Providers Must Follow Urgent Referral Request Standards |
CalOptima Health has experienced a noticeable increase in the number of urgent and expedited referral requests. However, upon review, many of these either do not meet urgent or expedited request standards or the provider did not indicate the reason the request was submitted as urgent.
When a request is processed as urgent, both the referring and servicing provider must maintain access and availability standards as required by state and federal mandates. For example, an urgent or expedited appointment is required within 96 hours of the request for an appointment. Unnecessary urgent or expedited requests make it difficult to maintain these standards and still ensure that actual urgent complaints are seen appropriately.
Urgent referrals are only to be submitted if the normal timeframe for authorization will:
- Be detrimental to the patient’s life or health
- Jeopardize the patient’s ability to regain maximum function
- Result in loss of life, limb or other major bodily function
A request should not be submitted as urgent or expedited so that it is reviewed faster, because a member has an appointment tomorrow or your office didn’t submit the request in a timely manner.
If you have any questions about submitting urgent requests, please contact your Provider Relations representative at 714-246-8600 or the Utilization Managment Provider Line at 714-246-8686.
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Reminder: Optum to Integrate Its Three Health Networks on January 1 |
Important reminder for Optum-contracted providers: Effective January 1, 2024, Optum is integrating its three health networks — Arta, Talbert and Monarch — into one single health network branded under the name Optum. This transition will enable Optum to streamline its operations using existing staff and leadership.
Optum will integrate operational processes and systems to enhance efficiency and further support providers in the delivery of health care services to members. CalOptima Health and Optum are dedicated to ensuring a seamless transition and positive experience for members and providers. Members currently enrolled in Arta, Talbert and Monarch will stay with Optum and are not required to take any action. To ensure minimal impact on members, Optum has worked diligently to maintain contracts with all its primary care providers (PCPs), and the majority of members will continue to receive care from their current specialists and ancillary providers. After this integration, members will have access to additional hospitals and urgent care locations. If provider changes do occur, members will be notified immediately.
Optum members were already notified about this integration, and they will receive their new ID cards — see the images below — by mid to late December.
Starting January 1, claims that Optum is financially responsible for should be mailed to:
Optum
11 Technology Dr.
Irvine, CA 92618
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CalOptima Health Streamlining Claims Dispute Process With One-Level Review |
Due to provider feedback requesting a more concise dispute process, effective January 1, 2024, CalOptima Health will transition to a single internal review for claim disputes for the CalOptima Health Community Network (CCN) and other claims where CalOptima Health has financial responsibility.
The process will be handled through our Grievance and Appeals Resolution Services (GARS) department. This one-level internal review streamlines our procedure by providing a fast, fair and cost-effective dispute resolution mechanism to process and resolve contracted and non-contracted provider disputes. It will also reduce the timeframe for providers to receive a final decision from CalOptima Health.
This change does not impact claim payments from CalOptima Health-contracted health networks or the provider dispute processes of those networks. For disputes related to a CalOptima Health-contracted health network’s claim payment, a provider must submit the dispute to the appropriate health network. If the provider is not satisfied with the health network’s decision, they may then submit a request for a second-level review by GARS.
CalOptima Health will update our online Provider Manual to reflect this new process. The updated version will be posted in the Providers section of www.caloptima.org on January 1.
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Medi-Cal Expansion Will Cover All Californias Regardless of Immigration Status |
Starting January 1, 2024, all adults between the ages of 26 and 49 will qualify for full coverage under Medi-Cal regardless of immigration status. With this expansion, Medi-Cal will now cover all Californians who meet eligibility requirements, including income limits.
According to the Department of Health Care Services (DHCS), the use of Medi-Cal benefits will not impact immigration status or trigger an alert to federal authorities. To check their eligibility for full-scope Medi-Cal coverage, your patients can call the County of Orange Social Services Agency (SSA) at 1-800-281-9799.
As part of its outreach campaign to announce this change, DHCS set up a Get Your Community Covered toolkit with promotional resources for providers, as well as web pages for the Medi-Cal population in English and Spanish with information about the expanded eligibility and how to apply.
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Registered Dietitian Services Available for Patients With Nutritional Needs |
CalOptima Health’s Population Health Management (PHM) department offers registered dietitian (RD) services at no cost for high-risk CalOptima Health members who would benefit from medical nutrition therapy (MNT). MNT is a therapeutic approach that can help individuals reduce symptoms of certain conditions and prevent further health complications by following personalized dietary recommendations. These services are available for Medi-Cal and OneCare members of all ages and with a nutrition-related condition.
RD interventions include:
- Assessing members’ nutritional and health needs
- Counseling members on nutrition issues and healthy eating habits
- Teaching about meals and nutrition plans based on members’ health conditions, cultural preferences, living situations, budget and other social determinants of health
- Evaluating and monitoring the effects of individualized nutrition plans and making changes as needed
- Collaborating and making recommendations to medical providers on behalf of the members
Common conditions addressed:
- Diabetes
- Gestational diabetes
- Heart disease
- Obesity
- Weight management for pre- and post-bariatric surgery
- Renal disease
- Gastrointestinal disorders
- Cancer
- Anemia
- Failure to thrive
- Modified Atkins diet
- Eating disorder
- Dysphagia
- Nutrient deficiencies
- Exclusions include tube feeding and total parental nutrition (TPN)
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CalOptima Health Encourages IHA Completion for New Members |
CalOptima Health is collaborating with our CCN providers and contracted clinics to improve completion rates for the Initial Health Appointment (IHA). We have started a new quarterly process of conducting IHA chart review audits to see how we can identify successful approaches and areas for improvement.
Per All Plan Letter (APL) 22-030, DHCS still requires the 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 Sets (MCAS) measures specific to infant and child/adolescent well-being visits.
IHA components can be completed over the course of multiple visits, so long as members receive all required screenings consistent with United States Preventive Services Taskforce (USPSTF) guidelines for adults and children. This includes blood lead level testing and anticipatory guidance for children.
As a reminder, IHAs should include at a minimum:
- A physical examination
- The member’s physical and mental health history
- An identification of health risks
- An assessment of need for preventive screenings or services
- A diagnosis and a plan for disease treatment
- Health education
Providers are required to document all efforts to complete IHA, including:
- Members who refuse to complete the IHA
- A minimum of three attempts to schedule members whose IHA is still pending during the first 120 days of enrollment
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NDCs Must Be Properly Documented on Claim Forms |
CalOptima Health is advising providers that they will now be held to DHCS and Centers for Medicare & Medicaid Services (CMS) billing guidelines. As part of these guidelines, providers will need to properly report national drug codes (NDCs) on the CMS 1500 and UB-04 forms. CalOptima Health will not send CMS 1500 or UB-04 forms to CMS or DHCS if the NDC value is not properly reported.
On the CMS 1500 form, NDCs need to be entered in the shaded area of Box 24A, with the product ID qualifier N4 followed by the 11-digit NDC without spaces or hyphens. In Box 24D, providers should enter the two-character unit of measure qualifier followed by the 10-digit numeric quantity administered to the patient.
On the UB-04 form, NDCs need to be entered in Box 43, with the product ID qualifier N4 followed by the 11-digit NDC without spaces or hyphens. The two-character unit of measure qualifier and numeric quantity are optional. If they are not present, it will not result in the denial of a claim. If a provider is reporting the unit of measure qualifier and numeric quantity, enter them immediately after the last digit of the NDC with no space in between.
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DHCS Distributes Fifth Version of 2024 Managed Care Plan Transition Policy Guide |
Updates to the Policy Guide include:
- New communication resources (Section XI). DHCS created and shared transition-related resources that MCPs should utilize to support members, providers and other stakeholders during the MCP transition on January 1, 2024.
- A new transition policy for assessment and screening tools (Section XII). This section explains requirements for three assessment and screening tools in the context of the 2024 MCP transition: Health Information Form (HIF)/Member Evaluation Tool (MET), IHA and Health Risk Assessment (HRA).
- Updates to the Continuity of Care Data Sharing Policy (Section VIII).
- Updates to Transition Monitoring and Oversight Reporting Requirements (Section IX).
- Updates to the Appendix: County-Level MCP Transitions.
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DHCS Letters Outline CSS Special Care Center Provider Requirements |
To continue ensuring high-quality service for the California Children’s Services (CCS) program, DHCS has released two numbered letters (NLs) outlining requirements for nurse practitioners and certified physician assistants providing services in CSS Special Care Centers.
The letters can be found on the CCS website or using the links below:
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Use Shared Decision-Making Aids to Improve Individualized Treatment Plans |
Shared decision-making (SDM) aids are tools that incorporate patients’ needs and preferences into their individualized treatment plans. SDM goes beyond traditional informed consent in health care; it is an interpersonal, interdependent process in which health care providers and patients collaborate to make decisions about patient care. SDM not only reflects medical evidence and providers’ clinical expertise, but also incorporates patients’ values, priorities and choices.
SDM benefits to health care professionals:
- Increased patient satisfaction
- Increased quality of care health care and improved outcomes
SDM benefits to patients:
- Treatment plans that better reflect patient goals
- Improved patient adherence to treatment recommendations
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DHCS Pushes Back CalAIM Justice-Involved Initiative Go-Live Date |
On October 20, DHCS announced that the go-live date for the California Advancing and Innovating Medi-Cal (CalAIM) Justice-Involved Initiative has moved from April 1, 2024, to October 1, 2024. DHCS still anticipates having a full two-year implementation period.
This change will allow correctional facilities, county partners, MCPs and community-based organizations to better prepare for the implementation of pre-release services as required by state law and authorized by CalAIM. The change will also allow more time to finalize policy, complete IT system modifications and for correctional facilities to use Providing Access and Transforming Health Justice-Involved Capacity Building grant funding to make necessary investments.
Additionally, DHCS distributed the updated Policy and Operational Guide for planning and implementing the CalAIM justice-involved reentry initiative.
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Proposition 56 Directed Payments Guide Updated With Latest Codes |
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In response to DHCS revising the Proposition 56 Directed Payments Expenditures File Technical Guidance, CalOptima Health has updated the Directed Payments Guide with the following changes to the Physician Services Program:
- Code 99201 — DHCS corrected guidance says this code is not termed, but will remain active for Proposition 56 payments
- Code 99394 — Changed upper age limit from 17 to 18
- Code 99395 — Changed lower age limit from 18 to 19
- Code 90863 — Added retro term date of December 31, 2020
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Nirsevimab Available for Prevention of Severe RSV Disease |
The Food and Drug Administration (FDA) has licensed nirsevimab (brand name Beyfortus), a long-acting monoclonal antibody, to protect all infants from birth to 8 months old, as well as some children 8 to 19 months old, against severe respiratory syncytial virus (RSV) disease.
Nirsevimab is now available to order through the California Vaccines for Children (VFC) program for eligible infants and toddlers. VFC providers may order nirsevimab on a monthly basis using the order form on their MyVFCVaccines account.
For additional information, please see:
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Please Review the Rights and Responsibilities of CalOptima Health Members |
As a CalOptima Health provider, you should be familiar with our members’ rights and responsibilities. The following are the standards CalOptima Health promises members:
Members have a right to:
- Be treated with respect and dignity by all CalOptima Health, health network and provider staff
- Privacy and to have their medical information kept confidential
- Get information about CalOptima Health, our health networks, our providers, the services they provide and member rights and responsibilities
- Choose a PCP within CalOptima Health’s network
- Talk openly with their health care providers about medically necessary treatment options, regardless of cost or benefit
- Help make decisions about their health care, including the right to say “no” to medical treatment
- Voice complaints or appeals, either verbally or in writing, about CalOptima Health or the care we provide
- Get oral interpretation services in the language that they understand
- Make an advance directive
- Ask for a State Hearing, including information on the conditions under which their State Hearing can be expedited
- Access family planning services, Federally Qualified Health Centers, Indian Health Service Facilities, sexually transmitted disease services and emergency services outside CalOptima Health’s network
- Have access to their medical record and, where legally appropriate, get copies of, update or correct their medical record
- Access minor consent services
- Get written member information in large-size print and other formats upon request and in a timely manner appropriate for the format being requested
- Be free from any form of control or limitation used as a means of pressure, punishment, convenience or revenge
- Get information about their medical condition and treatment plan options in a way that is easy to understand
- Make suggestions to CalOptima Health about their member rights and responsibilities
- Freely use these rights without negatively affecting how they are treated by CalOptima Health, providers or the state
Members are responsible for:
- Knowing, understanding and following the member handbook
- Understanding their medical needs and working with their health care providers to create their treatment plan
- Following the treatment plan they agreed to with their health care providers
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On November 3, DHCS released Revised APL 23-024: Doula Services, which clarifies that MCPs must work with contracted hospitals/birthing centers to ensure there are no barriers to care, ensure that there are available hospitals and coordinate out-of-network access for members when there are barriers at network hospitals and birthing centers.
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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 November 2023. 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 December 2023:
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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:
- 2023 Third Quarter Rate Updates for HCPCS Code J3490
- HCPCS Code J7214 Added as a Medi-Cal Benefit
- CCS Whole Child Model (WCM) Kaiser Permanente Transition
- Ages 16 through 49 Adult Full Scope Medi-Cal Expansion
- ICD-10-CM Diagnosis Code Required for Designated CPT Codes
- TAR Requirements Removed for HCPCS Code J9325
- HCPCS Code J9308 Policy Update
- Updated Exemption from Assembly Bill 97 Payment Reductions
- Skin Substitute Reimbursement Rate Update for 2023
- Skin Substitute Reimbursement Rate Update for 2022
- Rate Update for HCPCS Code J7304
- Billing Tips for Doula Providers
- Provider Manual Revisions
- San Mateo County FQHC/RHC Dental Services Update
- Family PACT Laboratory Services Update
- 2023–24 Commercialized COVID-19 Vaccines Medi-Cal Policy Update
- Implementation Delay for 2023 HCPCS Quarter 4 Update
- LTC Code and Claim Conversion: TAR, Crossover and Claim Completion Instructions
- Reminder: National Drug Code for Nexplanon
- Forthcoming EPC for CCS Claims for Low Protein Therapeutic Foods
- Updated Reimbursement Rates for LEA Medi-Cal Billing Option Program
- Long-Term Care: Subacute Care (Adult and Pediatric) Services
- Long-Term Care Enrollment
For detailed information regarding these changes, please refer to: September General Medicine Bulletin 592, Clinics and Hospitals Bulletin 589, Family PACT Bulletin 193, and Medi-Cal NewsFlashes from September 29, September 29, October 4, October 5, October 6, October 9, October 16 and October 16.
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- CalOptima Health Board of Directors: December 7 at 2 p.m.
- CalOptima Health Joint Provider and Member Advisory committees: December 14 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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