key Data Entry Unit.

Note: Authority cited: Sections 10725, 14005.9(c) and 14124.5, Welfare and Institutions Code; Section 133.5, AB 251, Chapter 102, Statutes of 1981. Reference: Sections 14005.4, 14005.7, 14005.9 and 14017, Welfare and Institutions Code.

History

1. Amendment of Subsection (a)(3) and new subsection (a)(8) filed 11-30-81 as an emergency; effective upon filing (Register 81, No. 49). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 3-30-82.

2. Certificate of Compliance filed 3-30-82 (Register 82, No. 14).

3. Amendment of subsection (a)(3) filed 10-1-82 as an emergency; effective upon filing (Register 82, No. 40). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 1-29-83.

4. Certificate of Compliance transmitted to OAL 12-30-82 and filed 2-2-83 (Register 83, No. 6).

5. Editorial correction of Note filed 4-12-83 (Register 83, No. 16).

6. Amendment filed 7-3-86; effective thirtieth day thereafter (Register 86, No. 27).