Medi-Cal: providers: remedies.

(1) Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which basic health care services are provided to qualified low-income persons. Existing law requires that health care providers apply to, and be certified by, the department prior to their participation in the Medi-Cal program. Existing law allows the department, if specified conditions are met, to grant provisional provider status or preferred provisional provider status to an applicant or provider, and requires the department to terminate that status if any of specified grounds exist. Existing law provides that, if an application for provisional provider status or preferred provisional provider status is denied under specified provisions, or that status is terminated under the provisions described above, the applicant or provider is prohibited from reapplying for enrollment or continued enrollment in the Medi-Cal program or for participation in any health care program administered by the department for a period of 3 years from the date the application package is denied or the provisional provider status is terminated, or from the date of the final decision following an appeal from that denial or termination, except as specified. Existing law provides that, if an application for provisional provider status or preferred provisional provider status is denied based upon a conviction for specified offenses or acts, the applicant or provider is prohibited from reapplying for enrollment or continued enrollment in the Medi-Cal program or for participation in any health care program administered by the department for a period of 10 years from the date the application package is denied or the provisional provider status or preferred provisional provider status is terminated, or from the date of the final decision following an appeal from that denial or termination. This bill would delete the provisions that provide that the 3-year and 10-year prohibitions may begin from the date of the final decision following an appeal from that denial or termination. (2) Existing law requires the Director of Health Care Services to adopt procedures for the review of grievances or complaints filed by Medi-Cal service providers concerning the processing or payment of money that the provider alleges is payable under the Medi-Cal program. A provider who complies with these procedures and is not satisfied with the director's decision regarding that claim may seek appropriate judicial remedies within a specified time period. This bill would, instead, specify that the provider who has complied with these procedures may, within the time period prescribed in existing law, seek a writ of mandate. (3) This bill would incorporate additional changes in Section 14043.28 of the Welfare and Institutions Code proposed by AB 1540, that would become operative only if AB 1540 and this bill are both chaptered and become effective on or before January 1, 2010, and this bill is chaptered last.