CalOptima Health and the Orange County Medical Association (OCMA) invite you to a virtual town hall concerning H.R. 1 and its impacts on health care in Orange County.

The 60-minute town hall will be held via Zoom on Thursday, August 14, 2025, at 6 p.m. and will cover the core provisions of H.R. 1, its impact on health care delivery and physician reimbursement, systemwide changes and local implementation at CalOptima Health, and how organized medicine is responding. The presenters will be Elizabeth McNeil, Vice President, Federal Government Relations for OCMA and Michael Hunn, Chief Executive Officer of CalOptima Health.

All interested physicians in Orange County are encouraged to attend. To register, please click here.

We invite all our contacted providers to complete the CalOptima Health Member and Population Health Needs Assessment Provider Survey. It only takes eight to 10 minutes to fill out and helps us better understand what services our members need and use.  

You can take the survey by clicking on the following link or copying and pasting the URL into your browser:  norcfed.gov1.qualtrics.com/jfe/form/SV_eFhtjOliJoixGzc. Please complete the survey on or before August 29, 2025.

Provider input is critical to shaping resources, programs and services that support our entire community. We ask our contracted health network and community partners to share this survey with providers and encourage their participation.

Thank you for taking the time to help us better serve the members you see every day. If you have any questions about the survey, please email mphna2025@norc.org. 

The Federal Bureau of Investigation (FBI) and the Centers for Medicare & Medicaid Services (CMS) have issued warnings about a rise in emails, phone calls, texts and faxes from scammers pretending to be trusted organizations to steal sensitive information. These scams, known as “phishing” or “smishing,” can lead to identity theft, fraud and disrupted care.

CalOptima Health takes these threats to our members’ personal information seriously. In addition to educating members about scams through text campaigns and newsletters, we have also updated the Health Care Fraud page on our website with tips on how they can avoid fraud and protect their personal information, including:

• Saving CalOptima Health’s texting number — 225678 (CALOPT) — in their contacts so they know it’s really us
• Being cautious of unexpected messages asking for personal information
• Double-checking who’s requesting their information
• Never sharing their CalOptima Health ID, Social Security number or other private details
• Reviewing their Explanation of Benefits (EOB) for services they didn’t receive

If a member thinks they’ve been targeted or shared their information by mistake, they should call us right away at 888-587-8088 (TTY 711).

We ask that providers review these tips and communicate them to their patients to help keep our members’ sensitive information safe.

The California Department of Social Services (CDSS) has shared the following know-your-rights resources for communities experiencing immigration raids:

• The governor’s office has a fact sheet with tips on what to do if someone witnesses an immigration arrest, how to recognize federal immigration agents and answers to common questions. This fact sheet is available in English and Spanish.
• CDSS’ website has resources for a number of immigration services, including free legal services and other programs.
• CDSS has contact lists to access legal services, along with a Refugee Programs Bureau page with additional resources for refugees, special immigrant visa holders and other specific populations.
• The state’s CA.gov website has information for immigrant families, including accessing public education, supporting mental health and how to report hate crimes and discrimination.

Providers should review these resources and share them with patients impacted by recent immigration raids. We have also added an Access to Care page to our website that rounds up information on virtual care options and immigration resources for members to use during challenging times.

We remind our contracted hospitals that, per CalOptima Health Policy 66.1639, they must ensure that members have access to a 72-hour supply of covered outpatient drugs in an emergency situation.

An emergency situation is defined as one where a covered outpatient drug needed for continuity of care routinely requires prior authorization, but where it would be delayed due to it being after hours (either a night, weekend or holiday).

Hospitals can comply with this policy by either supplying the member with the 72-hour supply or an initial dose and a prescription for the remaining supply. Prescriptions will be filled at the member’s pharmacy under the Medi-Cal Rx program.

Hospitals can review the full policy here. If you have any questions, please contact our Provider Relations department at 714-246-8600.

To help providers improve their rates on the Healthcare Effectiveness and Data Information Set (HEDIS) Appropriate Testing for Children With Pharyngitis (CWP) measure, we are sharing the best practices and appropriate billing codes below.

This measure is the percentage of episodes for members 3 years and older who were diagnosed with pharyngitis and dispensed an antibiotic and who also received a group A streptococcus (strep) test.

Best Practices:

Always perform a rapid strep test or throat culture to confirm the diagnosis of strep pharyngitis before prescribing antibiotics. Clinical findings alone do not adequately distinguish strep from non-strep pharyngitis. Also:

• Do not treat “red throats” empirically with antibiotics, since most cases are viral.
• Educate parents/caregivers on the difference between bacterial and viral infections and that antibiotics are not necessary for viral infections.
• Write a prescription for over-the-counter medications for symptom relief, e.g., throat spray/lozenges. The CDC has a Symptom Relief Prescription Pad, which can be downloaded from cdc.gov.
• If antibiotics are prescribed for another condition or illness, make sure to document the condition and submit diagnosis codes that apply to the claim or encounter.

Codes Included in the Current HEDIS Measure:                           

• Pharyngitis — ICD-10: Streptococcal sore throat J02.0; acute pharyngitis J02.8, J02.9; acute tonsillitis J03.00, J03.01, J03.80, J03.81, J03.90, J03.91
• Group A Strep Tests — CPT: 87070, 87071, 87081, 87430, 87650–87652, 87880

The following antibiotic medications, in conjunction with a strep test (rapid strep test or throat culture), will meet compliance for this measure:

• Aminopenicillins — Amoxicillin, Ampicillin
• Beta-lactamase inhibitors — Amoxicillin-clavulanate
• First generation cephalosporins — Cefadroxil, Cefazolin, Cephalexin
• Folate antagonist — Trimethoprim
• Lincomycin derivatives — Clindamycin
• Macrolides — Azithromycin, Clarithromycin, Erythromycin
• Natural penicillin —  Penicillin G benzathine, Penicillin G potassium, Penicillin G sodium, Penicillin V potassium
• Quinolones — Ciprofloxacin, Levofloxacin, Moxifloxacin, Ofloxacin
• Second-generation cephalosporins — Cefaclor, Cefprozil, Cefuroxime
• Sulfonamides — Sulfamethoxazole-trimethoprim
• Tetracyclines — Doxycycline, Minocycline, Tetracycline
• Third-generation cephalosporins — Cefdinir, Cefixime, Cefpodoxime, Ceftriaxone

Required Exclusions:

• Members who use hospice services or elect to use a hospice benefit any time during the measurement period.
• Diagnosis of comorbid conditions (e.g., HIV, cancer, immunodeficiency) either 12 months prior to or on the episode date.
• Visits that result in an inpatient stay.

Providers are invited to a continuing education webinar at Noon on Wednesday, August 13, 2025, about the intersection of health care and human trafficking.

The 90-minute Zoom course will cover how to identify and support human trafficking victims in the health care setting. Providers can earn 1.5 continuing medical education and continuing education credits for attending.

Please register for the webinar by Monday, August 11, by visiting https://bit.ly/4kz2WzM. If you have any questions, please contact Quynh Tran at continuingeducation@caloptima.org. 

On July 1, 2025, the Department of Health Care Services (DHCS) informed managed care plans (MCPs) of changes to COVID-19 benefits and services coverage from Assembly Bill (AB) 116. With this bill, Health and Safety Code Section 1342.2 has been amended so the provisions no longer apply to MCPs, including coverage of COVID-19 diagnostic and screening testing and health care services related to testing by out-of-network providers.

MCPs continue to be responsible for COVID-19 benefits and services coverage as required in AB 116, as well as other applicable state laws. MCPs must authorize and arrange for services from out-of-network providers when medically necessary services are unavailable within the MCP network. In addition, MCPs need to continue following the COVID-19 benefits and services guidance outlined in the Medi-Cal Provider Manual, relevant provider bulletins and updates and All Plan Letter (APL) 24-008: Immunization Requirements.

DHCS also notified MCPs that APL 22-009: COVID-19 Guidance for Medi-Cal Managed Care Health Plans has been retired effective July 2, 2025.

On July 18, 2025, DHCS notified MCPs of updates to the Subacute Care Programs sections of the Medi-Cal Long–Term Care Provider Manual, effective July 16, 2025.

The revised policy states that initial authorizations and subsequent reauthorizations for subacute services may be approved for up to one year, instead of six months. The updated guidance is reflected in the following sections of the Medi-Cal Long-Term Care Provider Manual:

• Subacute Care Programs: Level of Care for Adults and Children
• Subacute Care Programs: Adult
• Subacute Care Programs: Pediatric

DHCS will also update APL 24-010 to clarify authorization timeframes for subacute care services and clarify requirements related to the implementation of updated LTC rates. A draft of the updated APL will be distributed to stakeholders for input later this quarter.

• On July 11, 2025, DHCS distributed a revised version of APL 25-011: House Resolution (HR) 1 — Federal Payments to Prohibited Entities. The purpose of the APL is to provide MCPs with guidance for payments to Medi-Cal and Family Planning, Access, Care, and Treatment Program (Family PACT) providers impacted by the enactment of HR 1. 

Click on the link below to find an outline of changes made to CalOptima Health policies and procedures during June 2024. The full description of the policies below is available on CalOptima Health’s website at:

www.caloptima.org/for-providers/provider-resources/manuals-policies-and-guides

Policies and Procedures Monthly Update

Click below for training webinars and meetings happening in August 2025:

Health education webinars

Based on Medi-Cal Bulletins and NewsFlashes, CalOptima Health has updated the procedure codes and other relevant information for the subjects listed below:

• 2025 HCPCS Quarter 3 Update
• Modifications to the DETEC Application in the Provider Portal
• TAR Requirements for Subacute Care Programs
• Cell and Gene Therapy Policy Updates and New Manual Sections
• Additional Gene Tests Covered Under CPT Code 81403
• HCPCS Code G0561 Benefit Status Change
• Additional Dyadic Modifiers Added to Existing Dyadic Service Billing Codes
• Policy Updates for Auditory Osseo Integrated Implant CPT Codes
• Provider Manual Revisions
• Claim Criteria for Select Psychiatric Inpatient Hospital Services
• Reminder: Medi-Cal Provider Agreement Compliance Requirements
• 2025 Nursing Facilities – Level A Reimbursement Rate Update
• Update to the TAR Requirement for Select Breast Pump HCPCS Codes
• Seven Fact 2mg Payment Correction
• Justice-Involved (JI) Reentry Initiative: Former Foster Youth Update
• Enhancements to Appeal Status in Correspondence Center
• Reimbursement for Behavioral Health Treatment Services Provided to Medi-Cal Members with Fee-for-Service
• Important Update: House Resolution (H.R.) 1– Federal Payments to Prohibited Entities

For more detailed information regarding these changes, please refer to General Medicine Bulletin 613, Inpatient Services Bulletin 610, Long Term Care Bulletin 581, Pharmacy Bulletin 1068 and Medi-Cal NewsFlashes from June 20, June 20, June 27, July 2 and

July 3.

To access the updated Physician Administered Drug Prior Authorization List (PAD PA List), please refer to: www.caloptima.org/en/ForProviders/ClaimsandEligibility/PriorAuthorizations.aspx.

• CalOptima Health Board of Directors: August 7 at 2 p.m.
• Joint Meeting of the Provider and Member Advisory Committees: August 14 at Noon

All meetings have an option for virtual attendance. Visit the CalOptima Health website for more information.

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.