Cal. Code Regs. tit. 22, § 51000.40 – Reporting of Additional or Changed Information to Provider Applications.

(a) A provider, including a provider group, shall report to the Department within 35 days of any addition or change in the information previously submitted in the application package.
(b) A provider, including a provider group, shall complete the form “Medi-Cal Supplemental Changes,” DHCS 6209 (Rev. 12/14), incorporated by reference herein, to add or change the following information, or to request the following actions:
1. (1) “Pay to”, unless the provider is a substance use disorder clinic, or “mailing” address.
2. (2) Business telephone number.
3. (3) Managing employee.
4. (4) Pharmacist-in-charge, if the provider is a pharmacy.
5. (5) Medicare billing number.
6. (6) Business activities, if the provider currently provides durable medical equipment and/or incontinence medical supplies and:
  1. (A) The change requires the issuance of a new license, permit, or certificate; or
  2. (B) The provider is adding or deleting incontinence medical supplies.
7. (7) Name under which the provider or provider group is doing business (DBA).
8. (8) CLIA number.
9. (9) Deactivation of a provider number.
10. (10) Re-issuance of a Provider Identification Number (PIN), unless the provider is a substance use disorder clinic.
11. (11) For provider of medical transportation services:
  1. (A) Vehicle or aircraft information.
  2. (B) Driver or pilot information, or the addition of information on a new driver or pilot.
  3. (C) The days and/or hours of operation of the applicant's or provider's business.
  4. (D) The geographic area(s) served.
12. (12) A change of less than 50 percent in the person(s) with an ownership or control interest, as defined in Section 51000.15, of the provider, or provider group that does not result in a new Taxpayer Identification Number being issued by the IRS. Any cumulative change of 50 percent or more in the person(s) with an ownership or control interest, since the information provided in the last complete application package was approved for enrollment, requires a new application required pursuant to Section 51000.30(b)(6).
13. (13) Specialty Code.
14. (14) For a substance use disorder clinic the following additional actions:
  1. (A) A change of the substance use disorder medical director or physicians making medical necessity determinations for beneficiaries.
  2. (B) Deletion or addition of service modalities.
  3. (C) A change of any substance use disorder treatment professional or licensed substance use disorder treatment professional providing counseling services.
(c) A nonphysician medical practitioner or licensed midwife shall complete the “Medi-Cal Nonphysician Medical Practitioner and Licensed Midwife Application,” DHS 6248 (Rev. 07/05), to report to the Department any change in information previously submitted, as required pursuant to Section 51000.30(d), to add or change the following information, or to request the following actions:
1. (1) Delete a nonphysician medical practitioner or licensed midwife;
2. (2) Change the supervising physician, when the employing provider remains the same;
3. (3) Change the hours of supervision;
4. (4) Change the maximum hours worked per week.
(d) The Department may require the provider to submit a new application package when the provider uses the form “Medi-Cal Supplemental Changes,” DHCS 6209 (Rev. 12/14) to report information not listed in subsection (b) above.

Note: Authority cited: Section 20, Health and Safety Code; Sections 10725, 14043.75 and 14124.5, Welfare and Institutions Code. Reference: Sections 14043.15, 14043.2, 14043.25 and 14043.26, Welfare and Institutions Code.

History

1. New section filed 9-28-99 as an emergency; operative 9-28-99 (Register 99, No. 40). A Certificate of Compliance must be transmitted to OAL by 3-27-2000 or emergency language will be repealed by operation of law on the following day. Submitted to OAL for printing only pursuant to section 78, AB 1107 (Chapter 146, Statutes of 1999).

2. New section, including amendments, refiled 11-24-99 as an emergency; operative 11-24-99 (Register 99, No. 48). A Certificate of Compliance must be transmitted to OAL by 5-22-2000 or emergency language will be repealed by operation of law on the following day. Submitted to OAL for printing only pursuant to section 78, AB 1107 (Chapter 146, Statutes of 1999).

3. New section refiled 5-5-2000 as an emergency; operative 5-22-2000 (Register 2000, No. 18). A Certificate of Compliance must be transmitted to OAL by 9-19-2000 or emergency language will be repealed by operation of law on the following day.

4. New section refiled 8-28-2000 as an emergency; operative 9-6-2000 (Register 2000, No. 35). A Certificate of Compliance must be transmitted to OAL by 1-4-2001 or emergency language will be repealed by operation of law on the following day.

5. Certificate of Compliance as to 8-28-2000 order, including amendment of section, transmitted to OAL 12-26-2000 and filed 2-8-2001 (Register 2001, No. 6).

6. Amendment of section heading, section and Note filed 9-29-2004 as an emergency; operative 10-7-2004 (Register 2004, No. 41). A Certificate of Compliance must be transmitted to OAL by 2-4-2005 or emergency language will be repealed by operation of law on the following day. Deemed emergency exempt from OAL pursuant to Welfare and Institutions Code section 14043.75.

7. Amendment of section heading, section and Note refiled 1-27-2005 as an emergency; operative 2-5-2005 (Register 2005, No. 4). A Certificate of Compliance must be transmitted to OAL by 6-6-2005 or emergency language will be repealed by operation of law on the following day. Deemed emergency exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75.

8. Amendment of section heading, section and Note refiled 6-2-2005 as an emergency; operative 6-7-2005 (Register 2005, No. 22). A Certificate of Compliance must be transmitted to OAL by 10-5-2005 or emergency language will be repealed by operation of law on the following day. Deemed emergency exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75.

9. Certificate of Compliance as to 6-2-2005 order, including further amendment of section. transmitted to OAL 9-29-2005 and filed 11-10-2005 (Register 2005, No. 45).

10. Amendment of subsections (b)-(b)(1) and (b)(10), new subsections (b)(14)-(b)(14)(C), amendment of subsection (d) and amendment of Note filed 8-17-2015 as a deemed emergency exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75; operative 8-17-2015 (Register 2015, No. 34). A Certificate of Compliance must be transmitted to OAL by 2-16-2016 or emergency language will be repealed by operation of law on the following day.

11. Certificate of Compliance as to 8-17-2015 order transmitted to OAL 12-30-2015 and filed 2-11-2016 (Register 2016, No. 7).