New Contracted Providers Require Enrollment
Effective January 1, 2018, CenCal Health is required by federal law to ensure all new contracted providers are enrolled in the Department of Health Care Services (DHCS) Medi-Cal Program. Providers who enroll through DHCS are eligible to provide services to Medi-Cal Fee for Service (FFS) beneficiaries as well as CenCal Health Medi-Cal beneficiaries.
To verify enrollment with State Medi-Cal, you may search the Department of Health Care Services’ (DHCS) database via one or both of the links below (Enter your National Provider Identifier (NPI) in the search field).
Already enrolled?
- Search enrolled Medi-Cal providers here.
- Select “preview” on the CSV line.
- Enter your National Provider Identifier (NPI) in the search field and send us a screen capture that clearly shows your name, NPI, and enrollment effective date.
Not enrolled?
The State’s PAVE portal is a web-based application designed to simplify and accelerate the State Medi-Cal enrollment process. Providers must utilize the portal to complete and submit applications, report changes to existing enrollments, and respond to requests for continued enrollment or re-validation. Please be sure to maintain current and accurate information about yourself and/or your group, as data submitted through PAVE comprises the database DHCS uses to understand the network of Medi-Cal providers in California. This is important even if you only see CenCal Health members and never submit claims for Fee-For-Service members.
Once your application for enrollment is complete, send us a screen capture from your My Applications page that clearly shows your:
-
- NPI
- Name
- Application status
Note: If you are submitting a screen capture of your enrollment status from one of these two sources, please include as much of the page as possible, so that we can identify the source of the data.
DHCS allows providers to participate in CenCal Health’s network for 120 days while applications are under review.
At the end of that 120-day period, if the application is not yet approved or it has been denied, DHCS requires CenCal Health to remove the provider from our network until their currently-under-review application is approved, or a second application can be submitted and approved.
If you have any questions about enrollment requirements, please contact CenCal Health’s Quality Liaison at abutler@cencalhealth.org and our team will assist you with the enrollment process.
Medi-Cal Enrollment Requirements
Medi-Cal Enrollment FAQ for Newly Onboarding Providers
1. What is the source of this requirement?
Answer: This requirement is the result of the California Department of Health Care Services (DHCS) coming into compliance with federal regulations designed to reduce the incidence of fraud and abuse by ensuring that providers are individually identified and screened for licensure and certification. CMS-6028-FC enhanced the enrollment and screening processes for Medicaid Fee-For-Service providers pursuant to the Affordable Care Act.
2. How is credentialing different from enrollment?
Answer: In November of 2017, DHCS published new requirements for MCPs in line with the CMS requirements above. These new requirements (CMS & DHCS) make it clear that credentialing and screening/enrollment are two completely separate processes, and both are required. We are hearing many different terms being used interchangeably and understand that terminology is one of the most challenging aspects of this requirement. Consider these definitions:
Credentialing is the process of verifying that providers have the education, training, and licensure/certification to deem them qualified to provide covered medical services to our members. It also includes monitoring for various occurrences that may indicate a potential risk of harm to our members, such as disciplinary actions against a license or serious/excessive malpractice suits. The credentialing process CenCal Health has followed for many years already meets DHCS requirements and is not changed by the requirements for Medi-Cal enrollment.
Enrollment is the process to identify providers who are providing covered medical services to our members and ensure they understand the requirements of being a Medi-Cal provider. It also includes the processes designed to limit the potential for fraud and abuse, such as risk-based screening requirements, and disclosure of ownership and control of practices and entities who submit claims for medical services rendered to Medi-Cal members.
3. What is the screening process?
Answer: The screening process is also designed to limit the potential for fraud and abuse in the Medi-Cal system. Providers are deemed limited, moderate, or high risk based on provider type. Most providers are in the limited risk category, and that screening process is already accomplished through routine credentialing (such as verifying a medical license and that a provider has not been excluded from any State or Federal programs). Screening for moderate and high risk providers may include site visits, fingerprinting, and background checks. DHCS is retaining responsibility for screening of moderate and high risk providers. The screening requirements have been in place for years and are not changed by the requirements for Medi-Cal enrollment.
4. Which providers must enroll and what is the deadline to complete the enrollment process?
Answer: Effective January 1, 2018, all providers who render medical services to Medi-Cal members are required to enroll, with the exception of providers with no enrollment pathway such as registered dieticians and ABA providers
5. I’m not sure whether I’m enrolled – how can I find out?
Answer: DHCS has made an “Open Data Portal” available that can be searched using NPI (preferred) or other identifiers, such as name. These lists are refreshed monthly despite the date in the links. But, don’t try to download them, they are very large files! Most provider types can search the list at the link below (enter the NPI in the search field on the Data Table):
6. How do I begin the enrollment process?
Answer: DHCS’s Provider Enrollment Division (PED) has worked to expand the online enrollment process to most provider types. We recommend this method which can be accessed at the following link:
PAVE – Provider Application and Validation for Enrollment
7. Can CenCal Health help me enroll with DHCS?
Answer: Unfortunately, we have no control over the DHCS enrollment process and are only able to offer information and links to DHCS’s online resources.
8. What if I still have questions, or need guidance for more complicated or unique situations?
Answer: CenCal Health is here to help! Some of our core values include commitment to the community and collaboration with our provider partners, and we take that very seriously. We appreciate our providers and our goal is to assist you in this process. Please reach out to our Quality Liaison Specialist at providerservices@cencalhealth.org with any questions.