To continue supporting providers following the Change Healthcare cyberattack and to implement recommendations from the Department of Health Care Services (DHCS), CalOptima Health is temporarily extending its filing deadline for claims.
CalOptima Health and its health networks will allow an additional 90-day grace period to the existing 365-day timely filing deadline for provider claims received as of February 21, 2024, or later. This flexibility applies to both Medicare and Medi-Cal claims and will continue until such time as Change Healthcare remediates the effects of the incident.
This grace period is in line with a DHCS memo sent to all managed care plans (MCPs) on March 13, 2024, regarding Change Healthcare and MCPs’ legal obligation to pay all claims within contractually mandated statutory timeframes. DHCS also strongly encouraged MCPs to take the following steps:
- Accept paper claims
- Remove or relax timely claim filing requirements
- Remove or relax prior authorization or utilization management requirements
- Establish workarounds to continue paying claims
- Publish and update information on their websites
- Work with subcontractors, downstream subcontractors and network providers
Since February, CalOptima Health has notified providers about using Office Ally, its contracted electronic data interchange clearinghouse, as the preferred method to submit claims and how to submit hard-copy claims. Providers receiving physical checks have also been given instructions on how to receive electronic payments and check the status of their claims through the CalOptima Health Provider Portal.
CalOptima Health’s prior authorization process remains unchanged as the health plan does not use Change Healthcare for authorizations.
CalOptima Health is in close communication with Change Healthcare and monitoring developments carefully. Providers can find the most up-to-date information under the Provider section of our website, www.caloptima.org, or by visiting the Provider Portal. For additional questions, contact CalOptima Health’s Provider Relations department at 714-246-8600.
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Modivcare Now Providing All Medical Transportation Services
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As of April 1, 2024, CalOptima Health has contracted with transportation vendor Modivcare to coordinate all transportation services for members in Medi-Cal and OneCare (HMO D-SNP), a Medicare Medi-Cal Plan. This includes both Non-Medical Transportation (NMT) and Non-Emergency Medical Transportation (NEMT) benefits.
Your patient’s transportation benefits have not changed and the process for arranging NMT and NEMT services is the same. To schedule transportation, Medi-Cal patients should call 1-833-648-7528 and OneCare patients should call 1-866-612-1256. CalOptima Health has compiled this FAQ document to help answer provider questions about Modivcare and member transportation benefits.
If your patients already have trips scheduled with another transportation vendor, that information will be relayed to Modivcare. Members can call Modivcare at the numbers listed above to confirm any information or upcoming trips.
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Providers Should Use Provider Portal to Confirm Member Eligibility |
CalOptima Health has retired the Interactive Voice Response (IVR) System that was previously used to verify member eligibility. Providers can use the CalOptima Health Provider Portal to verify member eligibility. Through the Provider Portal, providers can see both the member’s assigned health network and primary care provider (PCP). Providers must be registered with CalOptima Health to use the portal.
Except for emergency services, providers rendering covered services to any CalOptima Health member should first verify eligibility. Verifying a member’s eligibility is critical to determine whether a member’s enrollment status has changed and to ensure payment. A membership card does not guarantee eligibility.
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New HCA Director Joins CalOptima Health Board |
Veronica Kelly, DSW, LCSW, has been appointed as the new Director of the Orange County Health Care Agency (HCA) and will join the CalOptima Health Board of Directors.
Dr. Kelley has more than 33 years of experience in the behavioral health field. Previously, she was HCA’s Director of Behavioral Health Services, overseeing the public behavioral health system. She also serves as the Alcohol & Drug Administrator for Orange County, which allows the county to receive federal funds to address substance use disorders.
Dr. Kelley spent 13 years serving the San Bernardino County Department of Behavioral Health, with six years as the Behavioral Health Director. During that time, she led the county’s crisis response and recovery efforts following the 2015 terrorist attack. Dr. Kelley remains active at the state level, addressing behavioral health issues as a Board member of NAMI California and the past president of the County Behavioral Health Directors Association. She is an appointee to the governor's No Place Like Home Advisory Committee and a steering committee member for DHCS’ Community Mental Health Equity Project.
Dr. Kelley earned a Doctor of Social Work from Capella University in Minnesota and a Master of Social Work from the University of Southern California, Los Angeles and is a licensed clinical social worker in the state of California. She is an assistant clinical professor at the Loma Linda University Department of Social Work and Social Ecology, and a part-time lecturer at CSU Fullerton, School of Social Work.
Her first CalOptima Health Board of Directors meeting will be April 4.
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Updated Provider Training Modules Available on CalOptima Health Website |
CalOptima Health has recently added updated versions of three provider training modules for 2024 to our website. The updated training modules include:
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Shape Your Life Classes Available for Vietnamese-Speaking Members |
Vietnamese-speaking members and their children are invited to a series of healthy living classes offered by CalOptima Health.
The six no-cost, in-person Shape Your Life group classes will focus on healthy eating, physical activity and other ways parents can build daily habits to improve their children’s health.
Providers are asked to share this flyer and the information below with their Vietnamese-speaking patients:
Shape Your Life classes
April 16, 23, 30 and May 7, 14, 21
5:30–7:30 p.m.
Westminster Family Resource Center
7200 Plaza St.
Westminster, CA 92683
Dinner will be provided. For questions or to reserve a seat, members should call the Westminster Family Resource Center at 1-714-903-1331.
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DHCS Funds New Digital Mental Health Apps for Children, Young Adults |
To better support the mental health of children, teenagers and young adults, DHCS is funding two new mobile apps, now available for Apple and Android devices.
Soluna is a no-cost mental health app for teenagers and young adults ages 13–25 that offers interactive tools to de-stress, quizzes, videos and forums, and one-on-one sessions with a professional coach.
Also available is the BrightLife Kids app, which is geared toward families with children ages 0–12. The app offers behavioral health support, guides to community resources and coaching sessions for parents.
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Video Series Provides Resources for Parenting Challenges |
In partnership with the Child Mind Institute, DHCS has released a new video series, Positive Parenting, Thriving Kids. This series gives parents and caregivers additional resources to face potential parenting challenges, particularly the mental health of children. Positive Parents, Thriving Kids and the previously released Healthy Minds, Thriving Kids series are a part of the California for All Kids initiative and aim to address youth mental health through tangible, evidence-based resources and support.
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DHCS Shares Sixth Version of MCP Transition Policy Guide |
DHCS has distributed the sixth version of the 2024 Medi-Cal MCP Transition Policy Guide, which includes DHCS policies and MCP requirements related to the member transition of Medi-Cal MCPs that occurred on January 1, 2024. This version updates the continuity of care policy to include enforcement actions through corrective action plans for failure to meet the PCP retention requirement. It also includes updates to align assessments and screening tools guidance with the Population Health Management Policy Guide and clarification on data elements and file transmissions. Please email questions about the policy guide to MCPTransitionPolicyGuide@dhcs.ca.gov.
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On February 20, DHCS reminded MCPs of the discontinuation of the Child Health and Disability Prevention (CHDP) Program on July 1, 2024, as part of the agency’s goals to make Medi-Cal a more consistent and seamless system to navigate.
The CHDP program includes:
- Preventive health, vision and dental screening and care coordination for members eligible for Medi-Cal for Kids & Teens, which is the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit
- The CHDP Gateway, a presumptive eligibility (PE) entry point for children to receive temporary preventive, primary and specialty health care coverage
- Responsibility for administering the Health Care Program for Children in Foster Care (HCPCFC)
- CHDP-Childhood Lead Poisoning Prevention (CLPP) program activities.
The end of the CHDP will not affect these services, as EPSDT services are covered by Medi-Cal fee-for-service and managed care, and PE services will continue and expand under the new Children’s Presumptive Eligibility and Hospital Presumptive Eligibility programs. HCPCFC will be a standalone program. CHDP-CLPP responsibilities will transition to MCPs and the California Department of Public Health Lead Poisoning Prevention Branch.
MCPs are contractually required to provide CHDP services to their members and ensure that providers are appropriately trained to conduct CHDP services. DHCS recognizes that some MCPs have historically relied on local CHDP programs for the provision of some of these services or training for CHDP–like services.
While the statewide CHDP program will sunset on July 1, some local CHDP programs have notified DHCS that they have ceased or will cease providing CHDP services before that date. DHCS reminds MCPs of the responsibility to partner with counties and ensure members receive all medically necessary services. MCPs should also work with counties to ensure awareness of when CHDP activities will end and find ways to exchange data if there are impacted members.
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Topical Fluoride Application Vital for Pediatric Oral Health |
CalOptima Health Community Network (CCN) providers play an important role in the oral health of their patients.
Children in their first few years of life are seen earlier and more frequently by a medical provider than by a dentist. Providers can optimize oral health for their young patients by applying topical fluoride varnish in their office. Topical fluoride varnish is one of the most effective means of preventing dental decay.
The American Academy of Pediatrics recommends the application of topical fluoride at least once every six months and once every three months for high-risk children. A child can safely receive up to four applications of topical fluoride a year without concern for fluorosis. Research shows the risk of fluorosis from topical fluoride treatments by health care or dental providers is low. For more information on fluorosis risk, click here.
If a member reports receiving topical fluoride from a dental provider, document the date of service of the fluoride varnish application in the child’s medical record.
CCN providers can be reimbursed $23.22 up to three times a year for the application of topical fluoride for members up to age 5 in their office. Providers must submit CPT Code 99188 on claims for reimbursement. For members ages 5–20, ensure that they have a dental home and provide a referral if needed.
When unsure whether a member has received topical fluoride from a dental provider within the past three to six months, providers should apply the topical fluoride in the office.
For questions or information on how to apply topical fluoride in your practice, contact CalOptima Health’s Quality Initiatives department at QI_Initiatives@caloptima.org.
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Updates Will Help Providers Complete Initial Health Appointments |
Per All Plan Letter (APL) 22-030, DHCS continues to require the Initial Health Appointment (IHA) to be completed within 120 calendar days of a Medi-Cal member’s enrollment in CalOptima Health. DHCS will measure primary care visits as a proxy for the IHA completion, leveraging Managed Care Accountability Set (MCAS) measures specific to infant and child/adolescent well-being visits.
To continue supporting providers in completing IHAs, CalOptima Health is sharing the following important updates:
Quarterly IHA Chart Review Audits Effective January 1, 2024: We are collaborating with our contracted CCN providers and clinics to improve completion rates for the IHA and to identify what is working well and areas for improvement.
Key Performance Indicator (KPI): As of January 1, KPI metrics for IHAs for delegated networks have been increased to 50%.
- The new benchmark will be included in the quarterly meeting reports.
- CalOptima Health will support health networks in meeting this goal by providing outreach to all new members.
The IHA report is now available on the Provider Portal:
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Visit https://provider.caloptima.org/
- Once logged in, click on “Reports,” select “Initial Health Appointment” from the drop-down menu, then input your provider details and click “Get IHA Report” to download the Excel document.
- The Primary Care Provider Member Roster now also has an “IHA Due Date” column to help identify new members.
For general information about the IHA, providers can use the following resources:
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Policies and Procedures Monthly Update |
Click on the link below to find an outline of changes made to CalOptima Health policies and procedures during March 2024. The full description of the policies below is available on CalOptima Health’s website at:
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Health Education: Trainings and Meetings |
Click below for training webinars and meetings happening in April 2024:
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Based on Medi-Cal Bulletins and NewsFlashes, CalOptima Health has updated the procedure codes and other relevant information for the subjects listed below:
- 2024 First Quarter Rate Updates for HCPCS Codes A4269, J3490 and J7304
- Additional Gene Tests Reimbursable under CPT Code 81404
- CPSP Provider Enrollment Process and Reimbursement Update
- Income Denials: Instruction to Presumptive Eligibility Providers for 2024 FPLs
- New Hospice Election and Non-Covered Items, Services and Drugs Notification Forms Required
- Non-Physician Medical Practitioners Medical Services Update
- Policy Update for HCPCS Code J9203
- HCPCS Code J9057 No Longer a Medi-Cal Benefit
- Every Woman Counts 2024 Income Eligibility Guidelines
- Appropriate ICD-10-CM Codes Updated for CPT Code 87624
- Every Woman Counts Consent and Signature Policy Updated
- Policy Update for HCPCS Code J9271
- TAR Requirement Removed for HCPCS Code J9309
- Policy Update for HCPCS Codes J9033 and J9034
- Policy Update for PLA Codes 0342U and 0343U
- Policy Update for HCPCS Codes J3357 and J3358
- Policy Update for CPT Code 36522
- HCPCS Code J2860 Policy Update
- RYR1 Gene Tests Reimbursable with CPT Codes 81406 or 81408
- Updates to the Medicine: Telehealth section of the Medi-Cal Provider Manual
- Updates for Adult and Pediatric Subacute Care Programs
- National Correct Coding Initiative Quarterly Update for April 2024
- The Newborn Gateway to Launch in July 2024
- Provider Manual Revisions
- Do Not Reimburse Policy Updated for Some DME Codes
- Modifier Reimbursement Rate Update for Non-Emergency Medical Transportation Service
- New Service Updates for FQHC and RHC Providers
- Rate Increase for Home and Community-Based Services Waiver and Programs
- New Hospice Election and Non-Covered Items, Services and Drugs Notification Forms Required
- Update to PDF Remittance Advice Details
- BCCTP Enrolling Providers Medi-Cal Provider Portal Registration Reminder
- Forthcoming EPC for Select CCS Claims with RAD Code 0037
- OHC System Change Notice for Select Rural Counties
To access the updated Physician Administered Drug Prior Authorization List (PAD PA List), please refer to:
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- CalOptima Health Board of Directors: April 4 at 2 p.m.
- CalOptima Health Joint Provider and Member Advisory Committees: April 11 at Noon
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Follow Us on Social Media |
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CalOptima Health regularly posts on social media to engage members with health tips, community resources, event dates, program updates and other pertinent information. Follow the agency on Facebook, Instagram, X and LinkedIn.
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CalOptima Health, A Public Agency www.caloptima.org
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