AltaMed Assuming Responsibility for Certain Medi-Cal Facility Claims 

CalOptima Health and AltaMed Health Services — AHN have announced a new agreement for financial responsibility for certain claims. Effective November 1, 2024, AHN will assume financial responsibility for all facility claims related to emergency room, inpatient or outpatient surgery services rendered to CalOptima Health Medi-Cal patients assigned to AHN as their health network. 

Due to this change, claims with a date of service beginning November 1, 2024, or later should be directed to AHN. 

For electronic claims, there are two Payer IDs available: 

• ALTAM or 95712 — Please consult with your biller/clearinghouse to determine which Payer ID you should use. 

For paper claims and other correspondence, the address is: 

AHN 

c/o Altura MSO Inc. 

P.O. Box 7280 

Los Angeles, CA 90022-7280 

Please see the FAQ below regarding this address change and other inquiries. If you have any additional questions, please contact AHN’s provider support line at 855-848-5252. 

Q. Why is it necessary to send my claims to the new P.O. Box? 

A.  AHN will assume financial risk for facility and other covered services. To be properly reimbursed, it is imperative that you send your facility claims dated November 1, 2024, or later to the new Payer ID or the P.O. box listed above.  

Q. When will the change go into effect?  

A. November 1, 2024. 

Q. What happens if I send my claims to the wrong P.O. Box? 

A. The claims will be denied with a Remittance Advice to the correct billing address. 

Q. Will I be able to submit claims electronically? 

A. Yes. Depending on your system, please select one of the two payer IDs provided above.  

Q. Who is at financial risk for patients admitted into a facility prior to November 1, 2024, and discharged after November 1, 2024? 

A.  The financial responsibility of claims for members admitted to a facility prior to November 1, 2024, and who remain admitted beyond November 1, 2024, is dependent on the contracted facility’s reimbursement methodology. CalOptima Health will be financially responsible for the entire inpatient hospital claim until the member is discharged if the contracted reimbursement methodology for inpatient services is All Patient Refined Diagnosis Related Group (APR-DRG). If the contracted reimbursement is a per diem methodology, CalOptima Health will be financially responsible for the date of service prior to November 1, 2024. AHN will be financially responsible for dates of services beginning November 1, 2024, and onward. 

Q. Does this change impact AHN’s other lines of business with CalOptima Health (i.e., OneCare)? 

A. No. The financial responsibility and billing submission for facility claims remain the same.  

Q. Who is financially at risk for long-term services and support? 

A.  CalOptima Health is at financial risk for long-term care, services and support.   

At CalOptima Health, we place a high degree of importance on provider satisfaction. As a health plan, we consider all of you partners in delivering quality care to our members.  

To help us better serve you, we invite you to participate in a quick provider survey that will aid us in understanding your experience with both CalOptima Health and our contracted health networks. We will be sending the 2024 Provider Satisfaction Survey via email in the coming weeks.   

Your practice’s opinions are an important source of information for us to identify needs and deliver solutions while streamlining our work together. The survey results will be used to improve the level of service provided by CalOptima Health and will be shared with our health networks. Thank you in advance for responding to the survey. We appreciate your time and look forward to receiving your valuable feedback.

The Department of Health Care Services is warning providers and managed care plans (MCPs) that a fake All Plan Letter (APL) regarding transportation benefits is being circulated. The fake APL is dated June 27, 2024, and has the title “Carving Out of Non-core Benefits of Non-emergency Medical and Non-medical Transportation.” This document contains false information regarding transportation benefits, and providers should disregard it. 

The CalOptima Health Community Network (CHCN) monthly report and supporting member-level details are now available on CalOptima Health’s Provider Portal. The files are based on claims and encounters submitted through the previous month. The information is intended to positively impact member care and to assist the providers with improving their Healthcare Effectiveness Data and Information Set (HEDIS) rates. If you have any questions, please email us at p4vprogram@caloptima.org. 

Also, effective August 15, providers can review behavioral health HEDIS measure data through the portal. Log in to the Provider Portal and view a monthly list of your patients who may require behavioral health services. CalOptima Health is providing this data to help address any gaps in your patients’ care.

CalOptima Health is again joining the call for more Latino doctors to serve in both Orange County and across the country. Along with fellow health care and elected leaders, we are promoting National Latino Physician Day on October 1. The day highlights the fact that while 19% of the United State's population — and 40% of California's population — is Latino, only about 6% of U.S. physicians are Latino. Research shows that the disparity can affect health care access and outcomes. To learn more, visit www.nationallatinophysicianday.com.

All CHCN providers are invited to attend the next CalOptima Health quarterly virtual lunch and learn meeting on September 25 at Noon. 

To register in advance for this webinar, use this Zoom link. You will receive a confirmation email with information about how to join the webinar.  

If you have any questions about this webinar, please contact your Provider Relations representative at 714-246-8600 or providerservicesinbox@caloptima.org.

 Providers are invited to attend two continuing education webinars coming soon.  

• Wednesday, September 25, 2024, Noon–1:30 p.m. — Chronic Kidney Disease: Diagnosis and Management. This webinar will cover the basics of kidney function; the definition, epidemiology, causes and staging system of chronic kidney disease; and the current management strategies for the common causes of pre-dialysis chronic kidney disease. To attend, please register by Monday, September 23, using this Zoom link. 
• Wednesday, October 9, 2024, Noon–1:30 p.m. — The Prevention of Childhood Lead Poisoning. This webinar will cover risk factors, anticipatory guidance, screening, management and public health surveillance surrounding childhood lead poisoning. To attend, please register by Monday, October 7, using this Zoom link. 

Each webinar will offer 1.5 continuing medical education and continuing education (CME/CE) credits for attending. 

If you have questions about these webinars, please contact Quynh Tran or Bao Anh Le at 657-235-6865 or email continuingeducation@caloptima.org. 

Alzheimer’s Orange County invites clinical providers to an in-person training on the early detection and care for dementia from 6:30–8:30 p.m. on September 10, 2024. 

Physicians, nurse practitioners and physician assistants are invited to attend the presentation, which will cover best practices for dementia screenings, screening tools, resources for billing Medi-Cal for cognitive health assessments, resources and supports for family caregivers, and the benefits of detecting cognitive issues. The featured speaker will be Sonia Sehgal, M.D., a geriatric internist at UCI Health. Attendees can earn one CME/CE credit. Dinner will be provided.  

The training will be held in the Molto Bello Room of Maggiano’s Little Italy, 3333 Bristol St., Costa Mesa, CA 92626.  

Please reserve your seat by emailing Patty Mouton with Alzheimer’s OC at patty.mouton@alzoc.org.

CalOptima Health has recently updated our Clinical Practice Guidelines (CPGs), which are used in making decisions about appropriate care for specific clinical conditions. The updated CPGs have been reviewed and approved by CalOptima Health’s Clinical Quality Improvement Committee and compiled into one document with direct links for ease of use. You can find the updated CPGs on CalOptima Health website here. 

Mental health plays a key role in our members’ overall health and involves balancing the emotional, psychological and social well-being of each person. We recognize that obtaining behavioral health services can add to an already overwhelming situation for our members. To support member care, we are sharing the behavioral health services we offer and how to link members to them. 

CalOptima Health’s Medi-Cal behavioral health services: 

• Outpatient psychotherapy (individual, family, couples and group therapy)  
• Psychological testing to evaluate a mental health condition 
• Outpatient services (monitoring drug therapy, lab work, drugs and supplies) 
• Psychiatric consultation 
• Dyadic services 
• Behavioral Health Treatment (BHT) for members under the age of 21 — Applied Behavior Analysis (ABA) 
• Substance use services — Screening, Assessment, Brief Intervention and Referral to Treatment (SABIRT) and Medication Assisted Treatment (MAT) 

How to access behavioral health services: 

1. Providers can warm transfer members or inform members to call our CalOptima Health Behavioral Health Line at 1-855-877-3885 (not a crisis line). 
2. Providers can inform members to call our new TeleMed2U line to access routine outpatient services, treat mild to moderate conditions, receive outpatient mental health evaluations, get help with medication management (5 years and older), get therapy services (13 years and older) and more. 

Members can visit the Behavioral Health page on our website for more information or call the CalOptima Health Behavioral Health Line at 1-855-877-3885. 

Lead exposure remains a persistent issue affecting children in the communities we serve. To continue safeguarding the well-being of our youngest members, providers are required to:

1. Provide oral or written anticipatory guidance at every periodic health assessment between 6 and 72 months to inform parents and guardians of the risks and effects associated with lead exposure, and document this in the patient’s chart. 
2. Perform blood lead screenings at 12 and 24 months of age, and in all children less than 6 years of age if lead testing was not done at 24 months or later. For guidance on the recommended actions to take based on blood test results, refer to California Management Guidelines on Childhood Lead Poisoning for Health Care Providers. 

Resources for providers: 

1. Use the Blood Lead Screening report in the CalOptima Health Provider Portal. This report identifies members 6 years of age and under who have missed a state-required test at 12 and 24 months. 
2. Review our Stay Compliant with State-Issued Blood Lead Requirements document for a quick snapshot of when to order or perform blood lead tests and electronic medical record documentation of anticipatory guidance and test refusals 
3. Attend CalOptima Health’s CME/CE workshop on preventing childhood lead poisoning on Wednesday, October 9, 2024. Register using this Zoom link by October 7. 
4. The Orange County Health Care Agency’s Local Childhood Lead Poisoning Prevention Program (CLPPP) is dedicated to supporting providers and offers case management and environmental investigations for eligible patients and no-cost patient education materials via Health Education Material Order Form. For more information, contact the CLPPP at 714-567-6220 or by email at lead@ochca.com. 

Additional resources are available in the Health Care Providers section of the Childhood Lead Poisoning Prevention Branch website. 

As the new school year begins, health care providers play an important role in preparing children by completing their annual well-child visits. These routine visits are the perfect opportunity to ensure that required vaccinations are completed and to address any health and developmental issues that can impact a child’s ability to thrive in school.  

How to support school readiness and vaccinations: 

1. Emphasize the importance of regular well-child visits — Encourage parents to prioritize well-child visits before the start of the school year.   
2. Review vaccination records and vaccinate — Review vaccine records at every visit, including sick visits, and vaccinate when needed. Your medical assistant or care team can review the immunization status in the chart prior to the visit and develop prompts on your charts to remind you of the needed immunizations.   
3. Use a presumptive approach for vaccines — Say, “Today we will vaccinate your child for [vaccine-preventable conditions].” Parents and guardians trust your recommendations. This approach is not met with resistance from those parents who are willing to vaccinate. This still allows you to address any concerns from parents who do not want to vaccinate their child.   

Below are some important vaccines required for the academic year:   

• Diphtheria, tetanus and pertussis — DTaP for < 7 years, Tdap for > 7 years  
• Polio  
• Measles, mumps, and rubella (MMR) (Only doses administered on or after the first birthday count toward the school requirement) 
• Hepatitis B   
• Varicella (chickenpox)   

The Centers for Disease Control and Prevention (CDC) offers the following catch-up guidance for various scenarios:  

• Guidance for Children 10-18 years of Age  
• Vaccine Catch-Up for Children Ages 7 + and No Record of Immunizations  

The University of California, Irvine School of Medicine is sponsoring a year-long fellowship for primary care providers (PCPs) looking for training in primary care psychiatry. 

The Train New Trainers (TNT) Primary Care Psychiatry Fellowship is currently accepting applications from providers working in internal medicine, family medicine, emergency medicine, pediatrics and neurology. The course consists of 45 hours of required training on: 

• How to complete an evidence-based and efficient psychiatric interview in the busy primary care/medical setting 
• How to effectively diagnose and treat commonly encountered psychiatric conditions, such as mood, anxiety, psychotic and substance use disorders 
• How to teach these principles to their primary care colleagues 

Tuition for the program is $15,500 per fellow, with scholarships available through the Department of Health Care Access and Information. 

Applications are due by October 31, 2024. For more information about the fellowship, please visit medschool.uci.edu/pcp. For questions, please email tntpcpfellowship@hs.uci.edu.

Click on the link below to find an outline of changes made to CalOptima Health policies and procedures during July 2024. The full description of the policies below is available on CalOptima Health’s website at:

www.caloptima.org/en/ForProviders/Resources/ManualsPoliciesandGuides.aspx.

Policies and Procedures Monthly Update

Click below for training webinars and meetings happening in September 2024:

Health education webinars

• CalOptima Health Board of Directors: September 5 at 2 p.m.
• Joint Meeting of the Provider and Member Advisory Committees: October 10 at Noon

All meetings have an option for virtual attendance. Visit the CalOptima Health website for more information.