December 2020 Edition

A Note from Dr. Keith Wilson Who knew at the time of our last newsletter how impactful the COVID-19 pandemic would be on our lives and that of our families, friends, patients and our clinical practice. As we stand at more than 200,000 lives lost, one-sixth of private sector businesses shuttered, and schools continue to struggle with what happens next.  At AltaMed, we remain committed to serving our patients and have embraced the "new norm" to keep our patients, providers and staff safe while striving to continue offering high quality health care.  Below, please find a grid of resources supported by each patient's individual health plan. You can call the health plan directly for more information.  Lastly, please continue to use personal protective equipment, wear your mask, practice social distancing, and wash your hands. We encourage providers and staff, in addition to your patients, to get your influenza vaccine as the flu season is upon us. Sincerely, Keith Wilson, M.D., FACOG

COVID-19 Update from Dr. Sherrill Brown Over the last several months, AltaMed has been a part of the response to the COVID-19 pandemic. We have transformed across our organization in order to deliver quality health care at the right place at the right time–all the while keeping our patients and staff safe. A few of our unprecedented accomplishments include: Implementation of telehealth Testing close to 60,000 people for COVID-19 Screening all patients, visitors and staff members for COVID-19 risk factors prior to entering our facilities Upgrading many of our clinics with isolation facilities Restructuring dental visits to make them as safe as possible Our response is not over yet; we still have a long road ahead. Following the five elements of safety for our Safe Environment plan and continuing with our new normal plans will be key to our ongoing health and success at AltaMed.  While we are still responding to this pandemic it is important to continue to deliver high quality care for our patients at the right place at the right time. This includes: Getting all of our staff and patients vaccinated against the flu as long as there are no contraindications for the vaccine Conducting telehealth visits appropriately to encourage our patients to access care Always being available to see patients in the clinic regardless of exposure or symptoms while utilizing our isolation rooms effectively Testing our patients and staff for COVID-19 according to Centers for Disease Control and Prevention (CDC) and local public health guidelines Reaching out and scheduling all of our patients for care who are in need of regular chronic disease management and timely preventative care During this pandemic, I have seen our company come together as a whole to tirelessly face this challenge head on with grace, creativity, speed and effectiveness. I know that we have the people and tools to continue to be successful now and into the future.

Five Elements of Safe Environment  Screening: All patients, visitors and staff attest that they do not have any high-risk exposures or symptoms of COVID-19 prior to entering our buildings Patients with high-risk exposures or COVID-19 symptoms will be isolated and cared for appropriately Hand Hygiene: Having access to and practicing frequent hand hygiene along with not touching our faces is important for our ongoing health and safety Mask and Appropriate PPE Use: All staff and patients need to wear a face mask at all times while outside of their homes according to Governor Newsom's face covering mandate for California Staff will wear appropriate PPE for every aspect of their work, including wearing a face shield or goggles, face mask and gloves for every patient encounter regardless of risk Physical Distancing: Maintain a distance of six feet or more from other staff members and patients while at work, including while on breaks If unable to be more than six feet from individuals, wearing a face shield or goggles in addition to masks is required Appropriate Cleaning of the Environment: Frequent cleaning and disinfection of high-touch surfaces throughout our work sites Appropriate deep cleaning of our work spaces

Network Management Updates

Senate Bill 137 - Provider Directory Accuracy In an effort to remain compliant with California Senate Bill 137 (SB 137), we are to provide current and accurate provider demographic information to patients via their respective health plan directories. Our bi-annual provider data validations were mailed out by November 5 to your primary office. Please remain alert for the notice as your completion of the document, even if there are no changes, is both required and appreciated. If you do not receive the form, and/or have any questions or concerns, please email Managed Care Health Plans Provider Operations.

Claims Reminder – It's Flu Season! Please visit the CMS website for the most up-to-date coding for administering the flu vaccine. Reminder: please make sure to submit your claim to the correct entity AltaMed or the health plan based on the Division of Financial Responsibility (DOFR).

PACE Opens New Site in Long Beach In September, AltaMed Health Services opened its ninth Program of All-Inclusive Care for the Elderly (PACE) Center in Long Beach. The new location, located at 1500 Hughes Way, Ste. C150, provides comprehensive health and social services to help frail seniors, who meet nursing home eligibility in the greater Long Beach and South Bay area. Referring patients to PACE can be beneficial to providers as it allows patients to receive a comprehensive set of services that are not available in the traditional MediCal or Medi-Medi plans. In addition, providers can offload the hours of intensive care coordination that is required to manage frail elderly patients with chronic comorbidities. If you have any patients who may benefit from PACE, please forward them via e-fax to (323) 853-6904 or email PACE Marketing.

Risk Adjustment Department Many offices have shifted to a telehealth environment to care for members, especially the senior population. Medicare (CMS) requires a telehealth video or face-to-face visit for risk adjustment, therefore televisits by phone only do not meet the requirement. Seniors may have difficulties using the video technology on their cell phones. Please bring them into our clinics for a face-to-face visit to complete risk adjustment or Medicare Health Assessment (MHA). This means that your assigned Medicare patients are missing important chronic conditions, such as (CKD, ESRD, CHF, COPD, DM, Major Depression, etc.) on their Problem List and have not been addressed as a Visit Diagnosis. Cozeva can help you track risk adjustment and five-star quality measures for seniors. If you do not have access to Cozeva, please email the Risk Adjustment department.

New This Year ALTAMED FQHC: Incentive for front and back office staff based on membership panel will be distributed this year for clinics that meet their goals. The incentive example is provided below:

Timely Access to Care The law requires health plans licensed by the Department of Managed Health Care (DMHC) to make providers available within specific geographic and time-elapsed standards. Health plans must ensure their network of providers, including doctors, can provide enrollees with an appointment within a specific number of days or hours. Links have been provided for you to see the DMHC standards: Appointment Availability After-hours and appointment availability Plans shall ensure that telephone triage or screening services are provided in a timely manner appropriate for the enrollee's condition and that the triage or screening waiting time does not exceed 30 minutes.

Utilization Management

Guidelines The Utilization Management (UM) department implements the UM program, policies, and processes for effectively handling requests for authorization of services to include: Pre-service review Concurrent inpatient review Retrospective review The UM department performs an annual program evaluation. In order to do so, it performs a variety of internal processes and audits, including, but not limited to: Monitoring over/under utilization of medical services Evaluating all medical necessity reviews to ensure that decisions are made through consistent adherence to the evidence-based guidelines Collaborating with other AltaMed departments to meet provider network adequacy Identifying appeals and grievances, then directing them to the health plans for resolution

Continuity of Care Newly enrolled members transitioning into AltaMed, and existing members undergoing care with a terminated provider, have the right to request continuity of care in accordance with California law and Managed Care Plan (MCP) contracts, with some exceptions. This allows members to complete treatment of an acute episode or care already in process, without interruption until the care can be transitioned to the AltaMed provider network. However, continuity of care protections does not extend to the following services: Durable medical equipment (DME) Transportation Other ancillary services Carve-out service providers

UM Department Staff Availability UM staff are available to members and providers Monday through Friday between 8:00 a.m. and 5:00 p.m. The toll-free number is (855) 848-5252. Providers should identify themselves by name, title, and organization name when initiating or returning calls regarding UM issues. The TDD/TTY service number is (800) 735-2922 and is available to members who have hearing or speech impairment. Language assistance is available to members to discuss UM issues.

Treatment Authorization Process (TAR) Process AltaMed accepts TAR submissions via the online portal, phone, fax, and mail. Phone requests must be followed by a written request. To avoid delays in the decision-making process, providers should submit TAR request with relevant clinical information (e.g., the reason for services requested, significant findings, procedures performed, and care, treatment, and services previously provided for the member's condition). When a TAR does not have the supporting clinical information, it may lead to an adverse determination or a delay in TAR processing. All decisions are made within the required timelines, based on the member’s clinical information using evidence-based criteria, and UM matrix.

Turnaround Times  Turnaround times are established as follows per regulatory requirements:

Urgent Referral Requests Referral requests are processed based on the member's condition, which may be classified as urgent or routine. To prevent delays in processing authorization requests for members who need urgent care, providers should classify the referral to coincide with the member's health care needs. "Urgent care" means health care for a condition that requires prompt attention, consistent with subsection (h)(2) of HSC § 1367.01. This occurs when: When the enrollee's condition is such that the enrollee faces an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life, limb, or other major bodily function. The normal time frame for the decision making process would be detrimental to the enrollee's life or health or could jeopardize the enrollee's ability to regain maximum function. Decisions to approve, modify, or deny urgent requests by providers prior to or concurrent with the provision of health care services to enrollees, must be made in a timely fashion appropriate for the nature of the enrollee's condition, not to exceed 72 hours.

How Decisions Are Made AltaMed renders coverage determinations based on benefit coverage, medical necessity, and medical appropriateness. AltaMed adopts clinical criteria and guidelines to make determinations of treatment requests. The UM department involves actively practicing health care providers, including Behavioral Health practitioners, in the decision-making process. Clinical criteria used to make utilization decisions and the procedure for appropriately applying these criteria, are reviewed annually, and updated when appropriate. Only licensed physicians or licensed health care professionals—with expertise in their respective fields—involved in administering the health care services requested by the provider, may deny or modify requests for authorization of health care services for members for reasons of medical necessity.

Criteria/Guidelines Are Available AltaMed makes utilization decisions based on clinical evidence using written clinical criteria or guidelines. The process for applying objective clinical guidelines is based on members’ individual needs. It is used when determining the medical appropriateness of requested health care services. Providers and members have the right to request a copy of the guidelines that AltaMed use to make service or treatment request determinations. Specific guidelines are also available to the public, upon request, with the following disclosure: "The material provided to you are guidelines used by this plan to authorize, modify, deny care for the person with similar illnesses or conditions. Care and treatment may vary depending on individual need and the benefits covered under your contract." Please contact the UM department at (855) 848-5252 to obtain a copy of a specific guideline.

Peer-to-Peer Requests AltaMed UM representatives can help coordinate any peer-to-peer requests for services that have been denied. The UM representative will connect the provider with the reviewing Medical Director or schedule a date and time for a peer-to-peer discussion. To initiate a peer-to-peer request, please contact the UM department at (323) 597-2928. The following services, which do not require prior authorization, will be approved and covered for claim settlement:

AltaMed Ensures Appropriate Utilization AltaMed clinical staff ensures appropriate utilization of medical services by basing decisions on evidence-based guidelines/criteria and the existing benefit coverage. Additionally, AltaMed does not specifically reward practitioners, providers, or other individuals for issuing denials of coverage or service. No financial incentives exist for UM decision makers to encourage decisions that result in low utilization.

24/7 Nurse Line AltaMed uses its Plan partner nurse lines to perform 24/7 assistance to its members. This service provides 24/7 access to registered nurses who can assist members with making informed decisions on their health care needs. Nurses assist members in the following: Offering recommendations on self-care for minor injuries or illnesses Determining the appropriate level of care for the member's condition at the time of the call Answering questions about the member's health condition, treatment options or medications Members can reach the Nurse Advice Line by calling the following telephone numbers:

When to Request a Second Opinion AltaMed will approve referrals for a second opinion when requested by a member or a provider, who is treating a member, for the following reasons: Uncertain of the reasonableness or necessity of recommended surgical or medical procedures Uncertain or hesitant about a diagnosis or plan of care for a condition that threatens loss of life, loss of limb, loss of bodily function, or substantial impairment (including, but not limited to, a serious chronic condition) Requests further professional guidance or description on the clinical indications that may be too complex and confusing Receives conflicting test results Provider is unable to diagnose the member’s condition If the current treatment plan is not improving member’s medical condition within an appropriate period of time of receiving the diagnosis Any other reasonable circumstance or necessity

UM Resources & Communications A new link has been added to the CONNECT Portal launch page that provides direct access to pertinent UM resources, including: UM Tar Form Listing of approved UM criteria Prescription Drug Form Medical Record Request information To access the link, go to the CONNECT Portal and select UM Resources and Communication.

Initial Health Assessment

An Initial Health Assessment (IHA) is a comprehensive assessment completed during a member's visit with his or her Primary Care Physician (PCP). AltaMed Health Services (AHS) has undergone several Health Plan audits on the completion of an IHA. IHA components include: Age appropriate comprehensive history, physical and mental status, developmental exam, and immunizations Individual Health Education Behavioral Assessment (IHEBA) using the Staying Healthy Assessment (SHA) Evaluation for Health Education and appropriate referrals for care coordination to include community resources All Medi-Cal members should receive timely access to an IHA within 120 days of enrollment, regardless of age. For Medicare Advantage, providers must make a “best-effort” attempt to conduct an initial assessment of each member's health care needs. Providers must follow up on unsuccessful attempts to contact the member, within 90 days of the effective date of enrollment. A total of three attempts must be made to reach the member, with at least one phone call and one mail notification. Additionally, if a member refuses an IHA, the refusal must be documented in the medical record. IHA exclusions: Existing members who have been your patient, for which documentation exists showing an IHA completed within the past 12 months Members who refuse the IHA. Refusal must be noted within the medical record Members who missed an appointment, where the provider documented two additional attempts to reschedule Based on the Health Plan audit results, a number of deficiencies were identified. In an effort to improve future outcomes AHS Medical Management team will perform the following: PCPs with a newly enrolled member list who require an IHA on a monthly basis. Perform random audits to ensure IHA completion Partner with Provider Network Operations to facilitate training, as needed Provide PCPs with a Medicare and MediCal IHA tool listing the required components of the IHA Medicare Exhibit A MediCal Exhibit B

Compliance Corner

Updated Business Code of Conduct Everyone is responsible for abiding by AltaMed’s core values, with particular regards to three: Integrity, Honesty, and Respect in All of Our Endeavors. To help achieve this common goal, our Board of Directors have approved a revision to the Business Code of Conduct. The Code of Conduct establishes AltaMed’s ethical standards for professional business conduct and affirms our commitment to compliance. While the Code of Conduct does not cover every issue that may arise, it lays out clear expectations for all board members, employees, contractors and all other representatives of the organization when conducting business on behalf of AltaMed.  AltaMed’s reputation is either upheld and enhanced or diminished by each person’s decisions, actions, and conduct. As such, it is important that you carefully read and understand the contents of the Business Code of Conduct and that you apply the principles to your daily work. Much of what’s in the Code of Conduct is not only the right thing to do, it is the law. If you are in a situation that you believe may violate or lead to a violation of the Code of Conduct, discuss the issue with your supervisor or speak directly with a staff member in the Office of Compliance and Ethics (OCE). In addition, you can report any concerns by using the anonymous Compliance Hotline, as directed in the Code of Conduct. Click here to review the updated Business Code of Conduct.

Cultural & Linguistic Competency

Regulatory Agency Requirements The following guide summarizes all regulatory agency requirements, including Title VI of the Civil Rights Act of 1964, Department of Health Care Services (DHCS) contractual requirements, Medi-Cal Managed Care Division (MMCD) Policy letters, the Centers for Medicare & Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA). Please review the entire guidance included here: CL Provider Responsibilities Summary Sheet RevAltaMed Medi-Cal Non-Discrimination Notice 1557 - LA Care Co-branded Contact Evelyn Gonzalez-Figueroa, Cultural and Language Director, at (323) 480-1905 if you need clarification or tools to implement these requirements. Additionally, you may visit connect.altamed.org to download the needed items, including: Document Insert_Medi-Cal_EDITABLE Phone Number LA Medi-Cal Language Assistance Notice.pdf

Language Preference  Record each patient’s language preference in the medical record.

Interpreter Services Poster Protocol for How to Access Interpreting Service  Post the "Free Interpretation Services including American Sign Language" sign at key points of contact. This sign informs patients, who are Limited English Proficient (LEP), hard-of-hearing, or deaf that free interpreter services are available to them.

Cultural & Language Related Complaints and Grievances Your patients have a right to file a complaint and grievance if they feel their cultural or language needs are not met in your office. Grievance forms are available in a variety of languages, including county threshold languages. You may reach out to the Member Services Department at 1-866-880-7805.

Referrals to Culturally Appropriate Community Resources and Services If a patient needs services from a community-based organization or a social service agency, please visit www.HealthyCity.org or use the Blue Shield of California Promise Health Plan Community Resource Directory to locate resources. The Community Resource Directory is available on the website. Please document the referral in the patient's record.

Bilingual Providers and Staff Providers and staff, who communicate with patients in a language other than English or who act as interpreters, are encouraged to take a language proficiency test by a qualified agency. At a minimum, either of the following should be kept on file bilingual providers and staff:  Completed language capability self-assessment form. Providers and staff may use the Industry Collaborative Effort "Provider & Staff Language Capability Self-Assessment" form. This form is available on the website. Those who report limited bilingual capabilities should not act as interpreters or communicate with patients in a language other than English.  Certification of language proficiency or interpretation training (i.e. resume or curriculum vitae, which includes number of years worked as interpreter).

Availability of Member Materials in Threshold Languages and Alternative Formats  Patients may request materials in their preferred language and in an alternative format. Alternative formats include audio, Braille and Large Print.

Cultural Competency Training We encourage you and your staff to attend disability sensitivity and cultural awareness/competency training programs. These trainings can help enhance your interpersonal and intra-cultural skills, which can improve communication with your culturally diverse patients, including seniors and people with disabilities. Programs are available through Blue Shield of California Promise Health Plan, L.A. Care and other agencies.