Medi-Cal Provider Enrollment
Health Center Enrollment
Health center sites enroll in the Medi-Cal program using the health center's National Provider Identifier (NPI) through the licensing process with the Centralized Applications Branch (CAB) of Licensing & Certification within the California Department of Public Health. For information on the Medi-Cal certification process for licensed and/or intermittent clinics, please visit our Licensing & Certification page.
Individual Enrollment
Individuals attached to health center sites must be individually enrolled into the Medi-Cal program as well. Federally Qualified Health Center (FQHC) providers need to be individually enrolled if:
- They order, refer, or prescribe on behalf of the FQHC and/or
- They provide in-patient services billed by the FQHC (Clinic-Based Physician)
Both enrollment types are available through Medi-Cal's electronic Provider Application and Validation for Enrollment (PAVE).
ORP Enrollment: For individuals who are simply ordering, referring, and/or prescribing on behalf of the FQHC, the ORP enrollment type is appropriate.
Clinic-Based Physician: Some FQHCs will choose to bill Fee-for-Service (outside of PPS) for inpatient services provided by an FQHC provider (OB services in a hospital are one example of this). In this case, or in similar scenarios where claims will be billed under the individual provider's NPI rather than the FQHC's, the individual can opt for the clinic-based provider application rather than the ORP enrollment.
If FQHCs do not individually enroll their providers, when they refer their patients to someone like a specialist, the specialist will not get paid which could cause the specialist to stop accepting referrals from the health center. The same with pharmacy - if the health center does not individually enroll their providers, the patient may not get their prescriptions filled, etc. Ultimately Medi-Cal also plans to deny claims that do not list a validly enrolled provider, though no date has been set for that level of enforcement.
For more information, visit the Department of Health Care Services Provider Enrollment Division (PED) webpage. To contact PED, please use their online Inquiry Form.
Medicare Provider Enrollment
FQHCs are required to enroll as Medicare providers. Once a new FQHC site is added into the HRSA Scope of Project, HRSA will send the site's information to CMS and the Medicare electronic enrollment system, PECOS, will be pre-populated with the site's information. From there, the health center will work within PECOS to complete the enrollment.
CMS Webinar on Medicare Enrollment (4/24/2019): This CMS webinar describes the process for Medicare enrollment. Download the webinar slides.
Definitions
National Provider Identifier (NPI): A 10-digit standard unique identifier for health care providers. The NPI replaces any health care provider identifiers in use today, including the nine-digit Medi-Cal provider number. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 required a standard unique identifier for all health care providers for use in the nationwide health care system- the NPI.
National Plan and Provider Enumeration System (NPPES): Developed by the Centers for Medicare & Medicaid Services (CMS) in compliance with the HIPAA requirement, the National Plan and Provider Enumeration System (NPPES) is the CMS-sponsored data repository for NPI-related information. NPPES processes new applications and updates and generates NPIs.
NPI Enumerator: A CMS-contracted vendor that performs provider registration and enumeration processing using the NPPES. The Enumerator enters data from paper applications, resolves problems, and answers questions related to NPI and the registration process. Once the data processing is completed, the Enumerator will notify providers of their assigned NPI.
Contact
For questions regarding provider enrollment, please contact Mahnoor Khan, Associate Director of Legal & Regulatory Affairs, at mkhan@cpca.org.