As a CalOptima Health provider, you may be asked how the ongoing federal government shutdown affects your patients who utilize CalFresh benefits. To keep you and our members informed, we are sharing the following update.

Due to the shutdown, CalFresh benefits are delayed in November. These benefits are anticipated to be retroactively issued when the shutdown is resolved.

CalFresh, known federally as the Supplemental Nutrition Assistance Program, or SNAP, helps low-income residents buy healthy food. More than 310,000 Orange County residents — mostly older adults and children — receive CalFresh.

During this time, providers are encouraged to have patients call 2-1-1 or visit 211oc.org to be connected to food, housing and utility resources.

Funding for CalWORKs and Medi-Cal benefits at this time is secured through the end of 2025. 

CalOptima Health is asking providers to encourage members to complete the Member and Population Health Needs Assessment. The purpose of this survey is to help us better understand what services our members need and use. It’s now open and anticipated to close the first week of December.

A sample of 25,000 members has been mailed a letter with instructions on how to complete the 12- to 15-minute online survey. Members are eligible to receive a gift card for completing the survey from our contracted vendor, NORC at the University of Chicago, via the Cal State Fullerton Social Science Research Center. 

If members have questions, they can call the survey helpline at 1-657-278-9495.

Member input is crucial in shaping programs, resources and services that support the entire CalOptima Health community. We appreciate providers helping our members to participate in this collaborative effort.

The CalOptima Health Provider Portal now includes the Program of All-Inclusive Care for the Elderly (PACE) line of business.

PACE providers can submit, read communications about and view the status of authorizations directly in the Provider Portal. All authorization requests for PACE should now go through the portal. When submitting authorization requests, please include appointment information in the comments section, which enables the scheduler to view the pending appointment. Providers should also check the portal for any pending authorizations prior to calling PACE.

To access the Provider Portal, visit providers.caloptima.org.

We recently updated the mailing addresses for submitting provider disputes for our various lines of business. We ask that provider offices ensure their records reflect these new addresses:

• Medi-Cal — For denied or underpaid claims, please submit a provider dispute for resolution of denied claims to:

CalOptima Health

Attn: Grievances and Appeals Resolution Unit

P.O. Box 57015

Orange, CA 92619

• OneCare (HMO D-SNP), a Medicare Medi-Cal Plan (noncontracted) — Submit a provider dispute for resolution of denied claims/authorizations to:

CalOptima Health

Attn: Grievances and Appeals Resolution Unit

505 City Parkway West

Orange, CA 92868

• All health networks, second level — Submit a provider dispute for resolution of denied claims/authorizations to:

CalOptima Health

Attn: Grievances and Appeals Resolution Unit

505 City Parkway West

Orange, CA 92868

• PACE — For denied or underpaid claims, please submit a provider dispute for resolution of denied claims to:

CalOptima Health

Attn: Grievances and Appeals Resolution Unit

P.O. Box 57015

Orange, CA 92619

All other contact information, including phone numbers and email addresses, will remain the same. If you have any questions or need assistance updating your records, please contact Provider Relations at providerservicesinbox@caloptima.org.

To help ensure that corrected claims can be processed in a timely manner with limited disruptions, we ask that providers adhere to the following guidelines:

• When submitting a corrected claim, please include all line items from the original submission, not just the ones being corrected. Submitting only corrected lines may result in overpayment recoupment requests.
• The corrected claim form should have a clear indication as to what information is being changed.
• All procedures performed on a single date of service should be filed on one claim, even when submitting correct claims with changed (i.e., added or deleted) codes or differing units.
• The original claim number assigned on your provider payment register/remittance advice is required when resubmitting the claims.
• A corrected claim submitted to adjust a claim should not include an Appeal and Claims Dispute Form, Letter of Appeal, Appeal Request Form or medical records.
• Clearly indicate “corrected claim” on your claim form. Corrected claims submitted on paper should also include the following:

o   CMS 1500: In Block 22, Original Reference Number, enter the original claim reference number

As of September 2025, the Centers for Disease Control and Prevention (CDC) and the California Department of Public Health (CDPH) have issued updated guidance on COVID-19, MMR and varicella vaccinations, with notable differences between federal and state recommendations. Providers in California are advised to follow CDPH guidance, which is supported by legal protections under Assembly Bill 144.

COVID-19 Vaccinations

For COVID-19 vaccination, the CDC now recommends a shared clinical decision-making model for all individuals ages 6 months and older. This approach emphasizes the provider’s role in assessing patient risk and guiding informed choices, particularly for those under 65 years of age with risk factors. Vaccines remain covered under Medi-Cal, Medicare, Children’s Health Insurance Program (CHIP) and Affordable Care Act (ACA) plans.

In contrast, CDPH provides more specific recommendations. It advises COVID-19 vaccination for all children ages 6 to 23 months, children ages 2 to 18 years with risk factors or close contact with high-risk individuals, and all children whose families wish to vaccinate. For adults, CDPH recommends vaccination for everyone ages 65 and older, adults under 65 with risk factors or close contact with high-risk individuals, and all women who are planning pregnancy, are pregnant, postpartum or lactating. These recommendations align with those from the American Academy of Pediatrics (AAP), the American College of Obstetrics and Gynecologists and the American Association of Family Physicians.

Varicella Vaccination

Regarding MMR and varicella vaccination, the CDC now recommends administering separate MMR and varicella vaccines for toddlers ages 12 to 23 months due to a higher risk of febrile seizures associated with the combined MMRV vaccine. The standalone varicella vaccine remains covered under the Vaccines for Children (VFC) program.

CDPH, however, allows for either the combined MMRV or separate MMR and varicella vaccines for children under 4, based on parental preference. Providers should counsel parents about the small increased risk of febrile seizures with the MMRV vaccine when used for the first dose. For the second dose at ages 4 to 6, the MMRV vaccine is preferred, as the seizure risk is not a concern. CDPH’s recommendations are consistent with AAP guidance.

California Assembly Bill 144

Assembly Bill 144, signed into law on September 17, 2025, reinforces CDPH’s authority to issue state-specific vaccine guidance. It mandates no-cost insurance coverage for CDPH-recommended vaccines, provides liability protection for providers who follow state guidance, and expands pharmacists’ authority to prescribe and administer vaccines independently.

Providers should remain aware of the differences between CDC and CDPH recommendations and ensure alignment with state guidance to maintain compliance and legal protection. This evolving landscape underscores the importance of provider engagement in vaccine decision-making and access.

As a reminder, CalOptima Health requires prior authorization for transcranial magnetic stimulation (TMS) services provided to Medi-Cal members, effective July 1, 2025.

Furthermore, we are presenting an amendment to our behavioral health contracts at the upcoming Board of Directors meeting on November 6. This amendment will add provisions to include TMS services and establish reimbursement for the services. Upon approval, we will distribute the Board-approved amendment for execution.

These changes align with an announcement from the Department of Health Care Services (DHCS) on April 9, 2025, that TMS Current Procedural Terminology (CPT) codes 90867, 90868 and 90869 are covered by Medi-Cal.

We have partnered with Exact Sciences Laboratories to send Cologuard kits to CalOptima Health Community Network (CHCN) members who are due for colorectal cancer screening. The Cologuard test is an easy-to-use, at-home screening test covered by CalOptima Health at no cost to your patients.

Here’s what to expect:

• Exact Sciences will ship the collection kit directly to eligible members.
• Staff from Exact Sciences will provide telephonic reminders to members and are available to answer any questions.
• Members collect their sample and return the test via UPS using the prepaid shipping label.
• Results are usually ready within two weeks. 
• The member’s primary care provider will receive a copy of the results.

For more information, please visit www.cologuardhcp.com/resources.

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, www.caloptima.org, 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. 

CalOptima Health is partnering with the Regional Center of Orange County (RCOC) to host a virtual training at 11 a.m. on Monday, November 10, 2025.

The 90-minute Zoom webinar will discuss Regional Center eligibility criteria, as well as available services and supports for those who qualify. Physicians, health network staff and hospital staff are encouraged to attend. Please register in advance using this link.

For questions, please contact Chrystian Merfalen at 714-347-5711 or chrystian.merfalen@caloptima.org.

We support health care professionals in delivering care that reflects the diverse needs of our members. Research shows that culturally responsive care enhances communication, fosters trust and leads to improved health outcomes. That’s why our Equity and Community Health (ECH) department offers no-cost learning opportunities and expert resources to help you stay informed and responsive to the communities you serve.

Culture & Health Conversations In-Person Training Series

Explore how culture shapes health beliefs and care-seeking behaviors. Each session is open to all health care professions, offers free Continuing Education (CE) credits, and includes a community-based presentation and culturally inspired meals. Previous sessions featured the Cambodian and Vietnamese communities.

This month, Casa De la Familia will present on how to address barriers and bias in Latino communities. The details are:

• Date: November 13, 2025
• Noon: 11:30 a.m.–1:30 p.m.
• Location:

CalOptima Health

505 City Parkway West

Room 109-N (First floor)

Orange, CA 92868

• A Latin cuisine lunch will be provided at 11:30 a.m.
• Registration for this session is now closed, but more Culture & Health conversations are coming soon.

Continuing Medical Education (CME/CE) Event:

• Management of Challenging Behaviors in Autism Spectrum Disorder
• Date: November 12, 2025
• Time: Noon–1:30 p.m.
• Space is limited. Sign up for this Zoom webinar using this link.

Specialty consultation services designed to support clinical decision-making are available to providers, offering timely access to expert guidance, with the goal of enhancing patient care and improving health outcomes. These no-cost external resources do not require registration:

• Reproductive Health Hotline (ReproHH) — A confidential hotline operated by University of California, San Francisco physicians offering evidence-based guidance on sexual and reproductive health.
• Perinatal Psychiatric Consultation Program — Psychiatric consultation for prescribers supporting patients during pregnancy, postpartum or preconception planning. Available by appointment.
• California Child and Adolescent Mental Health Access Portal (Cal-MAP) — Free support for providers caring for youth ages 0–25, including consultation, education and resource navigation from a team of behavioral health professionals.
• Training Opportunity: How Cal-MAP Equips Providers to Address Youth Mental Health — A one-hour, CME-accredited webinar offering an overview of Cal-MAP services to support trauma-informed care to youth and families impacted by adverse childhood experiences (ACEs). 

On October 6, 2025, DHCS provided information to managed care plans (MCPs) regarding the MCP Alignment with Cell and Gene Therapy Coverage.

As of March 2025, DHCS received approval to participate in the federal Cell and Gene Therapy (CGT) Access Model to improve access to two gene therapies for sickle cell disease (SCD), Lyfgenia and Casgevy. These drugs are carved out of MCP coverage and are covered by fee-for-service. However, MCPs remain responsible for all associated outpatient or inpatient medical services and nonmedical ancillary services that support members through their SCD CGT treatments, such as transportation. For more information regarding this update, refer to the following resources:

• APL 25-013 (Pages 4–5)
• DHCS CGT Access Model webpage
• DHCS CGT Provider Manual 
• DHCS’ notice regarding CGT coverage:
• Includes key MCP responsibilities such as claims payments, continuity of care, utilization management, provider relations and network adequacy.
• Includes a list of eight Lyfgenia Qualified Treatment Centers and six Casgevy Authorized Treatment Centers.

On October 3, 2025, DHCS distributed the Transitional Rent Payment Methodology to MCPs.

This document contains the maximum reimbursable amounts (reimbursable ceilings) and administrative fees associated with transitional rent, which MCPs must cover as the first mandatory Community Support beginning January 1, 2026.

Additional details within the document include the following:

• Background on payment structure: DHCS payments to MCPs will consist of two separate components:
• Cost of rent or temporary housing
• Administrative fee
• Payment for cost of rent or temporary housing: DHCS will reimburse MCPs the actual cost of rent or temporary housing paid to landlords or property owners up to a specified reimbursable ceiling, subject to an annual reconciliation process.
• Table 1: Displays reimbursable ceilings for a per-month unit of service.
• Table 2: Provides administrative fees that DHCS will pay to MCPs.
• CalOptima Health’s administrative fees are listed in Region G (Page 10).

On October 16, 2025, DHCS posted updated General Medicine, Medical Transportation and Community-Based Adult Services provider bulletin updates to the Medi-Cal website. Below is a summary of the updates that may impact CalOptima Health:

• Eligible Provider List Update for PP-GEMT IGT Add-On (dates of service on or after January 1, 2023) — List of eligible providers for PP–GEMT add-on has been updated here based on additional provider information received and criteria outlined in Welfare and Institutions Code (WIC) 14105.94.
• 2025 HCPCS Quarter 4 Update (dates of service on or after October 1, 2025) — Q4 2025 HCPCS codes updates are available in the HCPCS Policy Updates.
• Frequency Change for Select CPT Codes (dates of service on or after October 1, 2025) — Frequency for select CPT codes has been updated to same day, different provider.
• Community-Based Adult Services Billing and Reimbursement Rates Clarification (dates of service on or after October 1, 2025) — Clarifies billing codes and reimbursement rates for CBAS providers.
• Select Laboratory Test Codes Are Now Medi-Cal Benefits (dates of service on or after November 1, 2025) — Select laboratory codes have changed from non-benefit to benefit.
• Sterilization Consent Form Update (dates of service on or after September 1, 2025) — The only sterilization consent form currently accepted by Medi-Cal is Consent for Sterilization Form DHCS 8649. The form is posted on the DHCS Sterilization Material web page.
• Reminder and Clarification: Medi-Cal Coverage and Billing Policy for Noninvasive Prenatal Screening Laboratory Tests — Reminder of Medi-Cal’s coverage and billing policy for noninvasive prenatal screening laboratory tests.

On September 26, 2025, DHCS notified MCPs that the Ordering, Referring and Prescribing (ORP) web page, including the Enrollment Validation Lookup tool and FAQ, is no longer available. Further information can be found here. 

• On September 26, 2025, DHCS distributed All Plan Letter (APL) 25-014: Update to Provider Directory Requirements, which provides MCPs with guidance on updated provider directory requirements pursuant to the Consolidated Appropriations Act of 2023, State Health Official Letter (SHO) 24-003 and Title 42, Code of Federal Regulations (CFR), section 438.10(h)(1).
• On September 18, 2025, DHCS distributed revised APL 25-013: Medi-Cal Rx Pharmacy Benefits, and Cell and Gene Therapy Coverage and NCQA Medi-Cal Rx Crosswalk, which provides MCPs with guidance on the oversight and administration of the Medi-Cal pharmacy benefit. This APL supersedes APL 22-012.
• On October 2, 2025, DHCS distributed APL 25-015: Data Sharing and Quality Rate Production for Directed Payment Initiatives and Alternative Payment Methodologies, which provides details on MCPs’ obligations surrounding data sharing and quality measures in DHCS’ Directed Payment Initiatives or DHCS-administered Alternative Payment Methodology programs.

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

• 2025 HCPCS Quarter 4 Update
• Frequency Change for Select CPT Codes
• Select Laboratory Test Codes Are Now Medi-Cal Benefits
• Justice-Involved Reentry Initiative: Live Training Webinars in October 2025
• Reminder and Clarification: Medi-Cal Coverage and Billing Policy for Noninvasive Prenatal Screening Laboratory Tests
• Sterilization Consent Form Update
• Provider Manual Revisions
• Medi-Cal Adult Expansion Freeze Begins January 2026
• October 2025 Update to AEVS: Carrier Codes for Other Health Coverage
• Family PACT Update Allows One Site Certifier for Multiple Service Locations
• Family PACT Live Training Webinar in October 2025
• Important September 17, 2025, Update: H.R. 1 – Federal Payments to Prohibited Entities
• 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
• Updates to the Medi-Cal List of Contracted Incontinence Creams and Washes
• Coming Soon: New Online Hospice NOE Submission Form and Process
• Updates to the Medi-Cal List of Contracted Incontinence Absorbent Products
• Calendar Year 2026 LTC Rates Public Review
• Provider Dispute Resolutions With Managed Care Plans

For detailed information regarding these changes, please refer to General Medicine Bulletin 616, Medi-Cal Program & Eligibility Bulletin 39, Audiology and Hearing Aids Bulletin 601, Family PACT Bulletin 217, and Medi-Cal NewsFlashes from September 17, October 1, October 1, October 10, October 13, October 14, October 20 and October 22. 

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 September 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

• CalOptima Health Board of Directors: November 6 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.