CalOptima Health February 2024 Provider Update

February 7, 2024

In This Issue

In this issue of the Provider Update, read about an upcoming virtual learn meeting for CalOptima Health-contracted providers.

You’ll also find information about using topical fluoride to promote pediatric dental health, a new partnership between homeless shelters and FQHCs, and a proposed PP-GEMT fee increase.

This update also contains the monthly roundup of All Plan Letters, updates to CalOptima Health policies, health training webinars and details for upcoming meetings.

Provider News

New Internal Clinical Management Platform Goes Live

On February 1, CalOptima Health implemented a new internal clinical management platform called Jiva to manage utilization management, case management, appeals and grievances. The new system will increase efficiency and move us toward our vision of having same-day treatment authorizations by 2027.

All incoming faxes and Provider Portal treatment authorizations will automatically route to the new platform without any action on your part.

We don’t anticipate providers having any issues because of this change. In the event you do experience issues, please contact us at 714-246-8600, and we will expedite the resolution.

All CalOptima Health Community Network (CCN) providers are invited to the first quarterly virtual learn meeting of 2024.

The Zoom webinar will be held on Thursday, February 29, at 1 p.m. and cover topics such as doula services, health and wellness, dyadic services, Initial Health Appointments and the removal of the second-level dispute from CalOptima Health’s claims process.

Providers can register in advance using this link.

Topical Fluoride's Vital Role in Pediatric Oral Health

February is National Children’s Dental Health Month, which is a good reminder that primary care providers (PCPs) play an important role in the oral health of patients ages of 1–20. Tooth decay is the most common chronic condition affecting children, but the application of topical fluoride is highly effective in preventing this decay. Guidelines from the American Academy of Pediatrics (AAP) and the United States Preventive Services Task Force (USPSTF) recommend that PCPs and other qualified providers apply topical fluoride varnish at least once every six months to children’s teeth.

Fluoride has consistently been proven effective at preventing tooth decay, which can lead to pain, loss of teeth and serious infections when left untreated. PCPs have a unique opportunity to prevent dental disease by applying fluoride varnish in the office. Topical Fluoride in Children (TFL-CH) is also a new quality Pay for Value (P4V) measure for CalOptima Health providers for 2024.

Dental care and the application of topical fluoride is a no-cost Medi-Cal benefit. Support the oral health of your pediatric patients by doing the following at every visit:

Assess whether the patient has a dental home. You can help your patients find a dental home by visiting Smile, California at smilecalifornia.org/find-a-dentist or by calling the Telephone Service Center at 1-800-322-6384. Smile, California manages Medi-Cal dental benefits.
Encourage routine dental visits at least two times a year.
Apply topical fluoride varnish in the office if the child has not had a fluoride application within the past six months or does not have a dental home. If fluoride varnish was applied by a dental provider, support compliance by documenting the date of service in the patient’s medical record and specify that topical fluoride was applied by a dental provider.

For more information on topical fluoride application, please see the following resources:

CalOptima Health Topical Fluoride Varnish Guide
Steps to Implement Fluoride Varnish in Your Medical Practice
Smile, California Fluoride Fights Tooth Decay educational flyer in English and Spanish
AAP Fluoride Use in Caries Prevention in the Primary Care Setting, 2020
USPSTF Prevention of Dental Caries in Children Younger Than 5 Years: Screening and Interventions, 2021

For any questions, please contact our Quality Initiatives department at QI_Initiatives@caloptima.org.

New Program Encourages Partnerships Between FQHCs and Homeless Shelters

CalOptima Health is pleased to introduce the Homeless Clinic Access Program (HCAP), a partnership between Federally Qualified Health Centers (FQHCs) and homeless shelters to coordinate mobile clinics and provide accessible, reliable and quality medical care for individuals experiencing homelessness in Orange County.

HCAP began on January 1, 2024, and is designed to be inclusive and open to all members, regardless of network affiliation. Participating FQHCs will receive an incentive from CalOptima Health for providing services at shelters based on submitted claims documenting the services provided. Shelters will also receive an incentive for their participation in HCAP.

This list outlines current FQHC and shelter partnerships. Weekly schedules will be posted by the shelter.

If you have any questions regarding HCAP, please contact Jasmine Awadallah, Medi-Cal and CalAIM Program Manager, at jasmine.awadallah@caloptima.org. Health networks can direct their questions to Diana Rodriguez, Provider Relations Manager, at drodriguez@caloptima.org.

Reminder: CalOptima Health Has Ended Contracts With Prime Hospitals

For CCN members and providers — As of February 5, 2024, CalOptima Health ended its Medi-Cal and OneCare contracts with the following Prime Healthcare hospitals:

Garden Grove Hospital Medical Center
Huntington Beach Hospital
La Palma Intercommunity Hospital
West Anaheim Medical Center

What does this mean?

As a result of this termination, these facilities are no longer contracted to provide elective, scheduled services for CalOptima Health members, but members still have access for emergency services. Impacted members were notified in early January.

If you have an existing authorization for services, CalOptima Health will work with you to coordinate care and make sure that all medically necessary treatments provided to our members continue.

If you have questions regarding authorization of services, you may call CalOptima Health’s Utilization Management department at 714-246-8686. For escalation inquiries, please contact Judy Riley, Manager Outpatient Authorizations, at 657-900-1273.

For general questions, please contact CalOptima Health’s Provider Relations department at 714-246-8600 or refer to the FAQ here.

MCPs Participating in Child Preventive Health Initiative

The Department of Health Care Services (DHCS) has partnered with the Institute for Healthcare Improvement (IHI) to design the 12-month Child Health Sprint Collaborative to improve preventive services for children in California.

The sprint collaborative will focus on helping managed care plans (MCPs) implement best practices in children’s preventive services with their network providers to offer effective, equitable whole-person pediatric care for the Medi-Cal population. All MCPs in California, including CalOptima Health, are required to participate.

Every one to two months, MCPs will implement easily accessible, high-impact interventions and measure the results. IHI staff and subject matter experts will provide training and guidance throughout the 12-month collaborative.

For more information about this initiative, please see this DHCS flyer.

DHCS Proposes PP-GEMT Add-On Fee Increase

DHCS has proposed increasing the Public Provider Ground Emergency Medical Transportation (PP-GEMT) add-on increase fee for Calendar Year (CY) 2024.

The PP-GEMT Program was implemented on January 1, 2023, to provide increased reimbursements through the add-on increase fee for non-contracted emergency medical transportation provided by eligible public GEMT providers. The add-on increase applies to the fee-for-service schedule rate for certain emergency medical transport procedure codes and a rating increment applied to primary capitation rates for contracted Medi-Cal MCPs. DHCS may periodically adjust the statewide add-on increase to account for inflation, trends or other material changes.

The proposed CY 2024 add-on increase has not yet been finalized. MCPs will continue reimbursing public GEMT providers for eligible trips using the approved CY 2023 add-on amount of $946.92 until the new CY 2024 add-on is finalized by DHCS and approved by the Centers for Medicare & Medicaid Services (CMS). DHCS will share a revised PP-GEMT Interim Guidance or All Plan Letter (APL) with updated information about the CY 2024 add-on increase after receiving CMS approval.

To learn more about the PP-GEMT program please visit the DHCS PP-GEMT Program website. The website also contains a list of public GEMT providers as of December 15, 2023.

You can also visit the DHCS Public Notices for 2024 Proposed State Plan Amendments page for additional details regarding the overall proposal. Upon submission to CMS, the State Plan Amendment will be posted on the DHCS Pending State Plan Amendments page.

Monthly Notices

All Plan Letters (APLs)

On December 20, DHCS distributed APL 23-031: Medi-Cal Managed Care Plan Implementation of Primary Care Provider Assignment for the Age 26–49 Adult Expansion Transition, which provided MCPs with guidance on how to ensure that individuals retain their PCP during the Medi-Cal expansion to all adults ages 26 through 49.
On December 22, DHCS sent out APL 23-032: Enhanced Care Management Requirements, which contains guidance for MCPs for providing the Enhanced Care Management (ECM) benefit. This APL supersedes APL 21-012.
On December 27, DHCS distributed Revised APL 23-034: California Children’s Services Whole Child Model Program, which gives direction to MCPs participating in the California Children’s Services (CCS) Whole Child Model (WCM) Program.
On December 27, DCHS released CCS Numbered Letter (NL) 12-1223: California Children’s Services Program Whole Child Model (Revised), which provided guidance to county CCS programs about requirements pertaining to the WCM Program. This NL aligns with APL 23-034.
On December 28, DHCS updated Attachment 1: Rates for American Indian Health Programs for APL 17-020 and Attachment 2: Rates for Tribal Federally Qualified Health Centers (Tribal FQHC) for APL 21-008.

Policies and Procedures Monthly Update

Click on the link below to find an outline of changes made to CalOptima Health policies and procedures during January 2023. The full description of the policies below is available on CalOptima Health’s website at:

www.caloptima.org/en/ForProviders/Resources/ManualsPoliciesandGuides.aspx.

Policies and Procedures Monthly Update

Health Education: Trainings and Meetings

Click below for training webinars and meetings happening in February 2024:

Health education webinars

Policy Code Update

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

Injectable Drugs Available for Managed Care Plans
2024 HCPCS Quarter 1 Update
The Newborn Gateway to Launch in July 2024
Presumptive Eligibility Moving into the Provider Portal
Medi-Cal Introduces the New Transaction Center
Contracted Incontinence Supplies Product Updates
Policy Update for PLA Codes 0334U, 0379U and 0391U
Update to ICD-10-CM Codes 2021 Yearly Clinical Medical Policy
Rate Updates for HCPCS Codes A4269, J3490 and J7304
Updated Billing Information for CPT Code 76819
Important: Continuous Coverage Operational Unwinding Plan Reminder
Provider Manual Revisions
Update to the Orthotic and Prosthetics Provider Manual
LTC Claim Form and Code Conversion: Transition to UB-04 Effective February 2024
Whole Child Model Expansion
2024 Managed Care Plan Transition
Long-Term Care: Subacute Care (Adult and Pediatric) Services
Long-Term Care Enrollment
Revisions to Medi-Cal Waiver Program
Reminder to Outpatient Medical Supplies Billing and Coverage Policy for HCPCS Codes S8189 and T5999
Medi-Cal Targeted Provider Rate Increases Effective January 1, 2024
Place of Service Code 27 May Be Used for Street Medicine

For detailed information regarding these changes, please refer to Medi-Cal Program & Eligibility Bulletin 18, General Medicine Bulletin 595, Durable Medical Equipment and Medical Supplies Bulletin 580, Long Term Care Bulletin 563, and Medi-Cal NewsFlashes from December 27, December 27, December 27, December 27, December 29, January 4, January 5 and January 16.

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

Upcoming Meetings

CalOptima Health Board of Directors: March 7 at 2 p.m.
CalOptima Health Joint Provider and Member Advisory Committees: February 8 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.

For Questions

Please contact Provider Relations at 714-246-8600 or at providerservicesinbox@caloptima.org