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Information on Navigating the Agencies

An understanding of the difference between the licensure and certification process is important for prospective providers. A license is granted when the facility meets the initial requirements to open its doors and admit clients. A certification is the review process that is conducted to ensure that the facility meets the federal standards of participation in the Medi-Cal Program.

It is the certification portion of the process that qualifies the facility for the daily reimbursement from Medi-Cal. It is imperative that the licensee and facility staff involved understand that the facility must remain in continuous compliance with all federal and state regulations. Failure to do so jeopardizes the facility’s certification and Medi-Cal reimbursements.

Potential applicants interact with the following regulatory and state governmental entities that are responsible for different aspects of the licensing and certification process including, but not limited to:

• Regional Center: Determines the need for services and placement of clients.
• Department of Developmental Services (DDS), Health Facilities Program Section: Reviews and approves program plans.
• Department of Public Health (CDPH) Licensing and Certification: Grants licenses and conducts certification surveys.
• Department of Health Care Services (DHCS), Medi-Cal Field Office: Reviews and approves initial and continued client eligibility for level of care.
• Department of Public Health (CDPH) Life Safety Code Unit: Conducts the Life and Safety Survey.
• Electronic Data System (EDS): Reviews billings/processes and issues Medi-Cal payments.

It is essential that applicants become familiar with the state and federal regulations and the process for initial licensure and certification.