Optum to Integrate Its Three Networks on January 1 |
Important reminder for Optum-enrolled 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 allow 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 their 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 a 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.
Per regulation, Optum members will be notified about this integration by December 1, 30 days prior to the effective date of January 1. They will receive their new ID cards 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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Providers Required to Send Answers to Health Information Exchange Questions |
Reminder: Certain CalOptima Health-contracted providers and subcontractors are required to sign up and submit a copy of the Data Sharing Agreement (DSA) by November 30 to assist CalOptima Health and the Department of Health Care Services (DHCS) with the implementation of the Health Information Exchange (HIE).
Per DHCS All Plan Letter (APL) 23-013: Mandatory Signatories to the CalHHS Data Exchange Framework, managed care plans (MCPs) such as CalOptima Health must sign the California Health and Human Services Agency (CalHHS) Data Exchange Framework (DxF) DSA. The DSA defines who is subject to the DxF’s new data exchange rules and establishes terms, conditions and obligations supporting the secure exchange of and access to health and social services information.
By January 1, 2024, CalOptima Health must submit to DHCS a list of its providers and subcontractors, the status of their DxF DSA signatures and the proportion of providers and subcontractors in compliance. Providers and subcontractors that need DxF DSA signatures include general acute care hospitals, physician organizations and medical groups (of 25-plus providers), skilled nursing facilities, clinical laboratories, and acute psychiatric hospitals.
To help CalOptima Health meet this deadline, the contracted providers listed above should email responses to the following DHCS bullet points to providerservicesinbox@caloptima.org by November 30:
- Provider group or facility name
- Provider Taxpayer Identification Number (TIN)
- Administrative email/contact
- Are you using the HIE?
- If yes, which HIE vendor?
- If no, when do you intend to enroll in the HIE?
- Provide a copy of the signed DSA
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CalOptima Health Implementing Enhanced Claims Processes |
Over the past several years, CalOptima Health has been implementing payment policies that reflect guidelines set by industry authorities. Our goal is to process claims consistently and in accordance with best practice standards. Starting January 1, 2024, CalOptima Health will begin implementing additional enhancements to our claims editing programs that promote correct coding and billing practices. This will enable you and your billing staff to more readily understand our payment or denial of claims.
After the implementation, you may receive claims denials or payment changes based on these enhanced claim editing concepts on your Explanation of Benefits or electronic remittances. For additional information on the specifics of your claim submission payment decisions, please contact our call center at 714-246-8600 or your Provider Relations representative.
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Please Review After-Hours Telephone Access Standards |
CalOptima Health adheres to patient care access and availability standards as required by DHCS and the Department of Managed Health Care (DMHC). DHCS and DMHC implemented these standards to ensure that Medi-Cal beneficiaries can get an appointment for care on a timely basis, reach the provider over the phone and access interpreter services, as needed.
As a reminder, CalOptima Health has the following after-hours telephone access standards:
- A PCP or designee will be available 24/7 to respond to after-hours member calls or to a hospital emergency room practitioner.
- If using a recorded message, it should include the following: “If you feel that this is an emergency, hang up and dial 911 or go to the nearest emergency room.”
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CME Credit Available for Attending End-of-Life Decision-Making Seminar |
Physicians who serve Medi-Cal members are invited to attend a Continuing Medical Education (CME) seminar hosted by CalOptima Health and the Orange County Medical Association regarding end-of-life decision-making.
Physicians can earn one CME credit by attending the in-person seminar, which will be held from 6 to 8:30 p.m. on Wednesday, November 15 at the Hotel Fera Anaheim Doubletree in Orange. The featured speaker is Michael Hunn, a bio-medical ethicist and CEO of CalOptima Health.
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Eligible Members Can Now Receive More in CalFresh Benefits |
A recent cost-of-living adjustment implemented by the U.S. Department of Agriculture means low-income California residents may be eligible for more help to pay for groceries.
Qualifying families or individuals can receive monthly food assistance through CalFresh, California’s Supplemental Nutrition Assistance Program, which is overseen locally by the County of Orange Social Services Agency. The benefits are issued on a debit-type card that can be used at grocery stores, farmers markets and some online stores. A family of four can now qualify for up to $973 a month, while an individual can qualify for up to $291 a month.
To learn more about CalFresh and how to apply, members can visit the CalFresh page on CalOptima Health’s website. |
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Medi-Cal Expansion Will Cover All Californians 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.
The use of Medi-Cal benefits will not impact immigration status or trigger an alert to federal authorities. The U.S. Department of Homeland Security and U.S. Citizenship and Immigration Services do not consider receiving health, food and housing benefits as part of their public charge determination, or the ruling that someone will be primarily dependent on the government for subsistence.
As part of its outreach campaign to announce this change, DHCS has 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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Find Online Health and Wellness Resources From CalOptima Health |
CalOptima Health supports providers with member management using registered dietitians, health coaches and health educators. Our Health and Wellness team can assess members’ social needs and provide education, community resources and follow-up to promote behavior change.
Services available for all members include:
- One-on-one coaching (telephonic and face-to-face)
- Group classes in identified community locations
- Educational materials
We ask health networks to refer members for these services and share with their providers the multilingual flyers, health education handouts and videos below:
For questions about Health and Wellness services, call CalOptima Health Customer Service at 888-587-8088
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Improve Your HEDIS Performance by Screening for Developmental Disabilities |
One in six children between the ages of 3 and 17 have developmental disabilities, which are conditions that affect how children play, learn, speak, act or move. Many children with developmental delays or behavior concerns are often not identified in a timely manner. Given the prevalence of developmental delays and disabilities, all pediatric PCPs should be prepared to screen for them. Developmental screenings take a closer look at how children are developing and are part of regular well-child visits, even if there are no known concerns.
The American Academy of Pediatrics (AAP) recommends developmental screenings using a standardized screening tool for all children during their regular well-child visits at 9, 18 and 30 months.
The Developmental Screening in the First Three Years of Life (DEV) measure for the Health Effectiveness Data and Information Set (HEDIS) assesses the percentage of children who turned 1, 2 and 3 years old during the measurement period and who were screened for risk of developmental delays with a standardized developmental screening tool each time within the 12 months preceding their first, second and third birthday.
Developmental screenings must be completed using a standardized tool that assesses for all the following domains: developmental, behavioral and social delays. Standardized tools focused on one domain, such as Ages and Stages Questionnaires: Social-Emotional (ASQ-SE) or Modified Checklist for Autism in Toddlers (M-CHAT), do not meet the criteria.
Examples of standardized developmental tools that meet the criteria:
- Ages and Stages Questionnaires (ASQ) — 2 months to 5 years
- Ages and Stages Questionnaires, Third Edition (ASQ-3)
- Parents’ Evaluation of Developmental Status: Developmental Milestones (PEDS:DM)
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The Survey of Well-being of Young Children. Available for free download from www.theswyc.org
Please note that this list is set forth in the Centers for Medicare & Medicaid Services (CMS) core set measure requirements and is subject to change.
CalOptima Health created a summary to guide providers in optimizing their performance with developmental screenings. Please refer to the Developmental Screening in the First Three Years of Life Measure Guide. This guide outlines the clinical recommendations and provides examples of developmental screening tools and appropriate coding to get credit for conducting development screenings.
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DHCS Clarifies Medi-Cal Enrollment for Care Facilities |
On September 22, DHCS provided clarification to Medi-Cal MCPs about the Medi-Cal enrollment pathway for licensed assisted living community providers, including assisted living facilities, adult residential care facilities and residential care facilities for the elderly.
DHCS has confirmed that the Assisted Living Waiver (ALW) is not considered a state-level enrollment pathway for the purpose of enrolling these facilities as Medi-Cal providers offering Community Supports.
The ALW is a distinct waiver program with limited capacity and geographic coverage and remains outside of managed care. Staff responsible for enrolling providers under the ALW do not have the capacity to accept and process applications for all licensed assisted living community providers seeking to offer Community Supports. As a result, DHCS confirms that it does not see this as an already existing state-level enrollment pathway through which these providers could become enrolled in Medi-Cal.
Community Supports create a new opportunity outside of the existing ALW to expand access to assisted living and adult residential communities and to enhance the quality of life for members. All assisted living community providers must still be licensed by the California Department of Social Services. CalOptima Health is required to vet these providers for participation in Community Supports and to become Medi-Cal enrolled.
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DHCS Releases Version 4 of Managed Care Plan Transition Policy Guide |
DHCS has distributed Version 4 of the 2024 Managed Care Plan Transition Policy Guide, which includes the new MCP Transition Monitoring and Oversight policy, new Transition-Related Requirements for Incentive Programs policy, and updates to all other sections of the Policy Guide.
The Policy Guide includes DHCS policy and Medi-Cal MCP requirements related to members transitioning among MCPs on January 1, 2024. The Policy Guide is periodically updated to keep MCPs informed of new and developing guidance.
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Department of Public Health Encourages Enrollment in Vaccines for Children Program |
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The California Department of Public Health has announced that the California Vaccines for Children (VFC) Program will soon make federally purchased nirsevimab available at no cost to enrolled sites, including birth and neonatal care hospitals. California hospitals that serve infants eligible for VFC vaccines, including those who are uninsured or covered by Medi-Cal, are encouraged to enroll in the VFC program.
Nirsevimab is a long-acting monoclonal antibody that prevents severe disease from respiratory syncytial virus (RSV) in infants. In clinical trials, nirsevimab has been effective in preventing hospitalization and admission to intensive care for RSV infection.
To learn more about enrolling in the VFC program, please visit www.eziz.org. For enrollment support, hospitals can call the California VFC Program Customer Service Center at 877-243-8832.
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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 October 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 November 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:
- Post-PHE Policy Clarification for Medication Abortion
- Laboratory/Pathology Non-Specific ICD-9-CM Codes Update
- Diagnosis Code Requirement Update for HCPCS Code Q2053
- Additional Outpatient Services Added as a Benefit for PE4PW
- Coagulation Factor IX (Ixinity) Receives New HCPCS Code
- Signature Flexibilities for Presumptive Eligibility through CHDP
- Licensed Midwives Are CPSP Eligible Providers
- CCS Services Code Groupings Policy Update
- Updated Billing Policy for CPT Code 80305 for CNM
- National Correct Coding Initiative Quarterly Update for October 2023
- Provider Manual Revisions
- 2022–23 Distinct Part Pediatric Subacute Facilities Reimbursement Rate Update
- 2022–23 NF-A Rate Updates
- Updated 2022–23 DP/NF-B Reimbursement Rates
- Updated 2022–23 Rural Swing Bed Reimbursement Rates
- Exemption from 10-Month Rental Cap for DME Codes
- Updated 2022–23 Administrative Day Reimbursement Rates
- Hospital Presumptive Eligibility Applications and Tribal Insurance Reminders
- Erroneous Payment Correction for DRG Claims Submitted for SFY 2023–24
- Notice to Providers Regarding the Special Billing of Elevidys Claim
- Correction: Reimbursement Rates for Preventive Medicine
- Freestanding Skilled Nursing Facilities Reimbursement Rates for Calendar Year 2023
- 2024 ICD-10-CM/PCS Codes Update
- Modifier Reimbursement Rate Update for Non-Emergency Medical Transportation Service
- Billing Updates for Miscellaneous Supplies HCPCS Code Z7610
For detailed information regarding these changes, please refer to: September General Medicine Bulletin 591, Long-Term Care Bulletin 559, Durable Medical Equipment and Medical Supplies Bulletin 576, Inpatient Services Bulletin 588, Medical Transportation Bulletin 576, Rehabilitation Clinics Bulletin 588, and Medi-Cal NewsFlashes from September 1, September 1, September 8, September 15 and September 20.
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- CalOptima Health Board of Directors: November 2 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 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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