Section 51470 - Billing for Benefits Provided(a) A provider shall not bill or submit a claim to the Department or a fiscal intermediary for Medi-Cal benefits not provided to a Medi-Cal beneficiary.(b) A dental prosthesis, custom-made eye appliance, custom-made prosthetic applicance, or custom-made orthotic appliance shall be deemed provided after diligent attempts to effect delivery have proved unsuccessful or delivery is impossible due to circumstances beyond the control of the provider. Payment for undelivered appliances shall be limited to 80% of the amount which would have been payable had delivery been accomplished. Undelivered appliances for which claims are submitted and paid shall be retained by the provider for a period not less than one year from the date it was ordered from the fabricating laboratory for purposes of delivery to the beneficiary or the Department on demand. If delivery is made to the patient or a representative of the Department on demand within one year of the date of service, the payment on the original claim can be adjusted to provide a total compensation equal to that which would have been forthcoming had delivery been made on the date of service.(c) Services provided by a selected substitute provider shall be considered to have been provided by the billing provider if all of the following conditions are met: (1) Services are provided during the temporary absence of the billing provider.(2) The substitute provider is also a qualified Medi-Cal provider.(3) The substitute provider has an agreement with the billing provider to provide services in the absence of the billing provider and not to independently bill for the same service.(4) The claim clearly identifies the substitute provider by name and provider number.(d) A provider shall not bill or submit a claim to the Department or a fiscal intermediary for Medi-Cal covered benefits provided to a Medi-Cal beneficiary: (1) For which the provider has received and retained payment.(2) Which do not meet the requirements of Department regulations.Cal. Code Regs. Tit. 22, § 51470
1. New section filed 2-25-70; designated effective 4-1-70 (Register 70, No. 9).
2. Amendment filed 8-31-79; effective thirtieth day thereafter (Register 79, No. 35).
3. Amendment filed 11-29-79; effective thirtieth day thereafter (Register 79, No. 48).
4. Amendment of subsection (c)(3) filed 1-16-80; effective thirtieth day thereafter (Register 80, No. 3).
5. Editorial correction of NOTE filed 12-14-84 (Register 84, No. 50). Note: Authority cited: Sections 14105 and 14124.5, Welfare and Institutions Code. Reference: Section 14105, Welfare and Institutions Code.
1. New section filed 2-25-70; designated effective 4-1-70 (Register 70, No. 9).
2. Amendment filed 8-31-79; effective thirtieth day thereafter (Register 79, No. 35).
3. Amendment filed 11-29-79; effective thirtieth day thereafter (Register 79, No. 48).
4. Amendment of subsection (c)(3) filed 1-16-80; effective thirtieth day thereafter (Register 80, No. 3).
5. Editorial correction of NOTE filed 12-14-84 (Register 84, No. 50).