California Welfare and Institutions Code 14042 – Each contract for fiscal intermediary services shall provide for an …
Each contract for fiscal intermediary services shall provide for an automated system for verifying the eligibility of Medi-Cal recipients. The automated eligibility verification system shall provide the health care provider with a unique method of identifying the eligibility of the beneficiary. The provider shall include the eligibility identifier on the claim for payment. Where a recipient’s eligibility has been verified by the automated system and the provider provides a unique identifier on the claim form, the director may not require any label, card impression, or any other evidence to establish the recipient’s eligibility. The automated system for eligibility verification shall provide for the continuous updating of recipient eligibility determination.
The department shall periodically test the automated system for verifying recipient eligibility for completeness and accuracy, and report the findings of such testing to the Legislature. Unless and until the automated system for verifying recipient eligibility is accurate in at least 97 percent of the cases tested, the director shall provide for the issuance of proof-of-eligibility labels, or identity cards from which an identifying impression may be taken, or other evidence of eligibility to be used as a secondary recipient eligibility verification system. Notwithstanding the inability to provide verification of a recipient’s eligibility through use of the automated system for eligibility verification, presentation of a claim for service with evidence of recipient eligibility as is provided for by the secondary system shall conclusively establish the recipient’s eligibility.
Terms Used In California Welfare and Institutions Code 14042
- Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
- Contract: A legal written agreement that becomes binding when signed.
- department: means the State Department of Health Services. See California Welfare and Institutions Code 14062
- director: means the State Director of Health Services. See California Welfare and Institutions Code 14061
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Medi-Cal: means the California Medical Assistance Program. See California Welfare and Institutions Code 14063
On-line access shall be available to providers, at their discretion, upon the payment of a reasonable fee. The department shall establish the amount of the fees charged to providers for on-line access, which shall be based upon the costs of providing on-line access to providers.
(Added by Stats. 1982, Ch. 1508, Sec. 1.)