Providers May Receive Member Health Needs Assessment Surveys |
As part of our 2023 Member Health Needs Assessment, CalOptima Health will survey select contracted providers to solicit patient experience feedback.
In mid-September, the agency will send an initial email before its project partner, Harder+Company Community Research, sends the actual link to the 20-minute survey.
These surveys are your chance to give valuable feedback on the issues your patients face. The responses will be used to inform future strategic planning, guide future grants and steer program development. All provider information will remain confidential, with responses collected as part of an information pool with no names attached.
The full Member Health Needs Assessment will combine provider surveys with feedback from CalOptima Health members and community leaders so we can better address issues affecting members’ health.
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Member Health Advice Available Through No-Cost Nurse Phone Line |
CalOptima Health members can receive basic health advice by calling our toll-free Nurse Advice Phone Line.
If a member needs health advice, their first call should be to their primary care provider (PCP) or health network. However, if they cannot reach their PCP, members can use the nurse line to get the facts they need to make medical decisions. The nurse line helps members by:
- Figuring out symptoms and treatments
- Giving information about non-urgent and urgent care
- Providing advice on self-care at home
- Referring members to an in-network urgent care center or hospital
- Explaining a condition or diagnosis
- Giving facts about medicines
The CalOptima Health Nurse Advice Line is for health advice only. Nurses do not have access to members’ medical records, referrals or prior authorizations.
Members can reach the CalOptima Health Nurse Advice Line 24/7 at no cost by calling 844-447-8441 (TTY 844-514-3774).
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Learn About HEDIS Documentation Requirements During Upcoming Webinar |
Contracted providers and their office staff are invited to a webinar covering Measurement Year 2023 documentation requirements for the Healthcare Effectiveness and Data Information Set (HEDIS).
Two sessions of the 90-minute webinar are available: Thursday, September 7, and Wednesday, September 13, at 12:30 p.m. both days The training will consist of an overview of HEDIS, along with covering pediatric, women’s, diabetic and adult HEDIS measures.
To register, please email Irma Munoz, Quality Analytics Program Manager, at imunoz@caloptima.org with the date of the session you would like to attend in the subject line. Please register for only one webinar, as both sessions will cover the same content.
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Continuing Education Course Will Cover De-escalation and Crisis Intervention Methods |
Providers can learn about crisis intervention and de-escalation methods at a continuing education webinar on Wednesday, September 20, at 12:30 p.m.
The 90-minute course will present a real-life crisis situation and share a crisis response approach adapted from the Active Prevention & Intervention Crisis Response Model. Attendees can earn 1.5 continuing medical education and continuing education credits for attending.
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CalOptima Health Streamlines Claims Payment Dispute Process |
To streamline our process and align with industry standards, CalOptima Health is removing the second level from its claims payment dispute process.
Starting January 1, 2024, payment disputes will be transferred from the Claims department to Grievance and Appeals Resolution Services and will be reviewed only once. Providers will still have the right to file a government claim, as referenced in CalOptima Health Policy AA.1217 Legal Claims and Judicial Review. If you have questions, concerns or feedback, please contact Provider Relations at 714-246-8600.
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Use These Guidelines When Prescribing High-Risk Medications to Older Adults |
CalOptima Health encourages providers to follow recommended guidelines for prescribing high-risk medications to older adults. HEDIS is one tool we use to measure quality performance, and below are key features of the Use of High-Risk Medications in Older Adults (DAE) HEDIS measure.
DAE evaluates the percentage of Medicare members ages 67 and older who had at least two dispensing events for the same high-risk medication. Three rates are reported (a lower rate indicates better performance):
- Rate 1: The percentage of members who had at least two dispensing events for high-risk medications from the same drug class.
- Rate 2: The percentage of members who had at least two dispensing events for high-risk medications to avoid, from the same drug class where use is potentially inappropriate except for appropriate diagnoses.
- Total Rate: The sum of the members from the numerators of Rate 1 and Rate 2 divided by the members in the DAE measure.
The measure reflects potentially inappropriate medication use in older adults, both for medications for which any use is inappropriate (Rate 1) and for medications for which use under all but specific indications is potentially inappropriate (Rate 2).
How to Improve Your DAE HEDIS Scores:
- Incorporate a high-risk medication review into each encounter with members ages 67 and older.
- Check medication lists to ensure they do not include any high-risk medications.
- Substitute high-risk medications with safer alternatives.
- Before prescribing a new medication for an older adult, confirm that it is not a high-risk medication.
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Lower Benzodiazepine Use by Older Adults to Comply With HEDIS Measure |
The 2023 American Geriatrics Society (AGS) Beers Criteria recommends that benzodiazepines be avoided in older adults due to the increased risk of cognitive impairment, delirium, falls and fractures. HEDIS guidelines recommend deprescribing benzodiazepines slowly and safely, rather than stopping use immediately, to minimize withdrawal symptoms and improve patient outcomes. This deprescribing measure presents an opportunity to promote harm reduction by assessing appropriate tapering of benzodiazepine use.
The following tips detail some of the key features of the Deprescribing of Benzodiazepines in Older Adults (DBO) HEDIS measure. This measure evaluates the percentage of members ages 67 and older who were:
- Dispensed benzodiazepines
- Achieved a 20% decrease or greater in benzodiazepine dose (diazepam milligram equivalent [DME] dose) during the measurement year
How to Improve DBO HEDIS Scores:
- Consider a non-benzodiazepine alternative before prescribing a benzodiazepine for older adults.
- Query the Prescription Drug Monitoring Program (PDMP) to check controlled substance use across all providers before prescribing benzodiazepines and assess the frequency of utilization.
- Assess benzodiazepine use for all patients and periodically attempt dose reduction to ensure the lowest effective dose is prescribed.
- Consult evidence-based deprescribing guidelines to safely deprescribe benzodiazepines. The AGS recommends guidelines and algorithms available on the deprescribing.org website.
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How Providers Can Improve Harmful Drug-Disease Interaction HEDIS Scores |
The Potentially Harmful Drug-Disease Interactions in Older Adults (DDE) HEDIS measure evaluates the percentage of Medicare members ages 65 and older who have evidence of an underlying disease, condition or health concern and who were dispensed an ambulatory prescription for a potentially harmful medication, concurrent with or after the diagnosis from January 1, 2023, to December 1, 2023.
Three rates and a total rate are reported (a lower rate indicates better performance):
- Rate 1: A history of falls and a prescription for antiepileptics, antipsychotics, benzodiazepines, nonbenzodiazepine hypnotics or antidepressants (selective serotonin reuptake inhibitors, tricyclic antidepressants and serotonin and norepinephrine reuptake inhibitors)
- Rate 2: Dementia and a prescription for antipsychotics, benzodiazepines, nonbenzodiazepine hypnotics, tricyclic antidepressants or anticholinergic agents
- Rate 3: Chronic kidney disease (CKD) and a prescription for COX-2 selective nonsteroid anti-inflammatory drugs (NSAIDs) or nonaspirin NSAIDs
- Total rate: The sum of rates 1 to 3 divided by the sum of their denominators
Members with more than one disease or condition may appear in the measure multiple times.
How to Improve DDE HEDIS Scores:
- Add a disease state review and medication review into every encounter with members ages 65 and older.
- Check member diagnoses for history of falls, dementia and CKD and avoid respective harmful drug classes.
- If a diagnosis of history of falls, dementia or CKD is present, substitute harmful drug classes with appropriate alternatives.
- Before prescribing a new medication, check first that it is not in a potentially harmful class for the member’s condition.
- Record reason for prescribed medication, member’s age and condition in member’s chart.
- Code to the highest specificity using the Centers for Medicare & Medicaid Services (CMS) guidelines.
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Consult the American Geriatrics Society 2023 updated AGS Beers Criteria for the most current clinical guidance regarding potentially inappropriate medication use in older adults.
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Improve Upper Respiratory Infection HEDIS Scores |
The Appropriate Treatment for Upper Respiratory Infection (URI) HEDIS measure evaluates the percentage of episodes for members 3 months of age and older with a diagnosis of upper respiratory infection that did not result in an antibiotic dispensing event. A high rate indicates better performance.
How to Improve URI HEDIS Scores:
- If a member’s diagnosis is only URI, they should not be prescribed an antibiotic. Most URIs, also known as the common cold, are caused by viruses that require no antibiotic treatment.
- Symptomatic therapy is the mainstay of URI treatment. For moderate to severe symptoms, therapies that may be effective include analgesics and antihistamine/decongestant combinations. Therapies with minimal or uncertain benefits include dextromethorphan, decongestants and expectorants.
- Educate patients that the usual duration of illness is up to one and a half weeks.
- Provide specific materials on antibiotic resistance and realistic expectations of recovery time.
- Record a second diagnosis code for any competing diagnosis (e.g., pharyngitis, otitis media, enteritis, whooping cough, etc.) in addition to the URI code.
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Hospital and Birthing Centers Must Allow Access for Doulas |
In accordance with the requirements in All Plan Letter (APL) 22-031, hospitals and birthing centers must allow access and not create barriers for doulas when accompanying CalOptima Health members for prenatal visits, labor and delivery support, and postpartum visits regardless of the outcome (stillbirth, abortion, miscarriage or live birth).
Managed care plans (MCPs) like CalOptima Health are responsible for ensuring their subcontractors and network providers comply with all applicable state and federal laws and regulations, contract requirements and other Department of Health Care Services (DHCS) guidance, including APLs and Policy Letters.
If you have any questions about doula access, please contact the Provider Relations department at 714-246-8600 or email providerservices@caloptima.org.
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DHCS Releases ECM and Community Supports Implementation Report |
On August 3, DHCS released the Enhanced Care Management (ECM) and Community Supports 2022 Implementation Report.
This report summarizes ECM and Community Supports implementation trends and data, based on the Quarterly Implementation Monitoring Report submissions from CalOptima Health and other MCPs. The report narrative includes qualitative information about the phased rollout of these programs and efforts underway to support growth in ECM and Community Supports going forward.
For additional information and to read the report, please visit the following links:
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APL 23-014
On June 9, DHCS distributed APL 23-014: Proposition 56 Value-Based Payment Program Directed Payments. The purpose of this APL is to provide Medi-Cal MCPs with guidance on value-based directed payments to network providers for qualifying services tied to performance on designated health care quality measures in the domains of prenatal and postpartum care, early childhood prevention, chronic disease management and behavioral health care. This APL supersedes APL 22-019.
Significant updates to the APL include but are not limited to the following:
- Updated payment and other financial provision requirements including the following:
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CalOptima Health must ensure the payments required by this APL are made in accordance with the timely payment standards in the contract for clean claims or accepted encounters received no later than one year after the date of service. The contract specifies the requirements pertaining to timely payment in Exhibit A, Attachment 8, Provision 5. Services performed after June 30, 2022, are not eligible to receive value-based directed payments.
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CalOptima Health must communicate and provide clear policies and procedures to their network providers about CalOptima Health’s claims or encounter submission processes, including what constitutes a clean claim or an acceptable encounter. If the network provider does not adhere to these policies and procedures, CalOptima Health is not required to make payments for claims or encounters submitted one year following the date of service. These timing requirements may be waived through an agreement in writing. Providers can see an example of a clean claim here.
- CalOptima Health or its subcontractors must not pay any amount for any services or items, other than emergency services, to an excluded provider as defined in the “Definitions” section of the contract. This prohibition applies to non-emergent services furnished at the medical direction or prescribed by an excluded provider who knew or had a reason to know of the exclusion, or by an excluded provider that DHCS has failed to suspend payment while pending an investigation of a credible allegation of fraud.
- In addition, CalOptima Health must make available to network providers an itemization of payments made in accordance with this APL. The itemization must include sufficient information to uniquely identify the qualifying service for which payment was made, be provided upon the network provider’s request unless CalOptima Health has established a periodic dissemination schedule, and be made available in electronic format when feasible.
APL 23-015
Important updates include but are not limited to:
- MCPs have an obligation to communicate and provide clear policies and procedures to their providers about their claims or encounters submission processes, including what constitutes a clean claim or accepted encounter. Providers can see an example of a clean claim here.
- Updated data reporting requirements direct MCPs to follow the reporting requirements described in the Prop 56 Directed Payments Expenditures File Technical Guidance.
- Updated payment and other financial provision requirements include the following:
- MCPs and subcontractors are prohibited from paying any amount for any covered service or item (other than emergency services) to an excluded provider
- MCPs must have a process to communicate the requirements of the APL, including a description of the minimum requirements for a qualifying pregnancy termination, how payments will be processed, how to file a grievance and how to identify the responsible payer
- MCPs must make available an itemization of payments made to the provider in accordance with the APL.
Providers and health networks are to review the APL to ensure that all desktops, policies and procedures are updated to be in accordance with the APL requirements.
APL 23-016
On June 9, DHCS distributed APL 23-016: Directed Payments for Developmental Screening Services to provide MCPs with guidance on directed payments for the provision of standardized developmental screening services for children. The finalized APL supersedes APL 19-016.
Substantive changes include but are not limited to:
- MCPs have an obligation to communicate and provide clear policies and procedures to their network providers about their claims or encounters submission processes, including what constitutes a clean claim or accepted encounter. Providers can see an example of a clean claim here.
- Updated data reporting requirements direct MCPs to follow the reporting requirements described in the Prop 56 Directed Payments Expenditures File Technical Guidance
- Updated payment and other financial provision requirements include the following:
- MCPs and their subcontractors are prohibited from paying any amount for any covered service or item (other than emergency services) to an excluded provider
- MCPs have an obligation to communicate and provide clear policies and procedures to their network providers about their claims and encounter submission processes, including what constitutes a clean claim or acceptable encounter
- MCPs must make available to a provider an itemization of payments made to the provider in accordance with the APL.
APL 23-019
Substantive changes to the APL include but are not limited to:
- DHCS has requested CMS approval for this directed payment arrangement for calendar year 2023.
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Updated data reporting requirements direct MCPs to follow the reporting requirements described in the Prop 56 Directed Payments Expenditures File Technical Guidance.
- Updated payment and other financial provision requirements include the following:
- MCPs and subcontractors are prohibited from paying any amount for any covered service or item (other than emergency services) to an excluded provider.
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MCPs have an obligation to communicate and provide clear policies and procedures to their network providers about their claims and encounter submission processes, including what constitutes a clean claim or acceptable encounter. Providers can see an example of a clean claim here.
- MCPs must make available to a provider an itemization of payments made to the provider in accordance with the APL.
DHCS may impose corrective action plans and administrative and/or monetary sanctions for noncompliance with this APL.
APL 23-020
MCPs must ensure they, their subcontractors and their downstream subcontractors, operate in full compliance of the contract, applicable state and federal statutes and regulations, APLs, and all other applicable policy guidance relative to timely payments. MCPs are responsible for communicating timely claims payment requirements to all subcontractors and downstream subcontractors.
Timely Payments:
- CalOptima Health/health networks must pay all claims within contractually mandated statutory timeframes and in accordance with the timely payment standards in the contract for clean claims.
- CalOptima Health/health networks must maintain sufficient claims processing/tracking/payment system capabilities to comply with the contractual and statutory standards below (refer to Sections 1.a and 1.b of the APL for detailed requirements). CalOptima Health/health networks are encouraged to go beyond the minimum requirements, to the extent feasible, regarding the timely payment of claims to support and sustain providers to ensure access to care. DHCS expects MCPs to pay clean claims within 30 days of receipt, and MCPs must pay interest on untimely payments.
- If CalOptima Health has delegated the adjudication of claims for emergency service and care to a subcontractor, CalOptima Health must forward at least 95% of misdirected claims to the appropriate subcontractor within 10 working days of receipt of the claim. If CalOptima Health has delegated the adjudication of claims for services that do not involve emergency services and care to a subcontractor, CalOptima Health must either forward at least 95% of misdirected claims to the subcontractor or send a notice of denial, with instructions to bill the appropriate subcontractor within 10 working days of receipt of the claim.
Payments Related to State Directed Payments:
- CalOptima Health/health networks must adhere to timely payment requirements regardless of whether a provider’s claim, bill, invoice or equivalent encounter is tied to a State Directed Payment (SDP). CalOptima Health/health networks are not subject to timely payment of SDPs until so directed and the 30 calendar-day standard outlined in the APL does not apply in instances where the SDP amount is not published prior to the service date.
Provider Training Responsibilities:
- CalOptima Health/health networks must ensure that provider manuals issued to network providers, subcontractors and downstream subcontractors have up-to-date policies and procedures (P&Ps) on how to submit clean claims to CalOptima Health/health networks.
- CalOptima Health/health networks must ensure that all P&Ps regarding claims processing, billing and invoicing are up-to-date and reflective of current practices. For rejected claims and invoices, CalOptima Health/health networks must include sufficient detail on the additional information and/or appropriate billing codes the provider needs to submit a clean claim for review. Claims and billing materials must be publicly accessible for all providers.
- In addition to issuing clear P&Ps, CalOptima Health/health networks must ensure that all providers are afforded education and training on their billing, invoicing and clean claims submission protocols. Training must start within 10 working days and be completed within 30 working days after CalOptima Health/health networks place a newly contracted network provider on active status. CalOptima Health/health networks must routinely evaluate effectiveness of the training and adjust as needed.
- CalOptima Health/health networks are encouraged to hold office hours or other open-door approaches to working with their providers, particularly if systemic billing concerns are identified. Additionally, CalOptima Health/health networks are required to ensure providers have the training to effectively use electronic systems to facilitate timely submission of clean claims, equivalent encounters, bills or invoices.
Dispute Resolution:
- In accordance with HSC section 1367(h), CalOptima Health/health networks must have a fast, fair and cost-effective dispute resolution process in place for providers, network providers, subcontractors and downstream subcontractors to submit disputes for both contracted and non-contracted providers. This includes disputes related to provider claims and payments.
- CalOptima Health/health networks must have a formal procedure to accept, acknowledge and resolve provider, network provider, subcontractor and downstream subcontractor disputes. The resolution process must occur in accordance with the timeframes set forth in HSC sections 1371 and 1371.35 for both contracted and non-contracted providers.
APL Attachments
On August 7, DHCS updated the following APL attachments:
2024 Managed Care Plan Transition Policy Guide
The Policy Guide includes DHCS policy and Medi-Cal MCP requirements related to member transitions among MCPs that take effect on January 1, 2024. Updates from previous versions are reflected with highlights and strikethroughs to facilitate tracking changes. The Policy Guide will be updated throughout calendar year 2023 to keep MCPs informed of new and developing guidance.
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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 August 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 a list of training webinars and links happening in September 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:
- Simplified Bivalent Vaccine Administration Codes Added for COVID-19
- Elimination of COVID-19 Public Health Emergency Flexibilities for Hospital Presumptive Eligibility
- COVID-19 Medi-Cal Response Page Update and Vaccine Guideline Removal
- Resumption of Medi-Cal Renewals
- 2023 HCPCS Quarter 3 Update
- CCS Service Code Groupings Policy Update
- Select Infectious Agent Antigen Detection Codes Added as CLIA-waived Tests
- EWC Applicant Enrollment and Re-Certification Update
- Select Local EPSDT Service Codes are Terminated
- Rate Update for HCPCS Code J7304 with Modifier U2
- Updated Rates for Unclassified Drugs Billed with HCPCS Code J3490
- Medi-Cal Supplies Policy Reminder for HCPCS Code Z7610
- Diagnosis Related Group (DRG) State Fiscal Year 2023 to 2024 Grouper Setting Updates
- Paper and Mail Documents to be Replaced by Electronic Equivalents
- New Post-Public Health Emergency Reimbursement Rate for LEA
- System Interruption for PE4PW Program
- LTC Code and Claim Form Conversion: Alignment with CalAIM LTC ICF/DD Carve-In Transition
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- CalOptima Health Board of Directors: September 7 at 2 p.m.
- CalOptima Health Joint Provider and Member Advisory committees: October 12 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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