The second phase of our 2025 Annual Compliance Training has launched, including important trainings on diversity, equity and inclusion in the health care setting. All contracted providers need to complete these trainings by December 31, 2025. The trainings can be accessed by logging into the CalOptima Health Provider Portal.

The curriculum consists of three courses: “Cultural Competency: The Foundation of Equitable Health Care,” “Diversity, Equity, Inclusion, and Belonging,” and “Health Equity Fundamentals.” These trainings adhere to the requirements outlined in All Plan Letter (APL) 24-016.

Please complete these trainings as soon as possible. If you have any questions, contact our Provider Relations team at providerservicesinbox@caloptima.org.

With the recently ended government shutdown affecting the CalFresh benefits of 310,000 Orange County residents, we have launched a new page on our website to support our members who may be experiencing food insecurity.

The Important CalFresh News page points members toward additional food resources across the county and explains our Board of Directors’ action to release $8 million from reserves to fund two local food distributors and to send $25 grocery flex cards to members.

We encourage providers to refer their CalOptima Health patients who have questions about CalFresh or food insecurity to this page. 

With Medi-Cal changes coming in the future, CalOptima Health’s mission to keep members healthy has not changed. That is why we launched the Get Care Now Campaign to encourage members to continue seeking care.

The campaign features print ads, digital and social media ads, radio ads, outdoor transit shelter and bus interior ads, as well as place-based ads. Ads for this campaign are expected to run through March 2026. In addition, CalOptima Health created a toolkit for use by providers and community partners. Together, let’s spread the message that members have options for care, including virtual doctor visits and medicine home delivery. A flyer, FAQ and social media content can be downloaded here to share via your communication channels. Join us in encouraging members to stay healthy and well!

As of November 19, 2025, providers can download a monthly Behavioral Health Quality Measure Report from the CalOptima Health Provider Portal. This enhancement is part of our ongoing commitment to streamline access to performance data and support behavioral health quality improvement efforts.

Providers can also download a daily Behavioral Health Emergency Department Report from the Provider Portal. This report will include emergency department (ED) visits related to mental health and substance use disorders.

These resources are designed to provide timely and actionable insights that support better care and outcomes for our members. To access the Provider Portal, visit providers.caloptima.org.

To ensure timely access to care for members referred to specialists, providers should select specialists who are currently accepting new patients or have a preexisting relationship with the member.

The CalOptima Health Provider Portal offers visual cues and alerts, including a pop-up warning, when a provider selects a specialist who is not accepting new patients.

If a provider continues with the selection of a specialist who has a closed panel, the request will be set to “pending” while a nurse reviews to confirm an existing relationship between the member and specialist. If no relationship can be confirmed, the referral will be denied and redirected to an available provider.

CalOptima Health has revised its annual process for surveying timely access and appointment availability, beginning with Measurement Year (MY) 2025. This process includes monitoring and escalation to ensure that all contracted providers meet the timely access to care standards specified in their agreements with CalOptima Health. The process also ensures compliance with state and federal regulatory requirements, including those from the California Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS) and Centers for Medicare & Medicaid Services (CMS). The survey process consists of five distinct phases to be completed within a year, from one annual survey to the next. 

Phase 1: Initial Survey — CalOptima Health’s vendor, ATTAC Consulting Group (ACG), began conducting the MY 2025 annual survey in September 2025. 

Phase 2: Notifications of Noncompliance — Upon completion of the initial survey, providers who do not meet one or more standards or who decline to complete the survey will receive a notification of noncompliance. Notifications will be issued through various channels, including email, fax and mail. ACG will then contact noncompliant providers to educate and clarify any questions regarding the access and availability standards.

Phase 3: Resurvey — Within 30 to 60 days of the noncompliance notification, ACG will fully resurvey providers who did not meet the standards. Providers who remain noncompliant or continue to decline participation will receive a warning letter.

Phase 4: Corrective Action Plan — Three months after receiving the warning letter, noncompliant providers will be resurveyed to assess compliance. Providers who continue to be noncompliant will be issued a corrective action plan (CAP), which will require a formal response from the provider. CalOptima Health will be available to offer consultation on root causes and best practices to help providers meet the standards. 

Phase 5: Compliance Committee Review — During the following annual survey, any provider previously issued a CAP and found to remain noncompliant will be reviewed by the Compliance Committee for potential disciplinary actions, including sanctions. 

If you have questions regarding this process, please email us at QIP@caloptima.org. A meeting can be arranged to discuss the process and concerns. We appreciate your feedback.

We are excited to announce two new at-home health care initiatives to enhance care quality and improve health outcomes for CalOptima Health members. 

Annual Wellness Visits (AWVs)

In partnership with Transtreme, a home risk assessment company, we’ve launched an at-home visit program designed to:

• Deliver comprehensive at-home AWVs. 
• Facilitate routine preventive screenings through referrals. 
• Enhance health outcomes and satisfaction by bringing care into the home. 

Transtreme began outreaching to eligible patients in November 2025, prioritizing CalOptima Health OneCare (HMO D-SNP), a Medicare Medical Plan, members enrolled in CalOptima Health Community Network (CHCN) who have multiple care gaps. Transtreme will schedule and conduct AWVs at patients’ homes, and visit summaries will be shared with your office to ensure continuity of care. 

Closed care gaps will be incorporated into our Healthcare Effectiveness Data Information Set (HEDIS) data, positively influencing your performance for the Pay for Value (P4V) Program. 

At-Home A1C and Kidney Health Testing 

In partnership with Quest Diagnostics, we are sending members confidential, secure and convenient collection kits to check their kidney health and A1C levels at home. These kits are covered by CalOptima Health at no cost to your patients. 

Members will receive their collection kits in the mail in December 2025, which will include everything needed to complete the collection at home. Once the collection is complete, members can return the kits in the included postage-paid envelope. Members can drink water and take their regular medications as prescribed unless advised otherwise by their provider. 

The member and their primary care provider (PCP) will receive the results in the mail within three weeks of returning the kit.  

We believe these programs will be valuable extensions of your care team, helping to ensure that patients receive timely, comprehensive services in the comfort of their own homes. If you have any questions, please contact our Quality Initiatives department at QI_Initiatives@caloptima.org. 

Providers with Medi-Cal patients under the age of 21 are encouraged to review resources from DHCS and attend a webinar to stay up-to-date about the Medi-Cal for Kids & Teens program.

Medi-Cal for Kids & Teens, previously known as Early and Periodic Screening, Diagnostic and Treatment (EPSDT), provides free services to keep children under 21 healthy. To help providers offer these services to members, DHCS has resources available on its Medi-Cal for Kids & Teens webpage. These resources include:

• Member–facing brochures for children up to the age of 12 and those ages 12 to 20 summarizing how Medi-Cal for Kids & Teens works, what it covers, and its role in preventive care screening, diagnosis and treatment.
• A member-facing Medi-Cal for Kids & Teens: Your Medi-Cal Rights Letter, designed to explain Medi-Cal for Kids & Teens and what recourse is available if medically necessary care is denied, delayed, reduced or stopped.
• A standardized training to help providers better understand the program, including how children and families can access medically necessary care, how to bill for covered services and who to reach out to at DHCS with additional questions.

We ask providers to review these resources and share them with their members, as appropriate.

Kids & Teens Overview and Private Duty Nursing Webinar

Additionally, we are hosting a 60-minute webinar on Monday, December 8, 2025, that will review Medi-Cal Kids & Teens services for eligible members. Private duty nursing (PDN) services, a Medi-Cal Kids & Teens benefit, will also be reviewed. Physicians, health network staff and hospital staff are encouraged to attend.

• Time: 11 a.m.–Noon
• Where: Zoom
• RSVP: Click here

For questions about this training or how to register, please contact Soledad Arguello at 657-900-1778 or soledad.arguello@caloptima.org.

The Q4 CHCN Lunch and Learn webinar will happen at Noon on Thursday, December 18. 



Our Provider Relations team uses these Zoom webinars to keep providers informed about important regulatory updates, CalOptima Health news and other relevant information.

To register in advance, please click here. After registering, you will receive a confirmation email with information about how to join the webinar.

OB/GYN providers and others who care for perinatal members can receive an additional reimbursement of up to $1,424.84 while improving outcomes through the Comprehensive Perinatal Services Program (CPSP).

CPSP-approved providers can bill for enhanced services, such as nutrition, psychosocial and health education assessments; trimester follow-ups; and postpartum support. These services not only address social determinants of health but also help improve HEDIS measures. To learn more about CPSP or how to become an approved provider, visit the CPSP page on the California Department of Public Health website.

Are you treating a CalOptima Health Medi-Cal or OneCare member and need to know how to refer them for case management services? Providers may refer members who are with a delegated Medi-Cal health network or OneCare physician medical group (PMG) directly for case management by:

• Contacting the member’s assigned health network or PMG directly
• Contacting Case Management at 714-246-8686
• Faxing a request for case management services to the Case Management triage inbox at 714-571-2455

Emailing information to the Case Management triage inbox at cmtriage@caloptima.org.

Thank you for your continued partnership and support in advancing healthy equity. To that end, contracted providers must ensure their offices update and maintain in their records the following data elements to meet National Committee for Quality Assurance (NCQA) health equity requirements:  

1. Languages Spoken Fluently by Providers: Providers must include all languages other than English in which they can communicate fluently with members regarding medical care.  
2. Race/Ethnicity of Providers: Providers must include race and ethnicity information for all practitioners who provide services to members.  

The above elements are critical for supporting culturally and linguistically appropriate services and ensuring equitable care for all members.  

The provider Add, Change and Termination (ACT) Form on our website includes the following: 

• A section for indicating the language spoken fluently for communicating about medical care (please mark with an “^” next to the language).  
• Information on available language services, such as American Sign Language (ASL), and other interpreter services.  
• The race/ethnicity of the provider.  

To find the ACT form, navigate to the For Providers section, select Documents and Training, and then click on Common Forms.  

If you elect not to use the ACT Form, but have the health equity information listed above, please clearly identify and submit that data via email to provideronline@caloptima.org.  

If you have any questions, please send them to provideronline@caloptima.org. 

Starting January 1, 2026, CalOptima Health and our contracted health networks will use revised timelines for prior authorizations to align with new requirements from DHCS and CMS.

On November 10, 2025, DHCS notified all Medi-Cal managed care plans (MCPs) of these updated federal prior authorization processing requirements, as outlined in the CMS Interoperability and Prior Authorization Final Rule and 42 CFR 438.210(d)(2)(i).

Effective January 1, MCPs such as CalOptima Health must make a prior authorization decision and notify the member and provider within seven calendar days for standard prior authorization requests or 72 hours for expedited requests. These timeframes begin on the date the request is received, regardless of whether all necessary information has been submitted.

This is a change from the current timeframes based on APL 21-011, which are summarized below:

• Standard requests: No longer than five business days from the MCP’s receipt of information reasonably necessary and requested by the MCP to make a determination, not to exceed 14 calendar days following the MCP’s receipt of the request for service. Additionally, there are separate timeframes for notifying the provider and member of the authorization decision.
• Expedited requests: No longer than 72 hours after the MCP’s receipt of all information needed to make an authorization decision for the request for service. This timeframe includes notification to the provider and member of the authorization decision.

DHCS will issue additional guidance as needed to support implementation and compliance monitoring.

We will update our 2026 Evidence of Coverage, Member Handbook, Provider Manual, policies, and website to reflect these new timeframes.

If you have any questions regarding the new prior authorization timeframes, please contact Provider Relations at providerservicesinbox@caloptima.org.

On August 15, 2025, DHCS posted updated General Medicine and Durable Medical Equipment and Medical Supplies bulletins to the Medi-Cal website. A summary of these updates, which may impact CalOptima Health, is outlined below:

• PT Code 87636 is Reimbursable as a CLIA-Waived Test — Retroactive for dates of service on or after July 1, 2021.
• Modifier SL Allowable for CPT Code 90661 — Retroactive for dates of service on or after August 1, 2024, when used on claims for members not a part of the Vaccines for Children program.
• Updated Hospice Reimbursement Rates — Retroactively for dates of service on or after October 1, 2024.
• Justice-Involved (JI) Reentry Initiative: Authorized Provider Types Updated —Retroactive for dates of service on or after October 1, 2024.
• Required ICD-10-CM Diagnosis Codes Updated for HCPCS J1756 — Dates of service on or after June 1, 2025.
• Contracted Medi-Cal Fee-for-Service Intermittent Urinary Catheter Supplies Update — Dates of service on or after July 1, 2025.
• Policy Update for Echography and Radiological Ultrasound CPT Codes — Dates of services on or after August 1, 2025.
• Licensed Marriage and Family Therapist (LMFT) Services for Indian Health Services Memorandum of Agreement (IHS-MOA) and Tribal Federally Qualified Health Centers (FQHC) Providers New Effective Date — Dates of service on or after August 1, 2025.
• New Treatment Authorization Request (TAR) and Non-Benefit List Provider Manual Sections — Effective August 1, 2025.
• Clarification of Non-Benefit Billing Policy with an Approved TAR — Effective August 1, 2025.
• Frequency Update to PLA Codes 0037U, 0120U, 0239U, 0244U, 0287U and 0314U — Dates of service on or after September 1, 2025.
• Genetic Testing and Counseling Services Clarification — Dates of service on or after September 1, 2025.
• TAR Criteria Update for Select Durable Medical Equipment (DME) HCPCS Code — Dates of service on or after September 1, 2025.
• Clinical Laboratory Improvement Amendments (CLIA) Waived Test Reimbursement for Pharmacy Providers — Dates of service on or after September 1, 2025.
• Code 0345U is a New Medi-Cal Benefit — Dates of services on or after September 1, 2025.
• Additional CLIA-Waived Tests Procedure Codes — Varies by CPT code.

An article in the November 2025 Provider Update regarding updated billing addresses for denied/unpaid claims and provider disputes gave an incorrect address for the Medi-Cal and PACE lines of business. The correct address for denied/unpaid claims is:

CalOptima Health, A Public Agency

Attn: Grievance and Appeals Resolution Unit

P.O. Box 57015

Irvine, CA 92619

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

• Update to the List of Contracted Waterproof Sheeting
• HCPCS Code J1412 Dosing Based on Weight Update
• Required Modifiers LT and RT Added to HCPCS Code Q5155
• Clarified Guidance for Billing HCPCS Codes S5110 and S5111 for BHT Services
• CCS Gait Analysis Studies Billing Policy Reminder
• 2025 Clinical Laboratory Services Rate Update
• TAR Requirement Removed for HCPCS Code J9309
• Rate Update for Durable Medical Equipment
• Maximum Dose Update for HCPCS Code J3402
• Pulse Oximetry CPT Codes 94761 and 94762 Are Medi-Cal Benefits
• CPT Surgery Code 66174 Added as a Benefit
• Diagnosis Restrictions Removed for CPT Codes 84702 and 84703
• Updated: Medi-Cal List of Contracted Incontinence Absorbent Products
• Provider Dispute Resolutions With Managed Care Plans
• Updates to the Medi-Cal List of Contracted Incontinence Creams and Washes
• Provider Manual Revisions
• Medi-Cal Adult Expansion Freeze Begins January 2026
• Reminder: Provider Guidelines for ORP Provider Enrollment Requirements
• November 2025 Update to AEVS: Carrier Codes for Other Health Coverage
• Auditory Diagnosis Codes 92622 and 92623 Covered Under HACCP
• Justice-Involved (JI) Reentry Initiative: FQHC and RHC Providers Authorized to Provide JI Services
• 2026 Rate Increase for HCBS Waivers and Programs
• FS/NF and FS/SA Workforce Standards Program Rates for Calendar Years 2024 and 2025
• Ordering, Referring and Prescribing (ORP) Web Page No Longer Available
• Notification: DRG Payment System Update to Hospital-Acquired Condition V43.0
• National Correct Coding Initiative Quarterly Update for October 2025: PTP Replacement File
• Reminder: Timely Transfer of Care and/or Consultation for Pregnant or Postpartum Medi-Cal Members

For detailed information regarding these changes, please refer to General Medicine Bulletin 617, Medi-Cal Program & Eligibility Bulletin 40, Audiology and Hearing Aids Bulletin 602, Clinics and Hospitals Bulletin 614, Home Health Agencies/Home and Community-Based Services Bulletin 614 and Medi-Cal NewsFlashes from October 20, October 22, November 5, November 10, and November 10.

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

Click on the link below to find an outline of changes made to CalOptima Health policies and procedures during November 2025. 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 December 2025:

Health education webinars

• CalOptima Health Board of Directors: December 4 at 2 p.m.
• Joint Meeting of the Provider and Member Advisory Committees: December 11 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 us on Facebook, Instagram, X and LinkedIn.