Form Dhcs 4513 - California Cms Net Account Request - Department Of Health Care Services Children'S Medical Services (Cms) Branch Page 2
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1
2State of California—Health and Human Services Agency
Department of Health Care Services
Children’s Medical Services (CMS) Branch
INSTRUCTIONS
County*:
The name of the county submitting request.
Select One*:
Add:
Select check box if this request is for account activation.
Modify:
Select check box if this request is for account modification.
Delete:
Select check box if this request is for account deactivation.
Security Level:
Use only if user needs more than the default access.
County System Admin
Confidentiality Oath required:
User can:
1. Add, deactivate or reactivate users
2. Reset user passwords
3. Modify/assign user security profiles
4. Modify/Reauthorize Cancelled SAR
5. Modify historical referral/transfer dates
6. Edit permanently assigned case numbers
7. End Date Healthy Families Plans
Co System Admin-Plus
Confidentiality Oath required:
User can perform all above County System Administrator capabilities plus:
8. Correct program eligibility dates
9. Correct client eligibility closures/denials
10. Access transaction tracking to determine who last updated a particular record
MTP Add/Modify/Review
User can create and modify Patient Therapy Record (PTR), create and modify PTR
batches, and review PTR.
SAR EPSDT
User can approve Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
Service Authorization Request (SAR) and CCS Supplemental Services (SS)
authorizations for “Categories that Require State Approval”. Do not assign this security
role without approval from the State CMS Branch.
1. Approve-Yes or Approve-No for EPSDT-SS and CCS-SS SAR
2. Can enter a negotiated price for procedure codes that do not have a price on the
procedure master file.
SAR Override
User can override SAR business rules (Program and Client Eligibility cannot be
overridden):
1. Age 21 restrictions
2. End dated procedure codes
3. Procedure codes with a pend/deny indicator of T or D
4. One year limitation on SAR service dates
5. Age 19 restrictions for orthodontia
6. Length of stay at inpatient hospital
7. Can manually enter a National Drug Code (NDC) to pay for Brand Name drugs
Name (Last, First)* and Email*:
Type user’s last name, then user’s first name and user’s email address.
Credentials:
Type the user’s credentials in abbreviated form.
Phone*:
Type user’s phone number, including area code (and extension if applicable) in format
(999)999-9999.
Alternate County:
Type the county the user is employed by (if different from the county submitting the
request). Example: Courtesy case management between counties.
The name of person submitting request. Representative must be a State CMS Branch
Representative’s Name (Print)*:
manager, California Children’s Services (CCS)/CMS Administrator, CMS Net County
System Admin, or CMS Net County System Admin-Plus.
Phone*:
Type the representative’s phone number, including area code (and extension if
applicable) in format (999)999-9999.
Representative’s Name (Signature)*: Signature of representative.
Date*:
Date account request was signed by the representative.
DHCS 4513 (Rev 05/13)
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