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ACA Attest

 
Pursuant to the Affordable Care Act (ACA) and 42 CFR 447, State Medicaid agencies are required to reimburse Primary Care Physicians with a
specialty designation of Family Medicine, General Internal Medicine, or Pediatric Medicine, at parity with Medicare for specified Evaluation And
Management (E&M) and Vaccine Administration services.
In order to be eligible for enhanced payment, the physician rendering or supervising the service must personally attest to be the following:
* Physician, as defined in 42 CFR 440.50 with a Specialty designation of Family Medicine, General Internal Medicine, or Pediatric Medicine
  or a subspecialty within one of the listed specialties
   ....................AND.....................
* Meet at least one of the following Qualifications
  1) Board Certified in a Specialty or Sub-Specialty listed above recognized by the American Board Of Medical
      Specialties (ABMS), American Board Of Physician Specialties (ABPS), or American Optometric Association (AOA)
  2) At least 60% of total codes billed or paid for the most recently completed calendar year or for newly enrolled Physicians, the prior month, were for E&M (99201 - 99499)
      and Vaccine Administration (90460, 90461, 90471 - 90474, or their successors) services

Physicians wishing to attest to their eligibility to provide these services for which enhanced payments are made must provide the information requested below.


* Provider Number (NPI - ID) * Confirm Provider Number  * Provider Name
* Provider TIN (SSN)                * Confirm Provider TIN (SSN)
* Password (8 Characters)  * Confirm Password
* Email * Confirm Email

* California/OOS Medical Board License Number Or * California/OOS Osteopathic Board License Number
Managed Care Plans You Contract With (Up To 5) (click here for MCP Code Directory)
MCP - 1 MCP - 2 MCP - 3 MCP - 4 MCP - 5

The ACA and 42 CFR 447 also requires State Medicaid agencies to reimburse, at parity with Medicare, for E&M and Vaccine Administration services provided under
the personal/direct supervision of a Physician who has completed the Self Attestation process.

Enter up to 10 Non Physician Medical Practitioners (NMPs) You Personally/Directly Supervise for whom you accept professional responsibility and ONLY those who
bill Medi-Cal independently.
Please do not list the NMP NPI if the NMP Claim includes your Physician NPI as the Billing or Rendering Provider and the NMP does not bill Medi-Cal directly.
Having your NPI listed in the billing or rendering provider field will trigger the higher payment

      NMP Provider NMP Provider Effective Effective Effective Effective Effective Effective
      Number (NPI) Name Begin Date-1 End Date-1 Begin Date-2 End Date-2 Begin Date-3 End Date-3
01 -
02 -
03 -
04 -
05 -
06 -
07 -
08 -
09 -
10 -


Attestation To Practicing In A Primary Care Specialty Or Sub-Specialty (To be eligible, this box must be checked)
      I attest that, to the best of my knowledge, I am a physician as defined in 42 CFR 440.50 with the following Specialty and Sub-Specialty as defined by the American
      Board Of Medical Specialties, American Board Of Physician Specialties, or the American Osteopathic Association:























Attestation Qualifications (to be eligible, at least one box must be checked, though if applicable both qualifications can and should be checked):

Qualification-1 :
I attest that, to the best of my knowledge, I am Board Certified in the Specialty or Sub-Specialty stated above, recognized by the American Board
      Of Medical Specialties, American Board Of Physician Specialties, or the American Osteopathic Association.
      Note: The Certification Begin/End Dates may be used to determine your eligibility effective dates.

American Board Of Medical Specialties (ABMS)
ABMS Certification Begin Date - 1 ABMS Certification End Date - 1
ABMS Certification Begin Date - 2 ABMS Certification End Date - 2
ABMS Certification Begin Date - 3 ABMS Certification End Date - 3

American Board Of Physician Specialties (ABPS)
ABPS Certification Begin Date - 1 ABPS Certification End Date - 1
ABPS Certification Begin Date - 2 ABPS Certification End Date - 2
ABPS Certification Begin Date - 3 ABPS Certification End Date - 3

American Osteopathic Association (AOA)
AOA Certification Begin Date - 1 AOA Certification End Date - 1
AOA Certification Begin Date - 2 AOA Certification End Date - 2
AOA Certification Begin Date - 3 AOA Certification End Date - 3

Qualification-2 :
I attest that, to the best of my knowledge at least 60% of my total Medi-Cal codes billed or paid, for the most recently completed calendar year or
     
for newly enrolled Physicians, the prior month, were for E&M (99201 - 99499) and Vaccine Administration (90460, 90461, 90471 - 90474, or their successors) services
      or local codes that correspond to these E&M and Vaccine Administration codes.


By clicking the SUBMIT Button below, I personally attest to eligibility for enhanced primary care payments as described under 42 CFR 447.405.
I understand that the California Department Of Health Care Services (DHCS) will verify that I meet the criteria for payment at the Medicare
rate by validating board certifications or reviewing claims to ensure that the 60% threshold has been met. I agree to cooperate and provide
a copy of the board certification upon request by the DHCS. Furthermore, I agree to update my Self Attestation Form immediately if I no longer
meet the eligibility requirements. I further understand if it is determined that I did not qualify for the Medicare rate for any reason, then
the DHCS will recover any incremental payments or the difference between the Medicare and Medicaid rate paid for the service.