Requirements
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
All Medi-Cal members ages 18 months and older must have an initial health appointment (IHA), which includes an age-appropriate history and physical examination, within 120 calendar days after their date of enrollment. For Medi-Cal Members less than 18 months of age, the IHA must be completed within 120 calendar days following the date of Enrollment or within periodicity timelines established by the American Academy of Pediatrics (AAP) Bright Futures for ages 2 years and younger, whichever is sooner.
The member may be seen initially during a visit for episodic care. Regardless of the reason for the initial visit, the provider should conduct the IHA at the first health care contact and document the assessment in the medical record. The IHA must be completed by a provider in the primary health setting.
An IHA at a minimum must include: a history of the member's physical and mental health, an identification of risks, an assessment of need for preventive screens or services and health education, a physical examination, and the diagnosis and plan for treatment of any diseases, unless the member's primary care physician (PCP) determines that the member's Medical Record contains complete information, updated within the previous 12 months, consistent with the assessment requirements.
The IHA must be conducted in a culturally and linguistically appropriate manner for all members, including those with disabilities, and it must be documented in the member’s medical record.
IHA Guidelines
For members under age 21, the IHA and ongoing assessments must follow the current AAP Recommendations for Preventive Pediatric Health Care (PDF). The IHA must provide, or arrange for provision of, all immunizations necessary to ensure that the member is up to date with the Recommended Childhood Immunization Schedule (PDF) based on joint recommendations of the Advisory Committee on Immunization Practices (ACIP), Adverse Childhood Experiences (ACEs) screening, and any required age-specific screenings including developmental screenings. Providers must also ensure that members receive all screening, preventive and Medically Necessary diagnostic and treatment services required under the EPSDT benefit, as described by DHCS in the EPSDT Provider Information.
For members ages 21 and older, the initial appointment includes, but is not limited to, an evaluation and timely provision of applicable preventive services provided in accordance with the United States Preventive Services Taskforce (USPSTF) grade A and B recommendations.
IHA Documentation and Reporting
For all providers, a member eligibility report is available through Health Net Membership Accounting at the primary care physician's (PCP's) request to allow providers to reach out to their new members and ensure completion of all appropriate preventive care services and the IHA within 120 calendar days. Providers may log on to Health Net's provider portal to access the online IHA reports located under Provider Reports.
Health Net reviews monthly claims and encounter data of initial health appointments rendered by participating providers. These encounters are cross-checked against member enrollment data. A member eligibility report is available at the PCP's or participating physician group's (PPG's) request on a monthly basis to provide an aid for IHA compliance.
In all cases, the PCP must document all member contacts, including scheduling of the appointment or the member's refusal to schedule an appointment, in the member's medical record.
Childhood Blood Lead Screening
Providers must follow guidelines issued by the Department of Public Health's California Childhood Lead Poisoning Prevention Branch (CLPPB) Health and the California Childhood Lead Poisoning Prevention Branch (CLPPB)-issued guidelines on childhood blood lead screening, which includes CDC Recommendations for Post-Arrival Lead Screening of Refugees, of the Department of Public Health and also:
- Provide oral or written anticipatory guidance to the parents or guardians of a child that includes information that children can be harmed by exposure to lead. The guidance must be provided at each periodic health assessment for ages 6-72 months.
- Perform blood lead level (BLL) testing on all children as follows:
- At ages 12 months and 24 months.
- When the provider performing the periodic health assessment becomes aware that a child age 12-24 months has no documented evidence of a BLL test taken at age 12 months or thereafter.
- When the provider becomes aware that a child age 24-72 months has no documented evidence of BLL test results taken at age 24 months or thereafter.
- Whenever the provider becomes aware that a child age 12-72 months has had a change in circumstances that places the child at increased risk of lead poisoning, in the provider's professional judgement.
- When requested by the parent or guardian.
- The health care provider is not required to perform BLL testing in the following cases. The reasons for not screening must be documented in the child's medical record.
- The parent or guardian refuses consent for the screening. Providers must obtain a signed statement of voluntary refusal by the parent or guardian, or document reasons for not obtaining the signed statement (i.e. parent refused or is unable to sign, assessment done via telehealth, etc.).
- If in the professional judgement of the provider, the risk of screening poses a greater risk to the child's health than the risk of lead poisoning.
Blood lead level screening must be reported.
- Encounter or claims data is used to track the administration of blood level screenings. Providers must ensure that encounters are identified using the appropriate CPT codes for blood level screenings.
- Laboratories and health care providers performing blood lead analysis on specimens are to electronically report all results to CLPPB, with specified patient demographics, ordering physician and analysis data on each test performed. Information on how to report results to CLPPB can be found at CLPPB website.
Coordination by Health Net
Health Net sends new members a welcome packet that includes an initial health appointment (IHA) notification, provider directory, Evidence of Coverage (EOC), preventive care services, and other important plan information. Instructions are included for new members to schedule appointments with their primary care physicians (PCPs). Health Net contacts new Medi-Cal members by telephone after mailing the new member packet to communicate the importance of scheduling an IHA and to share other relevant information about members using their benefits. If the IHA has not occurred within 45 days of enrollment, Health Net conducts a third member contact via phone. If a member, or the parent or guardian of a child member, refuses to have the IHA performed, it must be documented in the member's medical record.
Providers may contact the Health Net Education Department for more information.