Provider Credentialing Steps in Medi-Cal

Provider Credentialing Steps in Medi-Cal

Provider credentialing is a process by which a healthcare provider is verified to ensure they meet the necessary requirements to provide healthcare services to patients. It is important to note that the credentialing process may take several months, so it is best to start the process early. The provider credentialing steps in Medi-Cal are as follows:

1. Complete the Provider Enrollment Application

In California, the Provider Enrollment Application is the process by which healthcare providers can enroll in the state’s Medicaid program, known as Medi-Cal. The enrollment process ensures that providers meet the state’s qualifications for participation and establishes a provider’s ability to receive payment for services rendered to Medi-Cal beneficiaries. The Provider Enrollment Application process is managed by the California Department of Health Care Services (DHCS) and is designed to be completed online through the Medi-Cal website. The application is used for both initial enrollment and re-enrollment, and the requirements and documentation needed vary depending on the type of provider.

To begin the enrollment process, providers must first register for a Medi-Cal provider number. This number is used to identify the provider and is required to submit claims for payment. Once registered, providers can begin the enrollment process by completing the online application and providing all necessary supporting documentation. The application requires information about the provider’s identity, practice location, medical specialties, and services offered, as well as information about the provider’s billing practices and compliance with state and federal regulations. Additionally, the provider must submit documentation such as licenses, certifications, and liability insurance information to support their application.

The Provider Enrollment Application process can take several weeks to complete, and providers are encouraged to submit their application as soon as possible to ensure timely processing. Once approved, providers are issued a Medi-Cal provider number and can begin billing for services rendered to Medi-Cal beneficiaries. It’s important to note that the Provider Enrollment Application process is a critical step for healthcare providers seeking to participate in the Medi-Cal program. Without enrollment, providers cannot bill for services rendered, and beneficiaries may not have access to necessary healthcare services.

2. Complete the National Provider Identifier (NPI) Application

If you do not have a National Provider Identifier (NPI) when applying for Medi-Cal, you will need to complete an application for an NPI. Here are the steps you can follow:

  1. Go to the National Plan and Provider Enumeration System (NPPES) website:
  2. Click on “Create or Manage an NPI” and select “Apply Online.”
  3. Read and agree to the NPI Terms and Conditions.
  4. Select “Type 1” as the application type.
  5. Enter your personal information, such as name, date of birth, and social security number.
  6. Enter your business or practice location information.
  7. Enter your contact information, including email address and phone number.
  8. Select your taxonomy code, which identifies your specialty or area of practice.
  9. Submit your application.
  10. Once your application is approved, you will receive your NPI number by email or mail.

You will then need to provide your NPI number to Medi-Cal, either during the application process or after your enrollment is approved. This will ensure that you can be reimbursed for the services you provide as a Medi-Cal provider.

3. Submit Required Documentation

You must submit supporting documentation such as your state medical license, malpractice insurance, DEA certificate, and other required documentation. You should follow these general steps:

  • Determine the required documents: Medi-Cal has specific requirements for provider credentialing. You can find the list of required documents on the Medi-Cal website or by contacting the Medi-Cal provider enrollment unit.
  • Gather the documents: Collect all the required documents in advance to avoid any delays in the application process. Make sure that the documents are complete and accurate.
  • Submit the documents: You can submit the required documents by mail or online through the Medi-Cal provider enrollment portal. Follow the instructions provided by Medi-Cal to ensure that your submission is accepted.
  • Follow up: After you submit your documents, it is important to follow up with Medi-Cal to ensure that your application is processed in a timely manner. You can check the status of your application by logging into the provider enrollment portal or by contacting the Medi-Cal provider enrollment unit.
  • Respond to requests for additional information: If Medi-Cal requires additional information or documentation, respond promptly to avoid any delays in the credentialing process.

It is important to note that the credentialing process can take several weeks or even months to complete, so it is recommended to start the process as early as possible.

4. Background Check

Providers must undergo a background check to ensure that they are in good standing with their state licensing board. Provider background checks are an important part of the Medi-Cal program. The purpose of these checks is to ensure that individuals who provide services to Medi-Cal beneficiaries are qualified and have no history of criminal or fraudulent activity that could compromise the quality of care provided to patients. The background check process includes a review of the provider’s criminal history, including any convictions, arrests, or pending charges. It also includes a check of the provider’s professional license status, education and training credentials, and any past disciplinary actions or sanctions.

The California Department of Health Care Services (DHCS) is responsible for conducting provider background checks for Medi-Cal. DHCS uses a variety of sources to obtain information about a provider’s background, including the California Department of Justice, the Federal Bureau of Investigation, and other state and federal agencies. If a provider has a criminal history or other issues that may affect their ability to provide quality care to Medi-Cal beneficiaries, DHCS may deny their application to participate in the program or take disciplinary action against them. This can include revoking their provider agreement, imposing fines, or suspending or revoking their professional license. Overall, the provider background check process is an important part of ensuring that Medi-Cal beneficiaries receive high-quality care from qualified providers who are committed to providing safe and effective services.

5. Credentialing Verification

The California Medicaid program verifies your credentials, including proof of education and training, licensure or certification, work experience, and any other qualifications that are relevant to their practice. The California Medicaid program may use various methods to verify these credentials, including contacting the provider’s educational institutions, licensing boards, and previous employers. The program may also use online verification services or databases to confirm the provider’s credentials. The program may also conduct site visits or audits to ensure that providers are complying with program rules and regulations. It is important for healthcare providers to provide accurate and complete information when applying for enrollment in the California Medicaid program and to keep their credentials up to date. Failure to do so may result in denial or revocation of enrollment, as well as potential legal and financial consequences.

6. Enrollment Approval

Once your application has been reviewed, and your credentials have been verified, you will receive approval to participate in the California Medicaid program.

7. Contracting

Once a provider has met all of Medi-Cal’s contracting requirements, they must sign a provider agreement with the program. This agreement outlines the terms and conditions of the provider’s participation in Medi-Cal, including the reimbursement rates they will receive for services provided to Medi-Cal beneficiaries. Once a provider is contracted with Medi-Cal, they can begin providing services to Medi-Cal beneficiaries and submitting claims for reimbursement. Medi-Cal reimburses providers at rates that are typically lower than private insurance, but providers can still see significant patient volume and revenue through their participation in the program.

Legion Healthcare Solutions is a leading medical billing company providing complete billing and coding including provider credentialing services. We shared information about provider credentialing steps in Medi-Cal, just for reference purpose only. Kindly consider them as general guidelines as credentialing requirements for Medi-Cal might change from time to time. To connect with our credentialing expert and know more about our credentialing and enrollment services, call us at 727-475-1834 or email us at

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