The Medi-Cal Operations Manual offers Health Net Community Solutions, Inc. (Health Net), CalViva Health, and Community Health Plan of Imperial Valley providers access to important information about plan benefits, limitations and administration processes to make sure members enrolled in the Medi-Cal managed care plan receive covered services when needed.
Health Net, CalViva Health, and Community Health Plan of Imperial Valley are regulated by the California Department of Health Care Services (DHCS) and the California Department of Managed Health Care (DMHC). The Health Net, CalViva Health, and Community Health Plan of Imperial Valley Medi-Cal plans are offered by Health Net, CalViva Health, and Community Health Plan of Imperial Valley under a contract with the DHCS.
CalViva Health contracts with DHCS to provide services to Medi-Cal managed care members under the Two-Plan model in all ZIP Codes in Fresno, Kings and Madera counties. The Operations Manual for CalViva Medi-Cal providers in Fresno, Kings and Madera counties is developed and maintained for CalViva Health by Health Net.
Community Health Plan of Imperial Valley contracts with DHCS to provide services to Medi-Cal managed care members under the Single-Plan model in Imperial County. The Operations Manual for Community Health Plan of Imperial Valley Medi-Cal providers in Imperial County is developed and maintained for Community Health Plan of Imperial Valley by Health Net.
In Los Angeles County, Health Net is a primary contractor with DHCS as the commercial plan under the Medi-Cal Managed Care Two-Plan Model. However, Health Net entered into a contract with Molina Healthcare as a subcontracting health plan to arrange for the provision of Medi-Cal services through Molina’s provider network. Some Medi-Cal members in Los Angeles County are Health Net members, even if assigned to Molina. Except as noted, the policies, procedures and programs described in the Medi-Cal Operations Manual are applicable to all contracting providers, including those contracting through Molina.
The four provider types, Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary, are listed at the top of each page. Unless specified within the body of the document, refer to the Provider Type listed at the top of the page to see if the content applies to you.
As a Health Net participating provider, you are required to comply with applicable DHCS laws and regulations and Health Net policies and procedures.
The contents of Health Net's Medi-Cal Operations Manual are in addition to your Provider Participation Agreement (PPA) and its addenda. When the contents of Health Net's Medi-Cal Operations Manual conflicts with the PPA, the PPA takes precedence.