Fillable CHDP TELECOMMUNICATIONS PROVIDER AND BILLER APPLICATION/AGREEMENT 1.0 Identification (Department of Health Care Services)

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CHDP TELECOMMUNICATIONS PROVIDER AND BILLER APPLICATION/AGREEMENT 1.0 Identification (Department of Health Care Services)

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State of California-Health and Human Services Agency Department of Health Care Services
DHCS 4431 (rev. 2/12) Page 1 of 4
CHDP TELECOMMUNICATIONS PROVIDER AND BILLER APPLICATION/AGREEMENT
(For electronic claim submission)
1.0 Identification of Parties
This agreement is between the State of California, Department of Health Care Services, hereinafter referred to as the
“Department,” and:
Provider Information
Provider name (full legal)
Last 4 digits of Tax Identification Number or Social
Security Number
DBA (if applicable)
Provider number
Provider service address (number, street)
City
State
ZIP code
Contact person
Contact person address (number, street)
City
State
ZIP code
Contact phone number
( )
Currently assigned submitter number (otherwise, leave blank to be assigned a new submitter number)
Biller Information (If other than the provider of service)
Biller name (full legal)
DBA (if applicable)
Biller phone number
( )
Biller address (number, street)
City
State
ZIP code
Contact person
Currently assigned submitter number (otherwise, leave blank to be assigned a new submitter number)
Full legal name(s) required as well as any assumed (DBA) name(s), address(es), and provider number(s). The
parties identified above will be hereinafter referred to as the “Provider” and/or “Biller.”
Privacy Statement (Civil Code Section 1798 et seq.)
The information requested on this form is required by the Department of Health Care Services for purposes of
identification and document processing. Furnishing the information requested on this form is mandatory. Failure to
provide the mandatory information may result in your request being delayed or not be processed.
Submission type:
CMC Telecommunications Magnetic tape Internet
1.1 CHDP Claim Type Will Be Submitted Electronically
1.2 Background Information
The Provider/Biller agrees to provide the Department with the above information requested in order to verify
qualifications to act as a CHDP electronic Biller or to report CHDP services for information only.
2.0 Definitions
The terms used in this agreement shall have their ordinary meaning, except those terms defined in regulations,
Title 17, California Code of Regulations (CCR), Section 6800, et seq. and/or 42 CFR, Part 400 and 440, Subpart B.
All terms and conditions of Title 17, CCR, Section 6800, et seq. and 42 CFR, Part 400 and 440, Part B, shall have
the meaning ascribed to them by that regulation as from time to time amended. The term “electronic,” or
“electronically,” when used to describe a form of claims submission, shall mean any claim services or CHDP patient
eligibility information, submitted through any electronic means, such as magnetic tape, or modem communications.
3.0 Claims Acceptance and Processing
The Department agrees to accept from the enrolled Provider/Biller, electronic claims submitted to the CHDP program
fiscal intermediary in accordance with the CHDP program provider manual. The Provider hereby acknowledges that
he has received, read, and understands the provider manual and its contents, and agrees to read and comply with all
provider manual updates and provider bulletins relating to electronic billing and/or reporting.
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State of California-Health and Human Services Agency Department of Health Care Services
DHCS 4431 (rev. 2/12) Page 2 of 4
3.1 Claims Certification
The Provider agrees and shall certify under penalty of perjury that all claims for services submitted electronically have
been personally provided to the patient by the Provider or, under his direction, by another person eligible under the
CHDP program to provide such services, and such person(s) are designated on the claim. The services were,
to the best of the Provider’s knowledge, medically indicated and necessary to the health of the patient. The Provider
shall also certify that all information submitted electronically is accurate and complete. The Provider understands that
any payments for claims will be from federal and/or state funds, and that any falsification or concealment of a
material fact may be prosecuted under federal and/or state laws. The Provider/Biller agrees to keep for a minimum
period of three years from the date of service an electronic archive of all records necessary to fully disclose the
extent of services furnished to the patient. A printed representation of those records shall be produced upon request
of the Department during that period of time. The Provider/Biller agrees to furnish these records and any information
regarding payments claimed for providing the services, on request, within the State of California to the California
Department of Health Care Services; California Department of Justice; Office of the State Controller; U.S.
Department of Health and Human Services; or their duly authorized representatives. The Provider also agrees that
medical care services are offered and provided without discrimination based on race, religion, color, national or
ethnic origin, sex, age, or physical or mental disability. The Provider/Biller agrees to include with each electronic
claims submission, submitted through the batch CMC system, a certification statement, which shall certify to the
following:
I submit these claims under penalty of perjury in accordance with the terms and conditions of the
Department of Health Care Services’ CHDP Telecommunications Provider and Biller
Application/Agreement form (DHCS 4431), paragraph 3.
3.2 Verification of Claims With Source Documents
Regardless of whether the Provider employs a Biller, the Provider agrees to retain personal responsibility for the
development, transcription, data entry, and transmittal of all claim information for payment. This includes usual and
customary charges for services rendered. The Provider shall also assume personal responsibility for verification of
submitted claims with source documents including the original CHDP Pre-enrollment Application (DHCS 4073)
signed by the parent/guardian, when applicable. The Provider/Biller agrees that no claim shall be submitted until the
required source documentation is completed and made readily retrievable in accordance with CHDP program
statutes and regulations. Failure to make, maintain, or produce source documents shall be cause for immediate
suspension of electronic billing privileges.
3.3 Accuracy and Correction of Claims or Payments
The Provider agrees to be responsible for the review and verification of the accuracy of claims payment information
promptly upon the receipt of any payment. The Provider agrees to seek correction of any claim errors through the
appropriate processes as designated by the Department or its fiscal intermediary including, but not limited to, the
process set out in Title 17, California Code of Regulations, Section 3800, et seq. and/or 42 CFR, Part 400 and 440,
Subpart B, and as from time to time amended. The Provider/Biller acknowledges that anyone who misrepresents or
falsifies or causes to be misrepresented (or falsified) any records or other information relating to that claim may be
subject to legal action, including, but not limited to, criminal prosecution, action for civil money penalties,
administrative action to recover the funds, and decertification of the Provider/Biller from participation in the CHDP
program and/or electronic billing.
3.4 Provider Responsibility
The Provider agrees, regardless of whether the Provider employs a Biller, to assume personal responsibility for, and
ensure that:
a. The county CHDP Office shall be sent a facsimile or an original CHDP claim for each CHDP visit, or the county
CHDP Office shall be sent a printed source document that contains all of the CHDP claim data elements billed
and/or reported to the CHDP program.
b. The patient’s parent or guardian shall be given a facsimile or an original CHDP claim form for each CHDP visit,
or the parent or guardian shall be given a printed source document that contains all of the CHDP claim data
elements billed and/or reported to the CHDP program.
4.0 Change in Electronic Billing Status
The Provider/Biller and the Department agree that any changes in Provider/Biller status, which might affect eligibility
to participate in electronic billing pursuant to federal and state law, shall be promptly communicated to each party.
5.0 Provider/Biller Reviews
The Provider/Biller agrees that agents of the Department, the Office of the State Controller, the Department of
Justice, or any other authorized agent or representative of the State of California, or any authorized representative of
the U.S. Department of Health and Human Services may, from time to time, conduct such reviews as are necessary
State of California-Health and Human Services Agency Department of Health Care Services
DHCS 4431 (rev. 2/12) Page 3 of 4
to ensure compliance with state and federal law and with this agreement. In particular, the Provider/Biller agrees to
make available to such agent or representative all source documents necessary to verify the accuracy and
completeness of claims submitted electronically.
5.1 Nonexclusive Reviews
The Provider/Biller agrees that the review set out in paragraph 5.0 above is not exclusive but supplements any other
form of audit or review the Provider/Biller may be subject to due to its status as a certified Provider/Biller of services
under the CHDP or EPSDT programs.
6.0 Effective Date
This agreement shall become effective upon approval of the Department.
6.1 Termination
The Department or Provider may terminate this agreement with or without cause by giving 30 days prior written
notice of intent to terminate, and the Provider has no right to appeal such termination by the Department. The
Department may, however, terminate this agreement immediately, pursuant to paragraph 6.2, upon determination
that the Provider/Biller has failed or refused to produce or retain source documents in accordance with federal and
state law or this agreement.
6.2 Termination for Cause
If the Provider/Biller is unable to produce source documents on request pursuant to paragraph 5.0, the Department
may terminate this agreement immediately by directing its fiscal intermediary to cease payment of any and all
electronic claims submitted by the Provider/Biller, including any claims in process on the date of such termination.
Provider/Biller has no right to appeal termination for cause pursuant to this subpart prior to the effective date of such
termination. The Provider/Biller may appeal any grievance resulting from the termination in accordance with the
procedure established by Title 22, California Code of Regulations, Section 51015, as from time to time amended.
The Department may demand repayment of claims for which no source documents are produced, and the
Provider/Biller shall have a right to appeal of such an overpayment finding to the extent provided by Section 14171 of
the Welfare and Institutions Code and regulations promulgated pursuant thereto, and as from time to time amended.
6.3 Effect of Termination and Appeal
On termination pursuant to paragraph 6.1 or 6.2, the Provider/Biller may submit hard copy claims.
7.0 Agreement Between Provider and Biller (If Other Than the Provider of Service)
The Provider stipulates that any agreements with Billers to submit CHDP program electronic billings shall be in
conformance with state law governing electronic claims submission, and shall contain provisions including, but not
limited to, the following:
a. The Provider shall specifically designate the Biller as the agent to the Provider for the purpose of preparation
and submission of CHDP program claims by the Biller. As the Provider’s agent, the Biller agrees to comply
with CHDP program requirements, including EPSDT requirements, as established by statutes and regulations.
b. Electronic billing and/or reporting for services rendered to CHDP beneficiaries shall be prepared by the Biller
solely from information supplied by the Provider. This information includes usual and customary charges for
services rendered. A printed representation of source documents as defined in Title 17, California Code of
Regulations, Section 6800, et seq. and/or 42 CFR, Part 400 and 440, Subpart B, and copies of the CHDP
Eligibility Information forms shall be kept, including all information transmitted as a claim by the Provider to the
Biller electronically, for a period of at least three years from the date of claims submission.
c. If a Department audit is initiated, the Billing Service shall retain all original records described in paragraphs 3.2,
5.0, and 7.0(b) above, until the audit is completed and every audit issue has been resolved, even if the retention
period extends beyond three years from the date of the service of termination of financial relationship or longer
period required by federal or state law.
d. The parties shall agree that the Department may accept electronic billings prepared, certified, and submitted by
the Biller on behalf of the Provider only as long as the agreement between the Provider and the Biller remains in
existence and in effect.
e. Both parties have a duty to notify the Department in writing immediately upon any change in or termination of
their agreement.
State of California-Health and Human Services Agency Department of Health Care Services
DHCS 4431 (rev. 2/12) Page 4 of 4
8.0 Declaration of Intent
This agreement is not intended as a limitation on the duties of the parties under the EPSDT requirements, but rather
as a means of clarifying those duties as they relate to the Provider/Biller in its capacity as an authorized
Provider/Biller for electronic billing.
8.1 Provider to Hold State of California Harmless
The Provider agrees to hold the State of California harmless for any and all failures to perform by billing services,
billing software, or other features of electronic billing which do not occur with (hard copy) paper billing. The Provider
explicitly agrees that the Provider is assuming any and all risks that accompany electronic billing and that the
Provider is not relying upon the evaluation, if any, that the State has made of the electronic billing system, software,
or Biller the Provider is using. Furthermore, the Provider acknowledges that if the electronic billing system, software,
or Biller contracted with, is or has been listed as available in CHDP program publications, that such listing was not an
endorsement by the State of California nor does it imply that the service, system, or software has met or is continuing
to meet a standard of performance.
9.0 Confidentiality of Records
The Biller agrees to provide adequate precautions to protect the confidentiality of CHDP program beneficiary records
and claims submission methods in accordance with statutes or regulations, Title 17, CCR, Section 6800, et seq.
and/or 42 CFR, Part 400 and 440, Subpart B.
Provider Signature Information
Full printed name Title
Provider signature (original signature required; DO NOT use black ink) Date
B illing Service S ignature Information (complete only if “B iller Information” is completed on page 1 of 4)
Full printed name Title
Owner or corporate officer signature (original signature required; DO NOT use black ink) Date
Return application/agreement to:
CMC Unit
P.O. Box 15508
Sacramento, CA 95825-1508
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CHDP TELECOMMUNICATIONS PROVIDER AND BILLER APPLICATIONAGREEMENT 1.0 Identification (Department of Health Care Services)

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Completed 23 November 2020

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