New Provider Enrollment Forms Requirement Effective May 23, 2007

Due to the National Provider Identifier (NPI) requirements, as of May 23, 2007, applicants must use the current versions of the Medi-Cal provider application forms. Current versions of the application forms show a revision date of March 2007 (3/07) at the bottom of the pages and, beginning May 23, 2007, previous versions will no longer be accepted. One of the most common reasons for an application being denied is that the application is not a current version or not a correct application for the provider type.

The following reminders are provided to assist with general provider enrollment issues.

Pay-To Address Changes: Correct Form Use
When reporting a change to your pay-to address, please note that the “Pay-To” Address Change Notification (DHCS 6129) form is for institutional provider use only. Only Inpatient, Outpatient and Long Term Care providers are considered Institutional providers. If you are not an institutional provider, you must use a Medi-Cal Supplemental Changes (DHS 6209) form to report a change to your pay-to address and/or your mailing address.

Business Address Changes
The W & I Code, Section 14043.26(a) states, in relevant part, that “…a provider not currently enrolled at a location where the provider intends to provide services, goods, supplies, or merchandise to a Medi-Cal beneficiary, shall submit a complete application package for enrollment…at a new location or a change in location.”

General Reporting of Changes to Your Medi-Cal Provider Record
It is the provider's responsibility to report to the California Department of Health Care Services (DHCS) any modifications to information previously submitted within 35 days of the change. If submitting additional changes to your Medi-Cal record (for example, a new taxpayer identification number, name change or change of ownership), the submission of a new application package is required, pursuant to CCR, Title 22, Sections 51000.30 and 51000.31. When submitting a change to your Medi-Cal record, you can obtain the application package from the Application Forms section of this Web page or by calling the Telephone Service Center (TSC) at 1-800-541-5555.

If you are no longer providing Medi-Cal services, you should submit a Medi-Cal Supplemental Changes (DHCS 6209) form to deactivate your provider number. This will minimize the risk of someone fraudulently using your provider number.

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