Thank You for Your Feedback on Our Provider Satisfaction Survey! |
CalOptima Health thanks you for your participation in our Provider Satisfaction Survey. We value your input and partnership and look forward to addressing the areas of improvement identified in your survey responses. As your partner, we want to ensure that your experience with us is positive and rewarding.
Your satisfaction while providing the highest quality health care is important to us, and your feedback is essential to CalOptima Health’s mission. Many interventions are underway to improve CalOptima Health’s provider experience, as listed below.
Thank you for your participation in the CalOptima Health Community Network and your ongoing support of our mission of serving member health with excellence and dignity, respecting the value and needs of each person. To submit any recommendations for improvement, please contact us at 714-246-8600 or providerservicesinbox@caloptima.org.
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Identified Areas of Improvement |
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Targeted Improvements Made |
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Issues with authorizations and referrals |
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Treatment authorizations are being processed within mandated timeframes:
- Inpatient Concurrent – Urgent: 24.58 hours (72 hours mandated)
- Prior Authorization – Urgent: 12.33 hours (72 hours mandated)
- Prior Authorization – Routine: 1.31 days (5 days mandated)
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Increasing reimbursement rates |
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CalOptima Health’s Board of Directors approved rate increases for Medi-Cal fee-for-service mental health outpatient assessment and counseling services effective January 1, 2023. |
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Difficulty contacting Claims, Customer Service, GARS and Provider Relations departments |
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Our Customer Service department has assigned additional staff to answer provider calls regarding claims and GARS statuses.
Provider Relations has assigned staff and created a process to streamline provider inquiries including the CalOptima Health Provider Portal and initial provider onboarding.
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Improving contracting and credentialing efforts |
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CalOptima Health has designated provider representatives to assist prospective providers with the end-to-end onboarding process. Additionally, provider communications, credentialing and contracting requirements are being streamlined at point of entry. |
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OneCare Providers Need to Submit Prior Authorizations for Medi-Cal Wrap Services |
As of January 1, providers participating in OneCare (HMO D-SNP), a Medicare Medi-Cal Plan, need to submit prior authorizations for Medi-Cal wrap services to CalOptima Health.
Under the previous OneCare Connect program, which ended December 31, 2022, these non-Medicare-covered services were overseen by members’ health networks. These services include but are not limited to:
- Hearing aids
- Durable Medical Equipment (various types), if not covered by Medicare
- Ear mold/insert not disposable (any type)
- Incontinence supplies over what Medi-Cal allows
- Non-Emergency Medical Transportation (NEMT) — wheelchair vans
For a complete list of Medi-Cal wrap authorization codes, please see this table.
Providers must submit prior authorization through the Provider Portal. Medi-Cal wrap authorizations need to be submitted under the Medi-Cal line of business for the member. Authorizations submitted under the OneCare line of business will produce an error message like the one pictured above.
Please see this PDF for detailed instructions on how to submit wrap services authorizations.
If you have not registered for the Provider Portal yet, please see our website, which contains helpful information such as a step-by-step Provider Portal training video, Provider Portal Reference Guide, etc.
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CalOptima Health Members Need to Verify Addresses Ahead of Medi-Cal Redetermination |
Providers can help inform members of an important step for the verification of their Medi-Cal eligibility.
Starting April 1, the Department of Health Care Services (DHCS) is returning to regular Medi-Cal eligibility and enrollment operations. During the declared COVID-19 Public Health Emergency (PHE), Medi-Cal members retained coverage regardless of any changes in circumstances. However, as part of the Consolidated Appropriations Act of 2023 signed by President Biden, the continuous coverage requirements will end after March 31, 2023, regardless of whether the PHE has ended. Counties will then have to determine if members are still eligible for Medi-Cal.
CalOptima Health members will receive a mailed letter asking to confirm their contact information as an initial step in this verification effort.
If a member has changed addresses or other contact information during the PHE, they should notify the County of Orange Social Services Agency by calling 855-541-5411 or visiting https://ssa.ocgov.com.
Providers with questions can call CalOptima Health’s Provider Relations department at
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OneCare Connect Has Transitioned to OneCare |
CalOptima Health’s OneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan) ended on December 31. OneCare Connect members have now transitioned to OneCare.
OneCare has been a CalOptima Health program since 2005. It will continue to assist members with their health care needs and coordinate benefits, including medical care, home- and community-based services, medical supplies, and medications. As before, members won't have premiums, fees or deductibles to obtain health care services from providers.
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CalAIM Forms Updated With New Populations of Focus and Community Supports |
CalOptima Health has revised its California Advancing and Innovating Medi-Cal (CalAIM) referral forms with updated information for new Community Supports and populations of focus (POFs) that were added on January 1.
The updated forms include:
- Enhanced Care Management (ECM) Referral Form
- Community Supports Referral Form
The newly added POFs are adults eligible for long-term care and adult nursing facility residents. The new Community Supports are respite services, environmental accessibility adaptations (home modifications), nursing facility transition/diversion to assisted living facilities, community transitions to home/nursing facility transition to a home, and asthma remediation.
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Virtual Community Resource Fair to Focus on Housing |
CalOptima Health will host a four-part virtual community resource fair in January highlighting housing resources in Orange County.
The fair will consist of four Zoom sessions, each covering the housing resources available for a different group. Advance registration for each session is required:
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CalOptima Health 2023 Report to the Community Highlights Accomplishments and Future Plans |
CalOptima Health released the agency’s 2023 Report to the Community, showcasing accomplishments in 2022, previewing plans for new programs and initiatives in 2023, and spotlighting stories from our members, providers and community partners.
The report outlines several improvements made during 2022 aimed at supporting providers including better communications, new medical leadership, increased supplemental COVID-19 funding and upgrades to the Provider Portal.
“CalOptima Health’s 2023 Report to the Community looks back on a busy 2022 and forward to a bright future,” said CalOptima Health Chief Executive Officer Michael Hunn and Chief Medical Officer Richard Pitts, D.O., Ph.D., in a joint letter introducing the report. “Perhaps you noticed our vibrant redesigned logo, experienced the energy of participating in our community events or helped a member access an impactful new benefit. A lot changed in 2022, and it was purposeful and positive.”
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January Is Cervical Cancer Awareness Month |
As a health professional, you know catching cancer early saves lives. Pap smears have been shown to decrease cervical cancer mortality. However, many of your patients may still need a cervical cancer screening.
Patients often report not being screened because their provider did not recommend it. By assessing your patient’s need for a cervical cancer screening and recommending a test, you increase the likelihood of completed screening. Begin talking to your patients about cervical cancer screening when they turn 21 years old.
You can also increase cancer screenings by making it easier for people to get screened. Offer alternative hours, mobile clinics and help with transportation. The transportation benefit is at no cost to CalOptima Health members when arranged by CalOptima Health. Members can call Customer Service at 888-587-8088 (TTY 711) to obtain more information.
CalOptima Health Medi-Cal members ages 21–64 may be eligible for a gift card after completing a cervical cancer screening. Visit www.caloptima.org/healthrewards to learn more.
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Measurement Year 2022 HEDIS Documentation Training Available |
Documentation requirement training for Health Effectiveness Data and Information Set (HEDIS) Measurement Year 2022 is available on CalOptima Health’s website.
This training contains annual content to help providers and staff understand the specifications and required documentation to meet compliance for each measure while working with CalOptima Health members.
If you have any questions regarding the training, please contact Senior HEDIS Project Manager Irma Munoz at 714-347-5762 or imunoz@caloptima.org.
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Schedule Patient Annual Wellness and Other Face-to-Face Visits for 2023 |
Providers need to complete their patients’ annual wellness visits and face-to-face chronic conditions management for 2023. After completing these visits, please provide the supporting progress notes for the 2023 dates of service along with completed provider attestation forms. Any conditions marked as "present" must be supported in the provider documentation. Providers should also update patients’ problem list, past medical/surgical history, social history, medication reconciliation, family history, allergies, etc.
Following face-to-face visits with patients, primary care providers (PCPs) should elaborate in their documentation the clinical thought process for each patient’s chronic condition status, including how they are being managed and treated by specialists. This serves as an acknowledgment that records have been reviewed as part of a patient’s continuum of care coordination.
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On December 27, DHCS distributed APL 22-029: Dyadic Care Services Benefit. This APL explains the coverage requirements for providing the new dyadic care services benefit that became effective January 1, 2023.
- On December 27, DHCS released APL 22-030: Initial Health Assessment. This APL covers the requirements for the Initial Health Assessment that began January 1, 2023. It supersedes APL 13-017 and Policy Letters 13-001 and 08-003.
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Health Education: Trainings and Meetings |
Click below for a list of training webinars and links happening in January and February 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:
- Booster Dose for Novavax and Pediatric Bivalent Pfizer-BioNTech and Moderna COVID-19 Vaccines
- 2023 HCPCS Quarter 1 Update
- New Medi-Cal Policy for Doula Services
- New Benefit for Same-Day Newborn Admission and Discharge
- CPT Codes 99152 and 99153 are PE4PW Benefits
- New Benefits for Home Sleep Apnea Tests
- Coming Soon: Provider Portal Authorization for Medi-Cal Submitters
- Newborn Metabolic Screening Panel Code Rate Update
- Medi-Cal Hospice Rates Update for 2022–2023
- National Correct Coding Initiative Quarterly Update for January 2023
- Dyadic Services Added as Medi-Cal Benefits and Psychotherapy Updates
- Update: Specific Continuous Glucose Monitoring and Disposable Insulin Delivery Devices No Longer DME Policy
- Incontinence Product List Update
- Long-Term Care Skilled Nursing Facility Services
- CMC Plans No Longer Covered in CCI Counties
- Mpox Vaccines and Laboratory Test Added as Family PACT Benefits
- Multipurpose Senior Services Program Untimely Submission Claims Denials
- UnitedHealthcare Community Plan of California No Longer a Medi-Cal MCP in San Diego County
- CalAIM Mandatory Managed Care Enrollment Transition Phase II
- Senior Care Action Network (SCAN) Health Plan Expansion
- Mpox Vaccines Reimbursement at the Medicare Rate
- Erroneous Cal MediConnect (CMC) Notice
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Reimbursement Adjustments for 4th Quarter 2021 through 3rd Quarter 2022
- Coming Soon: Rate Update for Diagnostic Radiology Code
For detailed information regarding these changes, please refer to December General Medicine Bulletin 582, December Durable Medical Equipment and Medical Supplies Bulletin 567, and Medi-Cal NewsFlashes from December 6, December 7, December 9, December 13, December 16, December 16, December 22, December 23, December 27, December 28 and December 28.
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- CalOptima Health Board of Directors: February 2 at 2 p.m.
- CalOptima Health Joint Provider and Member Advisory committees: February 9 at 8 a.m.
At this time, all meetings have an option for virtual attendance due to COVID-19. Visit the CalOptima Health website for more information.
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Follow Us on Social Media |
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CalOptima Health regularly posts on social media to engage members with heath tips, community resources, event dates, program updates and other pertinent information. Follow the agency on Facebook, Instagram, Twitter and LinkedIn.
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CalOptima Health, A Public Agency www.caloptima.org
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