Change Healthcare Claims Provider Information Form

PAYER ID: SKCA0
SUBMITTER ID: 2E5
Change Healthcare Claims Provider Information Form
*This form is to ensure accuracy in updating the appropriate account
1
Provider Organization
Practice/
Facility Name
Provider Name
Tax ID
Client ID
Site ID
Address
City/State
Zip
Code
Contact Name
E-mail Address
2
Telephone
Fax
Vendor (Change Healthcare certified vendor used to submit files to Change Healthcare)
Vendor Name
Vendor
Submitter ID
Division ID
Contact Name
E-mail Address
3
Payer
Payer ID
SKCA0 CALIFORNIA MEDICAID MEDICAL
Group ID
Individual Provider ID
4
NPI ID
Confirmations
Send Change Healthcare Claim Confirmations To:
Special Instructions:
• All Payer Registration forms must contain original
signatures, NO stamped signatures or photocopies are
accepted.
• SUBMIT COMPLETED FORM
TO: Change Healthcare
Donelson Corporate Ctr Bldg 3
3055 Lebanon Pike Ste 1000
NASHVILLE, TN 37214-2230
******* PLEASE USE THE NPI NUMBER AS THE PROVIDER NUMBER. THE FORM MUST BE SIGNED IN BLUE
INK, PROVIDER MUST SUBMIT ENROLLMENT FORM TO CHANGE HEALTHCARE, DO NO SEND DIRECTLY
TO THE PAYER********
CHANGE HEALTHCARE REVISION FORM DATE: 08/15/12
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
MEDI-CAL TELECOMMUNICATIONS PROVIDER AND BILLER APPLICATION/AGREEMENT
(For electronic claim submission)
1.0 IDENTIFICATION OF PARTIES
This agreement is between the State of California, Department of Health Care Services, hereinafter referred to as the
“Department,” and:
PROVIDER INFORMATION
Provider name (full legal)
Provider number
DBA (if applicable)
Last 4 digits of Tax Id Number or Social Security Number:
Provider service address (number, street)
City
Contact person
E-mail address
Contact person address (number, street)
City
Contact telephone number
(
State
ZIP code
State
ZIP code
Currently assigned submitter number (otherwise, leave blank to be assigned a new submitter number)
)
BILLER INFORMATION (If other than the provider of service)
Biller name (full legal)
Biller telephone number
( 866) 924.4634
Webmd/ENVOY
DBA (if applicable)
E-mail address
EMDEON
[email protected]
Business address (number, street)
City
State
Nashville
3055 Lebanon Pike Suite 1000
Contact person
TN
Zip code
37214
Currently assigned submitter number (otherwise, leave blank to be assigned a new submitter number)
Enrollment
2E5
Full legal name(s) required as well as any assumed (DBA) name(s), address(es), and Medi-Cal provider
number(s). The parties identified above will be hereinafter referred to as the “Provider” and/or “Biller.”
1.1
CMC Batch Submission Type:
x
Real Time Submission Type:
Dial-up
Magnetic tape
Internet*
Point of Service (POS)
Internet*
Leased Line
or
Dial-up
* Note: Requires a completed network agreement on file.
INDICATE CLAIM TYPES WHICH WILL BE SUBMITTED ELECTRONICALLY
NCPDP Version (indicate version):
Pharmacy (01)
ANSI X 12 837 Version (indicate version):
x
5010A1
Long-Term Care (02)
Medical/Allied Health (05)
Medicare Crossover Part A
Inpatient (03)
Vision (05)
Medicare Crossover Part B
Outpatient (04)
CHDP (11)
ANSI X 12 276/277 Version (indicate version):
Claim Status Inquiry/Response
ANSI X 12 278 Version (indicate version):
Health Care Services and Review
DHCS 6153 (Rev. 03/12)
Page 1 of 4
1.2
BACKGROUND INFORMATION
The Provider/Biller agrees to provide the Department with the above information requested in order to verify qualifications
to act as a Medi-Cal electronic Biller.
2.0
DEFINITIONS
The terms used in this agreement shall have their ordinary meaning, except those terms defined in regulations, Title 22,
California Code of Regulations, Section 51502.1, shall have the meaning ascribed to them by that regulation as from time
to time amended. The term “electronic” or “electronically,” when used to describe a form of claims submission, shall mean
any claim submitted through any electronic means such as: magnetic tape or modem communications.
3.0
CLAIMS ACCEPTANCE AND PROCESSING
The Department agrees to accept from the enrolled Provider/Biller, electronic claims submitted to the Medi-Cal fiscal
intermediary in accordance with the Medi-Cal provider manuals. The Provider hereby acknowledges that he has
received, read, and understands the provider manual and its contents, and agrees to read and comply with all provider
manual updates and provider bulletins relating to electronic billing.
3.1
CLAIMS CERTIFICATION
The Provider agrees and shall certify under penalty of perjury that all claims for services submitted electronically have
been personally provided to the patient by the Provider or under his direction by another person eligible under the
Medi-Cal Program to provide to such services, and such person(s) are designated on the claim. The services were, to the
best of the Provider's knowledge, medically indicated and necessary to the health of the patient. The Provider shall also
certify that all information submitted electronically is accurate and complete. The Provider understands that payment of
these claims will be from federal and/or state funds, and that any falsification or concealment of a material fact may be
prosecuted under federal and/or state laws. The Provider/Biller agrees to keep for a minimum period of three years from
the date of service an electronic archive of all records necessary to fully disclose the extent of services furnished to the
patient. A printed representation of those records shall be produced upon request of the Department during that period of
time. The Provider/Biller agrees to furnish these records and any information regarding payments claimed for providing
the services, on request, within the State of California to the California Department of HealthCare Services; California
Department of Justice; Office of the State Controller; U.S. Department of Health and Human Services; or their duly
authorized representatives. The Provider also agrees that medical care services are offered and provided without
discrimination based on race, religion, color, national or ethnic origin, sex, age, or physical or mental disability. The
Provider/Biller agrees that using his Medi-Cal Submitter ID plus DHCS-issued password when submitting an electronic
claim will identify the submitter and shall serve as acceptance to the terms and conditions of the Department’s
Telecommunications Provider and Biller Application/Agreement (DHCS 6153), paragraph 3.0. The Provider/Biller further
acknowledges the necessity of maintaining the privacy of the DHCS-issued password and agrees to bear full
responsibility for use or misuse of the Medi-Cal Submitter ID and password should privacy not be maintained.
3.2
VERIFICATION OF CLAIMS WITH SOURCE DOCUMENTS
Regardless of whether the Provider employs a Biller, the Provider agrees to retain personal responsibility for the
development, transcription, data entry, and transmittal of all claim information for payment. This includes usual and
customary charges for services rendered. The Provider shall also assume personal responsibility for verification of
submitted claims with source documents. The Provider/Biller agrees that no claim shall be submitted until the required
source documentation is completed and made readily retrievable in accordance with Medi-Cal statutes and regulations.
Failure to make, maintain, or produce source documents shall be cause for immediate suspension of electronic billing
privileges.
3.3
ACCURACY AND CORRECTION OF CLAIMS OR PAYMENTS
The Provider agrees to be responsible for the review and verification of the accuracy of claims payment information
promptly upon the receipt of any payment. The Provider agrees to seek correction of any claim errors through the
appropriate processes as designated by the Department or its fiscal intermediary including, but not limited to, the process
set out in Title 22, California Code of Regulations, Section 51015 and, as from time to time amended. The Provider/Biller
acknowledges that anyone who misrepresents or falsifies or causes to be misrepresented (or falsified) any records or
other information relating to that claim may be subject to legal action, including, but not limited to, criminal prosecution,
action for civil money penalties, administrative action to recover the funds, and decertification of the Provider/Biller from
participation in the Medi-Cal program and/or electronic billing.
4.0
CHANGE IN ELECTRONIC BILLING STATUS
The Provider/Biller and the Department agree that any changes in Provider/Biller status which might affect eligibility to
participate in electronic billing pursuant to federal and state law shall be promptly communicated to each party.
DHCS 6153 (Rev. 03/12)
Page 2 of 4
5.0 PROVIDER/BILLER REVIEWS
The Provider/Biller agrees that agents of the Department of Health Care Services, the Office of the State Controller, the
Department of Justice, or any other authorized agent or representative of the State of California or any authorized
representative of the U.S. Department of Health and Human Services may, from time to time, conduct such reviews as
are necessary to ensure compliance with state and federal law and with this agreement. In particular, the Provider/Biller
agrees to make available to such agent or representative all source documents necessary to verify the accuracy and
completeness of claims submitted electronically.
5.1
NONEXCLUSIVE REVIEWS
The Provider/Biller agrees that the review set out in paragraph 5.0 above is not exclusive but supplements any other form
of audit or review the Provider/Biller may be subject to due to its status as a certified Provider/Biller of services under the
Medi-Cal or Medicare programs.
6.0
EFFECTIVE DATE
This agreement shall become effective upon approval of the Department.
6.1
TERMINATION
The Department or Provider may terminate this agreement with or without cause by giving 30 days prior written notice of
intent to terminate, and the Provider has no right to appeal such termination by the Department. The Department may,
however, terminate this agreement immediately, pursuant to paragraph 6.2 upon determination that the Provider/Biller has
failed or refused to produce or retain source documents in accordance with federal and state law or this agreement.
6.2
TERMINATION FOR CAUSE
If the Provider/Biller is unable to produce source documents on request pursuant to paragraph 5.0, the Department may
terminate this agreement immediately by directing its fiscal intermediary to cease payment of any and all electronic claims
submitted by the Provider/Biller, including any claims in process on the date of such termination. The Provider/Biller has
no right to appeal termination for cause pursuant to this subpart prior to the effective date of such termination. The
Provider/Biller may appeal any grievance resulting from the termination in accordance with the procedure established by
Title 22, California Code of Regulations, Section 51015, as from time to time amended. The Department may demand
repayment of claims for which no source documents are produced, and the Provider/Biller shall have a right to appeal of
such an overpayment finding to the extent provided by Section 14171 of the Welfare and Institutions Code and regulations
promulgated pursuant thereto, and as from time to time amended.
6.3
EFFECT OF TERMINATION AND APPEAL
On termination pursuant to paragraph 6.1 or 6.2, the Provider/Biller may submit hard copy claims.
7.0
AGREEMENT BETWEEN PROVIDER AND BILLER (IF OTHER THAN THE PROVIDER OF SERVICE)
The Provider stipulates that any agreements with Billers to submit Medi-Cal electronic billings shall be in conformance
with state law governing electronic claims submission, and shall contain provisions including, but not limited to, the
following:
a. The Provider shall specifically designate the Biller as the agent to the Provider for the purpose of preparation and
submission of Medi-Cal claims by the Biller. As the Provider's agent, the Biller agrees to comply with all Medi-Cal
requirements on recordmaking and retention as established by statute and regulation including, but not limited to,
Welfare and Institutions Code, Sections 14124.1 and 14124 and Title 22, California Code of Regulations,
Section 51476.
b. Electronic billing for services rendered to Medi-Cal beneficiaries shall be prepared by the Biller solely from information
supplied by the Provider. This information includes usual and customary charges for services rendered. A printed
representation of source documents as defined in Title 22, California Code of Regulations, Section 51502.1 shall be
kept, including all information transmitted as a claim by the Provider to the Biller electronically, or a period of at least
three years from the date of claims submission.
c.
If a department audit is initiated, the Billing Service shall retain all original records described in paragraphs 3.2, 5.0,
and 7.0(b) above until the audit is completed and every audit issue has been resolved, even if the retention period
extends beyond three years from the date of the service of termination of financial relationship or longer period
required by federal or state law.
DHCS 6153 (Rev. 03/12)
Page 3 of 4
d. The parties shall agree that the Department may accept electronic billings prepared, certified, and submitted by the
Biller on behalf of the Provider only as long as the agreement between the Provider and the Biller remains in
existence and in effect.
e. Both parties have a duty to notify the Department in writing immediately upon any change in or termination of their
agreement.
8.0
DECLARATION OF INTENT
This agreement is not intended as a limitation on the duties of the parties under the Medi-Cal Act, but rather as a means
of clarifying those duties as they relate to the Provider/Biller in its capacity as an authorized Provider/Biller for electronic
billing.
8.1
PROVIDER TO HOLD STATE OF CALIFORNIA HARMLESS
The Provider agrees to hold the State of California harmless for any and all failures to perform by billing services, billing
software, or other features of electronic billing which do not occur with (hard copy) paper billing. The Provider explicitly agrees
that the Provider is assuming any and all risks that accompany electronic billing and that the Provider is not relying upon the
evaluation, if any, that the State has made of the electronic billing system, software, or Biller the Provider is using.
Furthermore, the Provider acknowledges that if the electronic billing system, software, or Biller contracted with, is or has been
listed as available in Medi-Cal bulletins, that such listing was not an endorsement by the State of California nor does it imply
that the service, system, or software has met or is continuing to meet a standard of performance.
9.0
CONFIDENTIALITY OF RECORD
The Provider/Biller agrees to provide adequate precautions to protect the confidentiality of Medi-Cal beneficiary record
and claims submission methods in accordance with statute or regulations Title 17, CCR, Section 6800, et seq. and/or 42
CFR, Part 400 and 440, Subpart B.
PROVIDER SIGNATURE INFORMATION
Full printed name
Title
Provider signature (original signature required; DO NOT use black ink)
Date

BILLING SERVICE SIGNATURE INFORMATION (complete only if “Biller Information” is completed on page 1 of 4)
Full printed name
Title
Owner or Corporate Officer signature (original signature required; DO NOT use black ink)
Date

Return Application/Agreement to: ACS
CMC Unit
P.O. Box 15508
Sacramento, CA 95852-1508
Privacy Statement (Civil Code Section 1798 et seq.)
The information requested on this form is required by the Department of Health Care Services for purposes of identification and
document processing. Furnishing the information requested on this form is mandatory. Failure to provide the mandatory
information may result in your request being delayed or not be processed.
DHCS 6153 (Rev. 03/12)
Page 4 of 4