Providers and Members Invited to Join CalOptima Health Advisory Committees |
CalOptima Health is asking for help filling open seats on our Board of Directors’ advisory committees that shape how the health plan interacts with and supports both our providers and members.
There are currently five open seats on our Provider Advisory Committee (PAC), a 15-member body representing diverse provider constituencies, including health networks, hospitals, physicians, nurses, allied health professionals, long-term care services and community health centers. PAC members serve as liaisons to CalOptima Health’s Board of Directors and advise the Board and staff on provider issues.
The following seats are available:
- Allied health services representative
- Behavioral health/mental health representative
- Health network representative
- Nurse representative
- Physician representative (fulfills a term ending in 2025)
CalOptima Health is also asking that providers encourage members to serve on our Member Advisory Committee (MAC) and Whole-Child Model Family Advisory Committee (WCM FAC). Both committees advise the Board and CalOptima Health staff and are composed of members, authorized family representatives and health care professionals. We are currently seeking to fill three authorized family member seats, a consumer advocate seat and a community-based organization seat on the WCM FAC and the following seats on the MAC:
- OneCare (HMO D-SNP), a Medicare Medi-Cal Plan, member or authorized family member (two seats)
- Behavioral health/mental health representative
- Children representative
- Family support representative
- People with special needs representative
OneCare members appointed to the MAC and WCM FAC are eligible for a $50 stipend per meeting they attend, up to six meetings per year.
If you or one of your patients is interested in serving on one of these committees, please visit the PAC, MAC or WCM FAC pages on our website to learn more and download an application.
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CalOptima Health Shares Updates to Help Providers Complete Initial Health Appointments |
Per All Plan Letter (APL) 22-030, the Department of Health Care Services (DHCS) continues to require the Initial Health Appointment (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 Set (MCAS) measures specific to infant and child/adolescent well-being visits.
To continue supporting providers in completing IHAs, CalOptima Health is sharing the following important updates:
Quarterly IHA Chart Review Audits Effective January 1, 2024: We are collaborating with our contracted CalOptima Health Community Network (CCN) providers and clinics to improve completion rates for the IHA and to identify what is working well and areas of improvement.
Key Performance Indicator (KPI): As of January 1, KPI metrics for IHAs for delegated networks have been increased to 50%.
- The new benchmark will be included in the quarterly meeting reports.
- CalOptima Health will support health networks in meeting this goal by providing outreach to all new members.
The IHA report is now available on the Provider Portal:
- Visit https://provider.caloptima.org/
- Once logged in, click on “Reports,” select “Initial Health Appointment” from the drop-down menu, then input your provider details and click “Get IHA Report” to download the Excel document.
- The Primary Care Provider (PCP) Member Roster now also has an “IHA Due Date” column to help identify new members.
For general information about the IHA, providers can use the following resources:
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CalOptima Health Performs Well in DHCS Quality Measures |
CalOptima Health is proud to announce that we met the 2022 DHCS standard for 100% of measures in the domains for behavioral health, chronic disease management, and reproductive health and cancer prevention. In the child health domain, CalOptima Health reached the 2022 DHCS standard for over 75% of measures. In total, CalOptima Health met the 2022 DHCS standard for 93.3% of all measures, ranking us among the top managed care plans in the state. CalOptima Health was not among the 18 plans across the state that received a financial sanction for low-quality standard results. Thank you to you and all our provider partners for your continued focus on quality. |
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Continuing Education Webinar to Focus on Gender-Affirming Care |
Providers are invited to learn about the components of gender-affirming care during a continuing education webinar on Wednesday, March 20 at 12:30 p.m.
The 90-minute course will present current clinical guidelines pertaining to the hormonal, surgical and social transition of gender nonconforming people, as well as current, safe and inclusive terminology in transgender health. Providers can earn 1.5 continuing medical education and continuing education credits for attending.
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Temporary Change to Claims Process In Place Following Change Healthcare Cyberattack |
On February 21, Change Healthcare, a subsidiary of UnitedHealth Group, experienced a cyber incident, leading the organization to proactively take its systems offline to safeguard partners and patients. To mitigate risks, we disconnected our systems from UnitedHealth Group subsidiaries, including Change Healthcare and Optum Healthcare, the latter of which acquired Change Healthcare in 2021.
Certain Change Healthcare functions used by CalOptima Health have been impacted — primarily claims payments and claims clearinghouse services. Claims submitted through Change HealthCare may not have been received by us. We are asking providers to bill any urgent claims through alternative channels to ensure CalOptima Health receives your claims data. We recommend that any claims submitted through Change Healthcare beginning February 19, 2024, be resubmitted using one of these alternatives:
Office Ally Submission (preferred method)
CalOptima Health has a contract with Office Ally to receive electronic data interchange (EDI) claims. There is no cost to the provider for services through our clearinghouse. To register and submit electronically, contact:
Office Ally
866-575-4120
Paper Claim Submission
Hard copy paper claims may be submitted directly to CalOptima Health at:
CalOptima Health
P.O. Box 11037
Orange, CA 92856
In addition, at this time, CalOptima Health is unable to provide claims status through our Provider Portal. Please note that medical care, member services and treatment authorizations for CalOptima Health members remain unaffected by the incident.
While we anticipate restoring connectivity with the Optum network shortly, contingent upon receiving an attestation letter certifying network safety, the recovery process for the Change Healthcare network is anticipated to take significantly longer. We will provide an update once the information is available. Thank you for your assistance and patience as we work to restore our normal claims processes.
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Review the Claims Dispute Process for CalOptima Health |
Reminder — On January 1, CalOptima Health transitioned to a single internal review process for CCN disputes and claims where CalOptima Health has financial responsibility. This process is handled through our Grievance and Appeals Resolution Services (GARS) department. The one-level internal review streamlines the process by providing a fast, fair and cost-effective dispute resolution mechanism to process and resolve contracted and non-contracted provider disputes and reduces the timeframe for providers to receive a final decision from CalOptima Health.
This change does not impact the claims payment or provider dispute processes for CalOptima Health-contracted health networks. For disputes related to a CalOptima Health-contracted health network’s claim payment, a provider must submit the dispute through the appropriate health network for resolution. If the provider is not satisfied with the health network’s decision, they may submit a request for a second-level review by CalOptima Health’s GARS department.
The provider complaint process follows different procedures, depending upon whether the provider filing the complaint is a Medi-Cal, OneCare or non-contracted provider. To review the complete provider complaint process, see section R1 of the CalOptima Health Provider Manual.
To guide you on the process and where to submit your request, we have created two new forms to distinguish the different types of requests:
For additional information, please visit the Provider Complaint Process section of our website.
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Your Medicare Medi-Cal Patients May Benefit from CalOptima Health’s OneCare Plan |
If you have patients who are eligible for both Medicare and Medi-Cal, then CalOptima Health’s OneCare plan might be right for them.
To be eligible for OneCare, a member must be:
- Age 21 and older
- Living in Orange County
- Enrolled in Medicare Parts A and B
- Receiving Medi-Cal benefits
OneCare supplemental benefits for 2024 include:
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Prescription medicines: Zero co-pays for generic and brand-name medicines throughout the year. Members will not have any donut hole.
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Over-the-counter (OTC) medicines: $100 allowance per quarter to buy items online, over the phone or by mail order.
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Vision care through Vision Service Plan (VSP) providers: A new pair of eyeglasses or contact lenses every year with a $250 limit.
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Hearing services: $1,000 allowance every year for hearing aids above the Medi-Cal limit of $1,510 per year.
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Fitness benefits: No-cost gym memberships available at many locations in Orange County, one home fitness kit, access to digital workout videos and much more.
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Unlimited transportation: Covered by Medi-Cal to plan-approved medical services, such as doctor visits, labs, X-rays, the hospital or the pharmacy. OneCare members have the supplemental benefit of unlimited transportation to and from the gym.
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Worldwide emergency care, urgent care and emergency transportation services outside the U.S.: Services to treat a condition that needs immediate medical care, such as an injury or a sudden medical illness. Members pay for the services, and OneCare will reimburse them up to $100,000 per year.
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Companion care: Up to 90 hours of non-medical services per year to help with activities of daily living, such as transportation, light housework, technology, exercise, grocery shopping, medicine deliveries, etc.
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Annual physical examination: One physical exam per year, including laboratory services as needed. The plan pays for one annual wellness visit every 12 months to make or update the member’s care plan to help prevent illness.
Dental services are provided through the Medi-Cal Dental program, but not as a supplemental benefit.
- Coverage includes dental exams, cleaning, crowns, root canals and partial dentures with adjustments, repairs and relines.
- Up to $1,800 in covered services per year and possibly more if medically necessary or if the member is living in a nursing home.
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DHCS Issues Updated ECM and Community Supports Guidance |
Updated guidance includes:
- Claims and encounter data that ECM and Community Supports providers submit to MCPs
- Encounter data that MCPs submit to DHCS to monitor program performance and integrity
Based on feedback from stakeholders throughout the first year and a half of the ECM and Community Supports implementation, DHCS updated this guidance to increase the level of statewide data standardization and ease administrative burden.
MCPs, ECM and Community Supports providers are expected to implement and adhere to the updates in this latest HCPCS coding guidance document by March 31, 2024. This document is also posted on DHCS’ ECM and Community Supports resource site.
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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 February 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 March 2024:
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- CalOptima Health Board of Directors: March 7 at 2 p.m.
- CalOptima Health Joint Provider and Member Advisory Committees: April 11 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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