The Medi-Cal Operations Manual offers CalViva Health and Health Net Community Solutions, Inc. (Health Net) providers access to important plan benefits, limitations and administration processes to make sure members enrolled in the Medi-Cal managed care plan receive covered services when needed. CalViva Health and Health Net are regulated by the California Department of Health (DHCS) and Department of Managed Health Care (DMHC). The Health Net Medi-Cal plan is offered by Health Net under a contract with the California Department of Health Care Services (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.
In Los Angeles County, Health Net is the 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. 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 every 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.
Applicable counties covered are also listed at the top of every page. Unless specified within the body of the document, review Counties Covered at the top of the page to see if the content applies to the county you operate in.
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 operations manuals are in addition to your Provider Participation Agreement (PPA) and its addendums. When the contents of Health Net's operations manuals conflict with the PPA, the PPA takes precedence.