Fillable Form 1: Medi-Cal Point of Service (POS) Network/Internet (California)

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Form 1: Medi-Cal Point of Service (POS) Network/Internet (California)

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Medi-Cal Point of Service (POS) Network/Internet
Agreement
Page updated: August 2020
This agreement is required for all providers and non-providers (provider representatives)
who intend to use the Medi-Cal POS Network or Medi-Cal website applications at
www.medi-cal.ca.gov.
I.
(a) The following is required only for enrolled Medi-Cal providers: The Department of
Health Care Services (DHCS) will permit the use of the California POS Network and
Medi-Cal website by the following Medi-Cal provider subject to the terms and
conditions of this agreement.
Provider Name: _______________________________
Provider Number/NPI: __________________________
Owner Number: _______________________________ (If applicable)
Tax ID: ________________________
(b) The following is required only if intending to use software that is not obtained through
Medi-Cal:
Vendor/Developer Company Name: ______________________________________
CMC Submitter Number (if applicable): ___ ___ ___
Contact Person: _________________________________
Phone Number: (___ ___ ___) ___ ___ ___ ___ ___ ___ ___
(c) The following is required only for non-provider users [provider representatives] of the
POS Network/Medi-Cal website: DHCS will permit the use of the Medi-Cal POS
Network and/or Medi-Cal website by the authorized provider representative
_____________________________________ (Representative) subject to the terms
of this agreement. When applicable, please attach to this agreement a list of all
provider numbers/NPIs and corresponding Tax Identification Numbers (TINs) for
which the non-provider user is also the authorized representative.
(d) Provider/Representative is requesting to delete access and usage of the POS
Network and/or Medi-Cal website to the following provider representative
_____________________________________ (Representative) subject to the terms
of this agreement. When applicable, please attach to this agreement a list of all
provider numbers/NPIs and corresponding TINs for deletion.
Part 1 – Medi-Cal Point of Service (POS) Network/Internet Agreement (PRO Pubs)
2
Page updated: August 2020
II. Provider/Representative agrees to limit the usage of the POS Network and Medi-Cal
website to the following Medi-Cal eligibility and claims-related transactions:
A. Verification of Medi-Cal eligibility
B. Share of Cost (Spend Down) clearance
C. Medi-Service reservations
D. Submission of Pharmacy claims (may only be performed by providers enrolled to
submit claims on the Pharmacy/Medical Supplies Claim Form): applies to Medi-Cal
website only
E. Submission of ANSI ASC X12N 837 professional claims (may only be performed by
providers enrolled to submit claims on the Medi-Cal Medical Services claim form):
applies to Medi-Cal website only
F. Submission of electronic Treatment Authorization Requests (i.e. eTAR and
Pharmacy NCPDP)
G. Submission of other transactions as may be subsequently permitted by DHCS and
as documented in one or more of the user manuals in the Publications area of the
Medi-Cal website
H. Browsing of Medi-Cal website
Provider/Representative acknowledges that failure to limit the usage of the POS Network
and/or Medi-Cal website to the transactions described above may, at a minimum, result
in DHCS revoking the privilege to use the POS Network and/or Medi-Cal website.
Provider/Representative acknowledges abuse of transactions available on the Medi-Cal
website may result in DHCS revoking provider access to Medi-Cal website.
III. The Provider/Representative agrees that the following constitutes the only authorized
methods of accessing the POS Network:
A. Provider- or Representative-provided leased phone lines
IV. Any computer accessing the Medi-Cal website is required to abide by all applicable State
and Federal laws enacted today or in the future.
Part 1 – Medi-Cal Point of Service (POS) Network/Internet Agreement (PRO Pubs)
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Page updated: August 2020
V. The Provider/Representative agrees to the following security requirements. All
computers that access Medi-Cal data must meet the following requirements, in addition
to any State and Federal required administrative, technical, physical, and organizational
safeguards:
A. Antivirus software. All workstations, laptops and other systems that access the
Medi-Cal website or process and/or store Medi-Cal Protected Health Information
(PHI) must install and actively use comprehensive anti-virus software solution with
automatic updates scheduled at least daily.
B. Patch Management. All workstations, laptops and other systems that access the
Medi-Cal Web site or process and/or store Medi-Cal PHI must have critical security
patches applied, with system reboot if necessary. There must be a documented
patch management process, which determines installation timeframe based on risk
assessment and vendor recommendations. At a maximum, all applicable patches
must be installed within 30 days of vendor release.
C. System Timeout. The systems that access the Medi-Cal website or process and/or
store Medi-Cal PHI must provide an automatic timeout, requiring re-authentication
of the user session. It is recommended that the automatic timeout be after no more
than 20 minutes of inactivity.
D. User Name and Password Controls. Systems that access the Medi-Cal website or
process and/or store Medi-Cal PHI should be accessed using a unique user name
and password combination. The user name must be promptly disabled, deleted, or
the password changed upon the transfer or termination of an employee with
knowledge of the password. Passwords are not to be shared. Passwords must be:
(1) At least eight characters, (2) A non-dictionary word, (3) Not be stored in
readable format on the computer, (4) Be changed every 90 days, preferably 60
days, (5) Be changed if revealed or compromised, and (6) Be composed of
characters from at least three of the following four groups from the standard
keyboard:
• Upper case letters (A-Z)
• Lower case letters (a-z)
• Arabic numerals (0-9)
• Non-alphanumeric characters (punctuation symbols)
E. Workstation/Laptop encryption. All workstations and laptops that access the Medi-
Cal website or process and/or store Medi-Cal PHI are recommended to be
encrypted using a FIPS 140-2 certified algorithm, which is 128-bit or higher, such
as Advanced Encryption Standard (AES); full disk encryption is recommended.
Part 1 – Medi-Cal Point of Service (POS) Network/Internet Agreement (PRO Pubs)
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Page updated: August 2020
VI. The Provider/Representative agrees to pay the following fees associated with the use of
the POS Network:
A. For eligibility transactions, including Share of Cost clearance and Medi-Service
reservations submitted through Medi-Cal-provided phone lines, there will be no
transaction fee.
B. For Provider and/or Representative submission of pharmacy claims transactions
through Medi-Cal-provided phone lines, there will be a fee of $ .10 per approved
claim transaction. An approved claim transaction is defined as a service, medical
supply, durable medical equipment or drug supply that is determined to be payable
through the claims adjudication process of the POS Network. This fee will be
withheld from your regular Medi-Cal claims payment.
C. Any claim and/or eligibility transaction submitted on the Medi-Cal website will not
have a transaction fee.
VII. Provider/Representative agrees, in order for the Provider/Representative’s system to be
activated for submission of actual Medi-Cal eligibility or claims-related transactions, to
perform testing as required by DHCS and as documented in the POS Network Interface
Specifications document or Medi-Cal website documents. Provider/Representative
acknowledges that multiple tests may be required to activate the full functionality
software/application and that all testing must be successfully concluded before the
software/application will be activated.
VIII. Provider/Representative agrees to report all malfunctions of the POS Network or Medi-
Cal website to California MMIS Fiscal Intermediary at the phone number and/or address
listed below.
IX. Provider/Representative acknowledges that neither DHCS nor its agent is responsible for
errors or problems, including problems of incompatibility, caused by hardware or software
not provided by DHCS.
Part 1 – Medi-Cal Point of Service (POS) Network/Internet Agreement (PRO Pubs)
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___________________________
___________________________
5
Page updated: August 2020
X. Provider or Non-Provider (Authorized Representative) Signature:
I, the undersigned, am authorized and do attest and agree to all of the terms and conditions
of this agreement.
Printed Name of Signee: _____________________________________
Authorized Signature: _______________________________________
Title: ____________________________________________________
Date: ___________________________________
Address: ___________________________
CMC Submitter Number (if applicable): ___ ___ ___
Please mail this completed form to:
California MMIS Fiscal Intermediary
Attn: POS/Internet Help Desk
820 Stillwater Rd
West Sacramento, CA 95605
1-800-541-5555
Part 1 – Medi-Cal Point of Service (POS) Network/Internet Agreement (PRO Pubs)
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Form 1: Medi-Cal Point of Service (POS) NetworkInternet (California)

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Completed 30 June 2021

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