DHCS 6153 (Rev.03/17) Page 2 of 4
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 Medi-Cal electronic Biller.
The terms used in this agreement shall have their ordinary meaning, except those terms defined in regulations, Title 22,
California Code of Regulations, Section 51502.1, 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 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 Medi-Cal fiscal
intermediary in accordance with the Medi-Cal provider manuals. 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.
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
Medi-Cal Program to provide to 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 payment of
these 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 HealthCare 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 that using his Medi-Cal Submitter ID plus DHCS-issued password when submitting an electronic
claim will identify the submitter and shall serve as acceptance to the terms and conditions of the Department’s
Telecommunications Provider and Biller Application/Agreement (DHCS 6153), paragraph 3.0. The Provider/Biller further
acknowledges the necessity of maintaining the privacy of the DHCS-issued password and agrees to bear full
responsibility for use or misuse of the Medi-Cal Submitter ID and password should privacy not be maintained.
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. The Provider/Biller agrees that no claim shall be submitted until the required
source documentation is completed and made readily retrievable in accordance with Medi-Cal statutes and regulations.
Failure to make, maintain, or produce source documents shall be cause for immediate suspension of electronic billing
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 22, California Code of Regulations, Section 51015 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 Medi-Cal program and/or electronic billing.
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.