1. (a) Notwithstanding any other provisions of these regulations, no provider shall charge for any service or any article more than would have been charged for the same service or article to other purchasers of comparable services or articles under comparable circumstances. However, if an organized outpatient clinic renders services without charge to the general public under programs, other than Title XVIII or XIX, financed by federal or state funds, Medi-Cal may be considered a third party payor and be billed for Medi-Cal covered services when rendered to Medi-Cal beneficiaries if:

   1. (1) The clinic has an established fee schedule; and
   2. (2) The clinic ascertains from all individuals served whether they have a third party coverage for medical care or services, and if such coverage is available that third party coverage is billed and a diligent effort made to collect such claimed amounts; and
   3. (3) Medi-Cal is not the only third party pay or from which the clinic seeks payment.
2. (b) Payments for benefits under the Medi-Cal Program can be made only to providers who meet the Standards for Participation specified in Article 3 (commencing with Section 51200), and the requirements for payment in Article 7 of this chapter.
3. (c) Payment by the Medi-Cal Program for each outpatient visit which involves copayment, emergency room service which involves copayment and each prescribed drug which involves copayment shall not be reduced by the amount of copayment required by these regulations.
4. (d) No provider shall submit claims to the Medi-Cal Program using any provider number other than that issued to the provider by the Department.
5. (e) Fees shall not be paid to any provider for professional services rendered in a hospital or other facility when such provider is compensated on a salary or contract basis, for performing the same or similar services, by that hospital or facility if the funds used to pay such salary or to discharge the obligation of such contract are subject to reimbursement in whole or in part from the General Fund of the State of California or from taxes or assessments paid to any of its subdivisions.
6. (f) A negotiated rate of payment between a Medi-Cal provider and any contractor contracting with the Department on an at-risk basis pursuant to Chapter 7 or Chapter 8, Part 3, Division 9, Welfare and Institutions Code shall not be the basis for finding a violation of (a) above or Section 51480 and shall not be the basis for otherwise reducing the provider's reimbursement pursuant to the payment regulations of this article.

Note: Authority cited: Sections 14105, 14124.5 and 14312, Welfare and Institutions Code; Section 133.5, Chapter 102, Statutes of 1981; Section 2, Chapter 237, Statutes of 1981; and Section 78, Chapter 146, Statutes of 1999. Reference: Sections 14000, 14053, 14088.16, 14105, 14106 and 14134, Welfare and Institutions Code.

History

1. Amendment of subsection (a) filed 4-1-74; effective thirtieth day thereafter (Register 74, No. 14). For prior history, see Register 72, No. 40.

2. New subsection (e) filed 3-5-76 as an emergency; effective upon filing (Register 76, No. 10).

3. Certificate of Compliance filed 7-1-76 (Register 76, No. 27).

4. New subsection (f) filed 12-10-79; effective thirtieth day thereafter (Register 79, No. 50).

5. Amendment of subsection (c) filed 11-17-81 as an emergency; effective upon filing (Register 81, No. 47). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 3-17-82.

6. Certificate of Compliance transmitted to OAL 3-16-82 and filed 4-16-82 (Register 82, No. 16).

7. Editorial correction restoring subsections (a)(A)-(f) inadvertently deleted during printing of Register 84, No. 50, and redesignation of subsections (a)(A)-(C) to subsections (a)(1)-(3) (Register 85, No. 12).

8. Amendment of subsection (f) filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 7-9-90.

9. Amendment refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed by operation of law on 11-6-90.

10. Request to readopt amendment on an emergency basis pursuant to Government Code section 11346.1 granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No. 6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or emergency language will be repealed by operation of law on the following day.

11. Certificate of Compliance as to 11-6-90 order transmitted to OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).

12. Amendment of subsection (f) filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No. 18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or emergency language will be repealed by operation of law on the following day.

13. Certificate of Compliance as to 3-25-91 order transmitted to OAL 7-19-91 and filed 8-19-91 (Register 92, No. 1).

14. Amendment of subsection (b) and Note 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).

15. Amendment of subsection (b) and Note 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).

16. Amendment of subsection (b) and Note 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.

17. Amendment of subsection (b) and Note 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.

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