Section 50657 - Completion of Form MC 177S(a) Form MC 177S shall be completed as follows: (1) The identifying information shall be completed by the county department. The only persons who shall be listed on form MC 177S as eligible to have the cost of their health services used to meet the share of cost are those: (A) Eligible members of the MFBU in accordance with Sections 50373, 50375 and 50377.(B) Ineligible members of the MFBU in accordance with Section 50379.(2) Form MC 177S shall be issued to the beneficiary for each month during which the beneficiary must meet a share of cost.(A) For continuing beneficiaries, form MC 177S shall be issued prior to the first day of the month of eligibility.(B) For new and restored beneficiaries, form MC 177S shall be issued at the time the approval notice of action is issued.(3) The beneficiary shall present form MC 177S to each provider when the cost of services provided will be used to meet the share of cost.(4) The provider will list on the form MC 177S health services which have been provided and meet all of the following criteria.(A) Were provided in the month specified on form MC 177S. Services are considered to have been provided in the month if the date of service is within the month. The date of service for:1. Health services provided under a Global Billing Agreement is the date the last service under the agreement is rendered or the date of delivery, if the global billing is for pregnancy and delivery.2. Dental prosthesis, prosthetic and orthotic appliances, and eye appliances is the date the item is actually ordered from the fabricating laboratory.3. Prescription drugs is the date the item was actually received.4. All other health services is the date the service was actually rendered.(B) Have not been submitted as a claim against the Medi-Cal program.(C) Have not been paid by Medicare, other health coverage, or any other party, and the provider for the amounts listed on form MC 177S.(5) For each service listed the provider shall include: (A) The date of service, in accordance with (a) (4) (A).(B) The total cost of the service provided.(C) The amount billed to the patient.(D) The patient Medi-Cal identification number.(E) Either of the following: 1. For Medi-Cal program covered services, the procedure/drug code for the service provided.2. For other services, a description of the service provided, such as inpatient, drug or dental.(F) The Medi-Cal provider number or provider license number.(6) The provider shall sign a declaration under penalty of perjury that: (A) Each service listed on form MC 177S was provided to the person listed on the date specified.(B) Payment for the amount listed in the Billed Patient column will be sought from the patient and not from the Medi-Cal program or a third-party payor.(7) When the amount in the Billed Patient column of form MC 177S equals or exceeds the share of cost, the beneficiary or the beneficiary's representative shall:(A) Sign the form indicating that the beneficiary has assumed legal responsibility for the amount shown in the Billed Patient column.(B) Return the form to the county department.(b) For purposes of this section, the following definitions shall apply: (1) Provider means the person or entity which provides health services to the persons listed on form MC 177S and which is a Medi-Cal provider or a licensed practitioner meeting the criteria of a Medi-Cal provider in accordance with Article 3, Chapter 3.(2) Health services means the medical services, social services, supplies, devices, drugs and any other medical care provided to a person listed on form MC 177S by a provider as defined in (b)(1).Cal. Code Regs. Tit. 22, § 50657
1. Amendment of subsection (a)(1)(A) filed 4-15-85 as an emergency; effective upon filing (Register 85, No. 16). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 8-13-85. For prior history, see Register 83, No. 16.
2. Certificate of Compliance including amendment of subsection (a)(1)(A) transmitted to OAL 8-13-85 and filed 9-18-85 (Register 85, No. 38).
3. Amendment filed 7-3-86; effective thirtieth day thereafter (Register 86, No. 27). Note: Authority cited: Sections 10725, 14005.9 and 14124.5, Welfare and Institutions Code; Section 133.5, AB 251, Chapter 102, Statutes of 1981; and Section 57(c), Chapter 328, Statutes of 1982; and Section 14, AB 1557, Chapter 1447, Statutes of 1984. Reference: Sections 14005, 14005.4, 14005.7, 14005.8, 14005.9, 14018, 14019 and 14019.6, Welfare and Institutions Code.
1. Amendment of subsection (a)(1)(A) filed 4-15-85 as an emergency; effective upon filing (Register 85, No. 16). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 8-13-85. For prior history, see Register 83, No. 16.
2. Certificate of Compliance including amendment of subsection (a)(1)(A) transmitted to OAL 8-13-85 and filed 9-18-85 (Register 85, No. 38).
3. Amendment filed 7-3-86; effective thirtieth day thereafter (Register 86, No. 27).