Medi-Cal Certification Process

The below information establishes the departmental procedures to control and monitor the Medi-Cal certification process for a contract provider who has a valid contract with the department and has requested certification. Certification allows the provider and subsequently the department to bill the State Department of Mental Health for Medi-Cal services. The certification process will normally be twenty-two (21) to thirty-one (31) days in duration.

Please follow the DBH certification process as outlined below before submitting a Medi-Cal application.

SC/MC provider certification is required for all providers as defined below:
Medi-Cal Site Certification Policy (QM6002)
Medi-Cal Site Certification Procedure (QM6002-1)
Detailed Certification Process

Contract Providers must contact the Department’s Contracts Administration Unit at (909) 387-7747 to request a valid contract prior to requesting Medi-Cal Certification. Fire safety requirements apply to all sites (including satellites) owned, leased or operated by a legal entity.

The following forms shall be completed by the responsible program manager or contract agency director and sent to the Regional Program Manager for forwarding to the State.

State of California – Medi-Cal Certification Packet

The Medi-Cal Certification Packet includes:

  • New Short-Doyle/Medi-Cal Provider Certification Application
  • Short-Doyle/Medi-Cal Program Provider Agreement Claim Certification
  • Medi-Cal Provider Data Form
  • Medi-Cal Provider Disclosure Statement of Significant Beneficial Interests

The following forms will also be required:

  • Mode of Service (BOP024) – Required to have procedure codes verified and established.
  • W-9 Form – Required to have a vendor number assigned.
  • Reporting Unit Setup Form (QM073) – Required to have provider established in InSyst (Simon) system.
  • Request for Cost Center Number (BOP023) – Fiscal will perform a final review of the cost center request form and notify the RPM should discrepancies exist for data correction prior to continuing the process.

A completed Provider Certification Packet includes all of the items above including the Letter of Intent and Fire-Clearance.
Below is the protocol followed by the DBH certification team during the on-site inspection.
SD/MC Certification Protocol