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Quality Management Program and Resources

The Plan's quality management program continuously monitors and evaluates the quality, appropriateness and outcome of care and services delivered to our members. It includes the development and implementation of standards for clinical care and service, measurement of compliance to standards, and the implementation of actions to improve performance.

Below is an overview of the components of the multifaceted Medi-Cal quality management program. It includes quality improvement (QI) processes and instructions on how to get more information from the Health Net provider website

For ongoing changes and requirements for COVID-19, visit the following web sites:

Open clinical dialogue

The Plans' Medi-Cal Provider Participation Agreement (PPA) states that participating providers can communicate freely with members about their medical conditions, treatment options and medications, regardless of limits to coverage.

Quality performance improvement projects

The Plan conducts quality performance improvement projects (PIPs) targeting specific health care issues that impact a significant number of members. PIPs may also address use of health services to enhance health outcomes. It includes testing small-scale changes at the provider-, member- and health plan- level to improve the quality of members’ health care and outcomes.

The current DHCS PIP cycle is November 2020–December 2022. The projects currently in process are:

  • Improving childhood immunization rates.
  • Reducing disparities in breast cancer screening outcomes.

PIPs require frequent reporting to DHCS and Health Services Advisory Group (HSAG). There are specific expectations for working with a clinic or federally qualified health center (FQHC) which include:

  • Completing a process map that reflects the clinic’s current progress.
  • Key driver diagram with potential interventions. (CalViva Health only)
  • Failure mode and effect analysis.
  • Intervention analysis.
  • Monthly progress monitoring.

Select provider groups are engaged engaging in these focused studies. 

CalViva Health only – At the conclusion of the projects, an overall assessment of the projects will be submitted to DHCS and HSAG. It will include whether the health plan achieved the SMART Aim goal, which interventions had the greatest impact and how timing of the interventions related to the changes in the SMART Aim measure rate (based on the final run chart). The successes, challenges, lessons learned, and the plan for sustainability of the interventions will be part of the PIP conclusion. 

Depending on the progress of the initiatives, the Plan will expand the interventions to other clinics and potentially across all counties. 

Quality of care and services provided to members have historically been measured through HEDIS performance measures for care and service, CAHPS for member satisfaction, member appeals and grievances, and access and availability surveys. In addition, the Plan conducts an annual provider satisfaction survey to find ways to better serve its participating providers.

Starting in 2019, DHCS began leveraging the CMS Adult and Child Core sets to measure health plan performance. The new measure set, called the Managed Care Accountability Set (MCAS), holds plans to significantly more measures and addresses care needs across preventive, chronic and behavioral health. DHCS revised the MCAS for MY 2022 and holds the Plan accountable to meet minimum performance levels at the 50th percentile on the following 15 measures:

  • Breast Cancer Screening (BCS).
  • Cervical Cancer Screening (CCS).
  • Child and Adolescent Well-Care Visits (WCV).
  • Childhood Immunization Status – Combo 10 (CIS-10).
  • Chlamydia Screening in Women (CHL).
  • Comprehensive Diabetes Care: HbA1c Poor Control > 9.0% (CDC-H9).
  • Controlling High Blood Pressure < 140/90 mm Hg (CBP).
  • Follow-up After ED Visit for Mental Illness – 30 days.
  • Follow-up After ED Visit for Substance Abuse – 30 days.
  • Immunizations for Adolescents – Combo 2 (IMA-2).
  • Lead Screening in Children.
  • Prenatal & Postpartum Care: Timeliness of Prenatal Care (PPC-Pre).
  • Prenatal & Postpartum Care: Postpartum Care – (PPC-Pst).
  • Well-Child Visits in the First 30 months of Life – Six or more well child visits in the first 15 months (W30).
  • Well-Child Visits in the First 30 Months of Life – Two or more visits during 15–30 months (W30).

Appropriate timeliness of services, outreach to members, clinical documentation, correct coding, as well as timely and complete encounter submissions, are important elements of meeting preventive care guidelines. The Plan's provider office training materials, member outreach calls, member newsletters, and an online provider newsletter are all designed to help providers and members accomplish these preventive measures.

As CalViva Health’s downstream subcontractor and Health Net’s behavioral health subsidiary, MHN administers behavioral health services to CalViva Health members. Practitioners and providers may refer members for behavioral health services or members can self-refer by calling CalViva Health Member Services at the phone number on the back of their CalViva Health identification cards. The QI Department utilizes several specific quality initiatives to help improve members’ physical and mental health outcomes. CalViva Health collaborates with MHN on quality improvement activities that may reach your office or practices. 

Overall, members and providers may receive live calls from MHN’s quality team. These calls provide members and providers with important educational information or reminders to take action when necessary. The focus of these initiatives may include antidepressant medication management. MHN conducts telephonic outreach to members about antidepressant medication management and the importance of coordination of care.

MHN is Health Net’s behavioral health division. Practitioners and providers may refer members for behavioral health services or members can self-refer by calling MHN at the phone number on their Health Net ID cards. The QI Department utilizes several specific quality initiatives to help improve members’ physical and mental health outcomes. The health plan collaborates with MHN on quality improvement activities that may reach your office or practices. 

Overall, members and providers may receive live calls from MHN’s quality team, .  These calls provide providing members and providers with important educational information or reminders to take action when necessary. The focus of these initiatives may include antidepressant medication management, follow-up for children prescribed ADHD medication, timely follow-up care after an emergency department visit or hospital stay for mental illness and/or substance use, and coordinating referrals and care. Below is a summary of the collaborative quality improvement projects:

MHN telephonic outreach to –

  • Families that have children who are prescribed ADHD medication.
  • Physicians who are prescribing ADHD medication.
  • Members about antidepressant medication management and the importance of coordination of care.

MHN written outreach to –

  • Physicians about antidepressant medication management and the importance of coordination of care.

The Chronic Conditions/Disease Management program aims to identify members at risk for asthma, diabetes and heart failure. The goal of the program is to help improve the care of members with chronic conditions by empowering individuals and to work with their health care providers to manage their condition and prevent complications.

The Plan mails educational materials and information about the program to enrolled members. The Plan conducts outbound telephonic interventions and makes referrals to case management as needed. A health plan physician or case manager may also refer members to the program, or members can self-refer.

To refer a member to the program, use the Case Management Referral Form (CalViva Health, Health Net) in the Provider Library. Members may self-refer to the program by calling the customer service number on the back of their ID cards and request a referral to Care Management.

The following interventions and resources are available at no cost to Medi-Cal members through self-referral or a referral from their primary care physician (PCP). For more information, members and providers can call the toll-free Health Education Information Line. Members will be directed to the appropriate service or resource based on their needs. Telephonic and web-based resources are available 24/7. Members and PCPs may request educational resources on health topics such as, but not limited to, nutrition, tobacco prevention and cessation, HIV/STD prevention, family planning, exercise, dental, perinatal care, diabetes, asthma, substance abuse and much more. Print educational resources are sent to members.

Fit Families for Life – Be in Charge!sm weight management resources

Providers should complete and fax a copy of the Fit Families for Life – Be in Charge!sm Program Referral form to the Health Education Department to refer members to these weight control resources, or to request program materials and resources. Members interested in these programs and nutrition related materials may also contact the Health Education Department.

Fit Families for Life – Home Edition

The Home Edition resources is one of a number of member-based offerings under the Fit Families for Life – Be in Charge!sm program. It is a five-week, home-based family intervention program that promotes healthier lifestyles. Through goal-setting strategies, participants receive guidance on making better food choices and increasing physical activity. A program workbook covers topics, such as how to read a nutritional facts label, tips for adding fruits and vegetables to everyday meals, family involvement in the kitchen, tips for eating out and aerobic exercise options. A healthy recipes cookbook and exercise band accompany the workbook. Program materials are available in English and Spanish, which providers can request for CalViva Health members (regardless of weight status).

Healthy Habits for Healthy People

The Healthy Habits for Healthy People resource guides older adults in eating healthy and being active. Topics include important dietary nutrients, tips to address eating problems, cooking and shopping when limitations are present, exercise, and much more. Members receive a booklet, exercise stretch band and cookbook. The Healthy Habits for Healthy People program is also available in a community workshop format. Materials extended to all participants at no cost are available in English or Spanish.

Pregnancy program

We want to help members take care of themselves and their babies from the time they find out they are pregnant through postpartum and newborn periods. The CalViva Pregnancy Program is a care management program for members who are pregnant.

The program can help members:

  • Find a doctor.
  • Set up appointments.
  • Find community resources.
  • Provide educational resources.
  • Locate nurse and social worker support.

Members identified as having a high-risk pregnancy can receive extra help from case management nurses during the pregnancy. They can contact Member Services to take part in the pregnancy program.

Tobacco cessation program

The Kick It California tobacco cessation program (formerly known as the California Smokers’ Helpline) is available to CalViva Health members. The program offers free phone counseling, self-help materials and online help in six languages (English, Spanish, Cantonese, Mandarin, Korean, and Vietnamese). Specialized services are available to teens, pregnant women and tobacco chewers to help members quit smoking and stay tobacco free. Non-pregnant adult members are offered a 90-day regimen of all U.S. Food and Drug Administration (FDA) approved tobacco cessation medications with at least one medication available without prior authorization.

CalViva Health members can enroll in the telephonic tobacco cessation program, without prior authorization for members of any age regardless if they opt to use tobacco cessation medications, by calling Kick It California. CalViva Health will cover tobacco cessation counseling for at least two separate quit attempts per year, without prior authorization, and with no mandatory break between quit attempts. Members may request a referral to group counseling by calling the Health Education Department .

Healthy Hearts, Healthy Lives

Members have access to a heart health prevention toolkit (educational booklet) to learn how to maintain a healthy heart. 

Behavioral health programs

CalViva Health offers myStrength®, a personalized website and mobile application, to help members deal with depression, anxiety, stress, substance use, pain management, postpartum depression and more. CalViva Health provides members with Adverse Childhood Experiences (ACEs) Education and Resources. Members can request CalViva Health’s ACEs education resources by contacting the toll-free Health Education Information Line or requesting them through their doctor.

Digital health education programs

T2X is a Web and mobile technology platform that educates and motivates individuals to adopt healthier lifestyles by addressing topics, such as nutrition, fitness, smoking cessation, depression, vaccination, anti-bullying, and sexual health. The goal of T2X is to increase participants’ capacity to access and the appropriate use of their health coverage, become more engaged in their health care and health behavior decisions, and develop pro-health attitudes. Individuals ages 13 and older, regardless of health coverage status, can go online to T2X and join at no cost.

CalViva Community Connect

Powered by findhelp, formerly known as Aunt Bertha, CalViva Community Connect offers the largest online search and referral platform. There are 10 topics to choose from, such as food, housing and transportation. Then select a subtopic which will contain a list of services based on the ZIP Code entered. The results can be viewed in over 100 languages. To use the tool, go to CalViva Community Connect, take the Social Needs Assessment, enter a ZIP Code, and click on Search.

The following interventions and resources are available at no cost to Medi-Cal members through self-referral or a referral from their primary care physician (PCP). For more information, members and providers can call the toll-free Health Education Information Line Members will be directed to the appropriate service or resource based on their needs. Telephonic and web-based resources are available 24/7. Members and PCPs may request educational resources on health topics such as, but not limited to, nutrition, tobacco prevention and cessation, HIV/STD prevention, family planning, exercise, dental, perinatal, diabetes, asthma, substance abuse and much more. Print educational resources are sent to members.

Fit Families for Life – Be in Charge!sm weight management resources

Providers should complete and fax a copy of the Fit Families for Life – Be in Charge!sm Program Referral form to the Health Net Health Education Department to refer members to the weight control resources, or to request program materials and resources.  Members interested in the program and nutrition related materials may also contact the Health Net Health Education Department.

Fit Families for Life – Home Edition

The Home Edition resources is one of a number of member-based offerings under the Fit Families for Life – Be in Charge!sm program. It is a five-week, home-based family intervention program that promotes healthier lifestyles. Through goal-setting strategies, participants receive guidance on making better food choices and increasing physical activity. A program workbook covers topics about how to read a nutritional facts label, tips for adding fruits and vegetables to everyday meals, family involvement in the kitchen, tips for eating out, and exercise options. A healthy recipes cookbook and exercise stretch band accompany the workbook. Program materials are available in English and Spanish, which providers can request for Health Net members (regardless of weight status).

Healthy Habits for Healthy People

The Healthy Habits for Healthy People resource guides older adults in eating healthy and being active. Topics include important dietary nutrients, tips to address eating problems, cooking and shopping when limitations are present, exercise, and much more. Members receive a booklet, exercise stretch band and cookbook. The Healthy Habits for Healthy People program is also available in a community workshop format. Materials extended to all participants at no cost are available in English or Spanish. 

Start Smart for Your Baby

We want to help members take care of themselves and their babies from the time they find out they are pregnant through postpartum and newborn periods. Start Smart for Your Baby® (Start Smart) is a care management program for members who are pregnant.

The program can help members:

  • Find a doctor.
  • Set up appointments.
  • Find community resources.
  • Provide educational resources.
  • Locate nurse and social worker support.

Members identified as having a high-risk pregnancy can receive extra help from case management nurses during the pregnancy. They can contact Member Services to take part in the program.

Tobacco cessation program

The Kick It California tobacco cessation program (formerly known as the California Smokers’ Helpline) is available to Health Net Medi-Cal members. The program offers free phone counseling, self-help materials and online help in six languages (English, Spanish, Cantonese, Mandarin, Korean and Vietnamese). Specialized services are available to teens, pregnant women, and tobacco chewers to help members quit smoking and stay tobacco-free. Non-pregnant adult members are offered a 90-day regimen of all U.S. Food and Drug Administration (FDA) approved tobacco cessation medications with at least one medication available without prior authorization.

Health Net Medi-Cal members can enroll in the telephonic tobacco cessation program, without prior authorization for members of any age regardless if they opt to use tobacco cessation medications, by calling Kick It California. Health Net will cover tobacco cessation counseling for at least two separate quit attempts per year, without prior authorization, and with no mandatory break between quit attempts. Members may request a referral to group counseling by calling Health Net’s Health Education Department.

Diabetes prevention program

Eligible members ages 18 and older with prediabetes can participate in a year-long evidence-based, lifestyle change program. The program promotes and focuses on emphasizing weight loss through exercise, healthy eating and behavior modification. The program is designed to assist Medi-Cal members in preventing or delaying the onset of type 2 diabetes.

Healthy Hearts, Healthy Lives

Members have access to a heart health prevention toolkit (educational booklet) to learn how to maintain a healthy heart.

Behavioral health programs

Health Net offers myStrength®, a personalized website and mobile application, to help members deal with depression, anxiety, stress, substance use, pain management, postpartum depression and more. Health Net provides members with Adverse Childhood Experiences (ACEs) Education and Resources. Members can request Health Net’s ACEs education resources by contacting the toll-free Health Education Information Line or requesting them through their doctor.

Digital health education programs

T2X is a Web and mobile technology platform that educates and motivates individuals to adopt healthier lifestyles by addressing topics about nutrition, fitness, asthma, diabetes, smoking cessation, depression, vaccination, anti-bullying, teen pregnancy and sexual health. The goal of T2X is to increase participants’ capacity to access and the appropriate use of their health coverage, become more engaged in their health care and health behavior decisions, and develop pro-health attitudes. Individuals ages 13 and older, regardless of health coverage status, can go online to T2X and join at no cost.

Health Net also offers myStrength®, a personalized website and mobile application, to help members deal with depression, anxiety, stress, substance use, pain management, postpartum depression, and more.

Health Net Community Connect

Powered by findhelp, formerly known as Aunt Bertha, Health Net Community Connect offers the largest online search and referral platform. There are 10 topics to choose from, such as food, housing and transportation. Then select a subtopic which will contain a list of services based on the ZIP Code entered. The results can be viewed in over 100 languages. To use this tool, go to Health Net Community Connect, take the Social Needs Assessment, enter a ZIP Code, and click on Search.

Case management is available to eligible CalViva Health members. The goal of case management is to address the holistic needs of each member through their individual continuum of health care.

Basic case management

At the basic level, care management is the responsibility of the primary care physician (PCP). The PCP is responsible for providing initial primary care management, maintaining continuity of care and initiating specialist care. This means providing care for the majority of health problems, including preventive care services, basic care management, acute and chronic conditions, and psychosocial problems.

Comprehensive case management

Clinical licensed nurses and social workers lead our case management (CM) teams and are familiar with evidence-based resources and best practice standards. They also have experience with the population, the barriers and obstacles they face, and how socioeconomic factors impact their ability to access services. The CalViva Health CM team coordinates care for members whose needs are functional and social in nature, as well as those with complex physical and or behavioral health conditions including high-risk pregnancy. CalViva Health uses a holistic approach by integrating referral and access to community resources, transportation, follow-up care, medication review, specialty care, and education to assist members in making better health care choices. Case managers partner with PCPs to support members with achieving their self-management health care goals.

Program components

This program supports CalViva Health members, families and caregivers by coordinating care and facilitating communication between health care providers. Once a member agrees to participate in the program, a care manager contacts the member’s PCP to coordinate care. This helps to facilitate an appropriate personalized level of care for members, which may include:

  • Telephonic and face-to-face (as needed) interactions.
  • Comprehensive assessment of medical, psychosocial, cognitive, medication adherence and durable medical equipment (DME) needs.
  • Development of an individual care treatment plan in collaboration with the member and the health care team that reflects the member’s ongoing health care needs, abilities and preferences.
  • Consolidation of treatment plans from multiple providers into a single plan of care to avoid fragmented or duplicate care.
  • Coordination of treatment plans for acute or chronic illness, including emotional and social support issues.
  • Coordination of resources to promote the member’s optimal health or improved functionality with referrals to other team members or programs, as appropriate.
  • Education and information about medical conditions and self-management skills, compliance with the medical plan of care, and other available services to reduce readmissions and inappropriate utilization of services.
  • Communication to the provider and medical home.
  • Support and education for pregnancies. High-risk pregnancies are offered extra help.

Referrals

Providers can refer a member to the Case Management Department by email or fax. The Case Management Referral Form is available in the Provider Library Members may self-refer to the program by calling the CalViva Health Member Service Department’s 24-hour toll-free number.

Clinical licensed nurses and social workers lead our case management (CM) teams and are familiar with evidence-based resources and best practice standards. They also have experience with the population, the barriers and obstacles they face, and how socioeconomic factors impact their ability to access services. The Health Net CM team coordinates care for members whose needs are functional and social in nature, as well as those with complex physical and or behavioral health conditions, including high-risk pregnancy. Health Net uses a holistic approach by integrating referral and access to community resources, transportation, follow-up care, medication review, specialty care, and education to assist members in making better health care choices. Case managers partner with PCPs to support members with achieving their self-management health care goals.

Program components

This program supports Health Net members, families and caregivers by coordinating care and facilitating communication between health care providers. Once a member agrees to participate in the program, a care manager contacts the member’s PCP to coordinate care. This helps facilitate an appropriate personalized level of care for members, which may include:

  • Telephonic and face-to-face (as needed) interactions.
  • Comprehensive assessment of medical, psychosocial, cognitive, medication adherence and durable medical equipment (DME) needs.
  • Development of an individual care treatment plan in collaboration with the member and the health care team that reflects the member’s ongoing health care needs, abilities and preferences.
  • Consolidation of treatment plans from multiple providers into a single plan of care to avoid fragmented or duplicate care.
  • Coordination of treatment plans for acute or chronic illness, including emotional and social support issues.
  • Coordination of resources to promote the member’s optimal health or improved functionality with referrals to other team members or programs, as appropriate.
  • Education and information about medical conditions and self-management skills, compliance with the medical plan of care, and other available services to reduce readmissions and inappropriate utilization of services.
  • Communication to the provider and medical home.
  • Support and education for pregnancies. High-risk pregnancies are offered extra help.

On an ongoing basis, Health Net evaluates the efficacy of this program by reviewing and comparing specific member outcomes and utilization before and after case management intervention.

Referrals

Providers may refer a member by email to the Case Management Department by email or fax. The Case Management Referral Form is available in the Provider Library. Members may self-refer to the program by calling Member Services Department, option 2 and requesting case management.  

Clinical practice guidelines

Evidence-based clinical practice guidelines are from nationally recognized sources and form the foundation for disease management programs. All guidelines are reviewed and updated at least biannually and when new scientific evidence or national standards are published. The clinical practice guidelines and tools are available on the provider website.

Guidelines sources include, but are not limited to, the following:

  • Disease management – Clinical guidelines and overview summaries are available for providers. They can to quickly reference information about chronic conditions, which include asthma, diabetes and heart failure (HF). Sources are found within the guidelines.
  • Behavioral health – Clinical guidelines are available for such disorders as attention deficit hyperactivity disorder (ADHD) and substance use disorder.

Preventive health guidelines

The Plan recommends that participating providers follow the preventive guidelines adopted from the United States Preventive Services Task Force (USPSTF), Centers for Disease Control and Prevention (CDC), American College of Obstetrics and Gynecology (ACOG), American Cancer Society (ACS), and American Academy of Family Physicians (AAFP) in the treatment of adult, senior, prenatal, and postpartum members. The guidelines of from the American Academy of Pediatrics (AAP) and Advisory Committee for Immunization Practices (ACIP) are recommended for the preventive care and treatment of infants, children and adolescents. A member’s medical history and physical examination may indicate that further medical tests are needed. As always, the judgment of the treating physician is the final determinant of member care.

Current recommended guidelines of the specialty boards, academies and organizations used in the development of the health plan’s preventive health guidelines are available on the following websitesline at:

Preventive health guidelines are available on the provider website. All information offered on the provider website is available to participating providers in print copy upon request.

Childhood blood lead level screenings

Providers who conduct periodic health assessments on Medi-Cal children ages 6 and under are responsible for screening children for elevated blood lead levels. Providers must follow the California Department of Public Health Guidelines for interpreting blood lead levels and performing follow-up activities for elevated levels.

The Plan provides electronic and web-based care gap reports to providers to help identify children who need a lead test. Reach out to your provider representative for information on how to obtain or review these reports. More information on DHCS’ childhood blood lead screening requirements, including provider reporting and documentation, and exceptions to conducting lead screening, can be found on the provider website.

Initial health assessments

New members must receive an IHA, which includes an age-appropriate history, preventive care services, physical examination and Individual Health Education Behavioral Assessment (IHEBA) within 120 days after the date of enrollment. In addition to assessing the member’s health, this examination should be used to determine health practices, values, behaviors, knowledge, attitudes, cultural practices, beliefs, literacy levels, and health education needs.

Members under age 18 months require a health assessment within periodicity timelines established by the AAP for ages 2 years and younger, whichever is less.

For members ages 21 and older, the IHA must follow DHCS guidelines and Health Net preventive care services guidelines. The preventive care guidelines in the USPSTF Guide to Clinical Preventive Services A and B Recommendations are considered the minimum acceptable standards for adult preventive care services. Guidelines for members under age 21 follow the AAP Recommendations for Preventive Pediatric Health Care’s periodicity schedule for wellness examinations.

DHCS’s approved IHEBA is the SHA. The SHA is the established assessment tool that enables PCPs to assess Medi-Cal members’ current acute, chronic and preventive health needs. The SHA includes standardized questions to assist PCPs in:

  • Identifying high-risk behaviors, including tobacco use and alcohol consumption, of individual Medi-Cal members.
  • Assigning priority to individual health education needs related to lifestyle, behavior, disability environment, culture, and language.
  • Initiating discussion, counseling and documenting health education interventions, referrals, and follow-up care regarding high-risk behaviors.
  • Identifying members whose health needs require coordination with appropriate community resources and other agencies for services not covered under the current contract.

All SHA questionnaires must include the PCP’s name, signature and date. The SHA should be completed at age-related intervals, as appropriate. If a member refuses to complete the SHA, the PCP must make note of the refusal in the member’s medical record.

Providers can access and download or print electronic versions of the SHA directly from the DHCS website. It is available in nine threshold languages. The SHA is also available in Arabic, English, Farsi, Khmer and Spanish in the Provider Library under Forms and References.

Providers are encouraged to contact the Health Education Department for more information about SHA.

Health risk assessment

The Plan makes every effort to complete a health risk assessment (HRA) for new members. For new Seniors and Persons with Disabilities, the Plan works to complete the HRA within 45 or 90 days of enrollment, depending on risk level, and on an annual basis thereafter. HRAs can be completed more frequently than annually, due to a change in health status or by member request. HRA completion helps with early and ongoing identification of member needs, enabling the Plan and participating physician group (PPG) care management teams to develop more comprehensive member-centric care plans. HRAs also help predict future consumption of medical care which is essential to the success of the care management program for both PPGs and the Plan.

CalViva Health has established access and availability standards, which are reviewed and revised annually as needed. The standards strive to ensure compliance with all applicable state, federal, regulatory, and accreditation requirements. They also help ensure members have a comprehensive provider network and timely access to care. 

CalViva Health and Health Net monitor the network and evaluate whether members have sufficient access to practitioners and providers who meet their care needs. The plan notifies all applicable providers of the established appointment access standards, network adequacy requirements, and access and availability monitoring processes. The standards include, but are not limited to, appointment waiting times for routine, urgent and preventive care; requirements for after-hours access to care; 24-hour nurse advice line triage; and other requirements and guidelines for access to medical care as mandated by the applicable regulatory body. 

Provider office wait times

DHCS requires CalViva Health and Health Net to monitor provider office wait times. In-office wait times for scheduled appointments must not exceed 30 minutes. To demonstrate compliance with this requirement, CalViva Health requests that providers submit completed in-office wait time logs the first Tuesday of every month by fax to (559) 446-1998 or email to MMAC@calvivahealth.org.

The complete set of access standards and after-hours scripts is available in the Provider Library > Access to Care and Availability Standards. Providers who do not have access to the internet may contact CalViva Health to request printed copies of these standards and after-hours scripts.

Health Net has established access and availability standards, which are reviewed and revised annually as needed. The standards strive to ensure compliance with all applicable state, federal, regulatory, and accreditation requirements. They also help ensure members have a comprehensive provider network and timely access to care.

Health Net monitors the network and evaluates whether members have sufficient access to practitioners and providers who meet their care needs. These include waiting time standards for regular and routine appointments, urgent care appointments and after-hours care, triage, and provisions for appropriate back-up for absences. The access standards are reviewed annually against applicable state and federal regulations and mandates, and are revised as needed. Health Net recommends providers review these periodically. After-hours scripts are also available that include examples on how to implement the script for live voice, auto attendant or answering machine messaging.

The complete set of access standards and after-hours scripts is available in the Provider Library > Access to Care and Availability Standards. Providers who do not have access to the internet may contact the Health Net Provider Services Center to request printed copies of these standards and after-hours scripts.

The Plan has established standards for the administration of medical records to ensure medical records conform to good professional medical practice, support health management and permit effective member care. A good medical records management system not only provides support to clinical participating providers in the form of efficient data retrieval but also makes data available for statistical and quality of care analyses.

The medical record serves as a detailed analysis of the member’s history, a means of communication to assist the multidisciplinary health care team in providing quality medical care, a resource for statistical analysis, and a potential source of defense to support information in a lawsuit. It is the participating provider’s responsibility to ensure not only completeness and accuracy of content but also the confidentiality of the health record. Providers are required to adhere to the standards for maintaining member medical records and to safeguard the confidentiality of medical information.

Participating providers are responsible for responding to demands for information while protecting the confidentiality interests of members. All participating providers must have policies and procedures that address confidentiality and the consequences of improper disclosure of protected health information (PHI). Providers should refer to the Medi-Cal Provider Manual in the Provider Library >Medical Records > Confidentiality of Medical Records > Procedure to review specific levels of security of medical records. Security of medical records must be addressed by the participating provider’s policies and procedures governing the confidentiality of medical records and the release of members’ PHI.

The Plan monitors medical record documentation compliance and implement appropriate interventions to improve medical recordkeeping. Medical record guidelines are available in the Provider Library. Then select Medical Records > Medical Record Documentation.

Medical record and facility site reviews

The Facility Site Review Compliance Department conducts periodic medical record reviews (MRRs) and facility site reviews (FSRs) to measure PCP compliance with current DHCS medical record documentation and facility standards. These reviews are initially conducted prior to assignment of CalViva Health members and then periodically every three years thereafter in accordance with DHCS requirements, or on an as needed basis for monitoring, evaluation or corrective action plan (CAP) issues.

In an effort to decrease duplicative MRRs and FSRs and minimize the disruption of patient care at participating provider offices, the Plan, and all other Medi-Cal managed care plans are required to collaborate in conducting FSRs and MRRs. On a county-by-county basis, the plans cooperatively determine which plan is responsible for performing a single audit of a PCP and administering a CAP when necessary. The responsible plan shares the audit results and CAP with the other participating health plans to avoid redundancy.

DHCS reviews the results of site reviews and may also audit a random sample of provider offices to ensure they meet DHCS standards. Detailed information about audit criteria, compliance standards, scoring, and CAPs is available in the Provider Library. Select Quality Improvement > Facility Site Review.

Physical accessibility review surveys

A component of the FSR is the Physical Accessibility Review Survey (PARS). PARS is conducted for participating PCPs, high- volume specialists, ancillary providers, community-based adult services (CBAS) providers, and hospitals. All PCP sites must undergo PARS.  Based on the outcome of PARS, each PCP, high-volume specialist, ancillary, CBAS, or hospital provider site is designated as having basic or limited access along with the six specific accessibility indicator designations for parking, exterior building, interior building, restrooms, examination rooms and medical equipment (accessible weight scales and adjustable examination tables).

  • Basic access demonstrates facility site access for members with disabilities to parking, building access, elevator, physician’s office, examination rooms and restrooms.
  • Limited access demonstrates facility site access for members with disabilities as missing or incomplete in one or more features for parking, building access, elevator, physician’s office, examination rooms and restrooms.

Results of the PARS are made available in the provider directory, Health Plan website and to Member Services Department (CalViva HealthHealth Net) to assist members with selecting a PCP who can best serve their health care needs.

The Utilization Management (UM) Department determines medical appropriateness using recognized guidelines and criteria sets that are clearly documented, based on sound clinical evidence and includes procedures for applying criteria based on the needs of individual members and characteristics of the local delivery systems. For the Medi-Cal program, the following criteria are used:

  • Title 22 of the California Code of Regulations (CCR).
  • Medi-Cal Managed Care Division (MMCD) policy letters.
  • DHCS Manual of Criteria for Medi-Cal Authorization.
  • DHCS Medi-Cal Provider Manual.
  • The Plan's medical policies. If no plan-specific clinical policy exists, then nationally recognized decision support tools such as InterQual® Clinical Decision Support Criteria or MCG (formerly Milliman Care Guidelines®) criteria are used.

Additional information that the applicable Health Plan Medical Director will consider, when available, includes:

  • Reports from peer-reviewed medical literature, where a higher level of evidence and study quality is more strongly considered in determinations.
  • Professional standards of safety and effectiveness recognized in the U.S. for diagnosis, care or treatment.
  • Nationally recognized drug compendia resources such as Facts & Comparisons®, DRUGDEX® and The National Comprehensive Cancer Network® (NCCN) Guidelines.
  • Medical association publications.
  • Government-funded or independent entities that assess and report on clinical care decisions and technology such as Agency for Healthcare Research and Quality (AHRQ), Hayes Technology Assessment, Up-To-Date, Cochrane Reviews, and the National Institute for Health and Care Excellence (NICE).
  • Published expert opinions.
  • Opinion of health professionals in the area of specialty involved.

When a decision results in a denial, the criteria used to arrive at the determination are identified in the denial letter. Each denial letter explains the health plan’s appeal process. A physician reviewer is available to discuss denial decisions. Copies of specific Health Plan criteria are available on request by contacting the Provider Services Center (CalViva Health, Health Net). 

Health Net only – Participating providers contracting with a delegated PPG may also contact the PPG’s utilization management (UM) department for the UM criteria.

Under California Health & Safety Code Section 1367(g), medical decisions regarding the nature and level of care to be provided to members, including the decision of who renders the service (for example, PCP instead of specialist, or in-network provider instead of out-of-network provider), must be made by qualified medical providers, unhindered by fiscal or administrative concerns.

Health Net only – Providers may contact the UM staff through the Provider Services Center. Providers must contact PPG UM staff through the PPG.

UM decisions are based only on appropriateness of care, service and existence of coverage. The Plans do not specifically reward participating providers or other individuals for issuing denials of coverage for care or service. There are no financial incentives for UM decision-makers to encourage decisions that result in underutilization.

As of January 1, 2022, managed care plan outpatient pharmacy benefits were carved-out and transitioned to the Medi-Cal FFS program known as Medi-Cal Rx. Magellan Medicaid Administration (MMA), Inc. administers the pharmacy benefit under Medi-Cal Rx.

Medi-Cal Rx covers prescription drugs as well as over-the-counter (OTC) medications and some medical supplies. The Medi-Cal Rx list of covered items and services under the pharmacy benefit is collectively referred to as the Contract Drug List and can be found on the Medi-Cal Rx website at https://medicalrx.dhcs.ca.gov/home/cdl.

  • CalViva Health > select CalViva Health’s Medi-Cal Drug List under Drug Information for California State Health Programs, or go to calvivahealth.org.
  • Health Net > select Medi-Cal Rx Contract under Drug Information for California State Health Programs

Providers should submit prior authorization requests for items under the pharmacy benefit by fax to 800-869-4325Providers may also submit prior authorization requests through Cover My Meds.

Providers and members should contact Medi-Cal Rx with any questions or concerns regarding the Contract Drug List, Pharmacy Network or other services covered under the Med-Cal Rx program. 

Health Net only – In Los Angeles County, providers affiliated with Molina Healthcare, a subcontracting health plan, will also use the Medi-Cal RX Contract Drug List when prescribing medications to Health Net members linked to Molina Healthcare PCPs.

The Plan is committed to treating members in a manner that respects their rights, recognizes their specific needs and maintains a mutually respectful relationship. In order to communicate this commitment, the Plan has adopted member rights and responsibilities, which apply to members’ relationships with the Plan, its practitioners and providers, and all other health care professionals providing care to its members. Member rights and responsibilities statements are distributed to new practitioners when they join the network and to existing practitioners, if requested.

The member rights and responsibilities are also available in the Medi-Cal Provider Manual in the Provider Library > Member Rights and Responsibilities. Pvoiders can request copies by contacting the Provider Services Center (CalViva HealthHealth Net).

A member or a member representative who believes that a determination or application of coverage is incorrect has the right to file an appeal. The appeal must be filed within 60 days of the Notice of Action. The Plan esponds to standard appeals within 30 calendar days. A 72-hour appeal resolution is available if waiting could seriously harm the member’s health.

Additionally, a member must go through the Plan’s internal appeals process before requesting an external state fair hearing and an independent medical review (IMR). Once the internal appeals process has been exhausted, the member may request a state hearing from the California Department of Social Services (DSS) by calling the Public Inquiry and Response Unit at 800-743-8525 (TDD: 800-952-8349), online, or in writing via mail or secure fax to:

California Department of Social Services
State Hearings Division
PO Box 944243, MS 9-17-37
Sacramento, CA 94244-2430
Fax: 916-309-3487

In addition to the appeal process described above, members may contact the California Department of Managed Health Care (DMHC). DMHC is responsible for regulating health care service plans. However, DMHC requires that grievances must first be addressed with the Plan unless the DMHC decides an expedited review is needed due to uncommon and compelling conditions. DMHC receives complaints and inquiries about health plans via a toll-free number at 888-466-2219 or (TDD: 877-688-9891). DMHC’s website has complaint forms and instructions online at www.dmhc.ca.gov.

Health Net only – Health Net does not delegate member grievances or appeals.  

All grievances and appeals should be forwarded immediately to the Member Services Department (CalViva Health, Health Net).

The members’ protected health information (PHI), whether it is written, oral or electronic, is protected at all times and in all settings. Practitioners and providers can only release PHI without authorization when:

  • Needed for payment.
  • Necessary for treatment or coordination of care.
  • Used for health care operations (including, but not limited to, HEDIS reporting, appeals and grievances, utilization management, quality improvement, and disease or care management programs).
  • Where permitted or required by law.

Any other disclosure of a member’s PHI must have a prior, written member authorization.

CalViva Health only – Authorization for disclosure of PHI forms can be found on the CalViva Health website

Particular care must be taken, as confidential PHI may be disclosed intentionally or unintentionally through many means, such as conversation, computer screen data, faxes, or forms. Participating providers must maintain the confidentiality of member information pertaining to the member’s access to these services. The Plans require PPGs to obtain Health Insurance Portability and Accountability Act (HIPAA) Business Associate agreements from people or organizations with which the PPG contracts to provide clinical and administrative services to members.

Special authorization is required for uses and disclosures involving sensitive conditions, such as psychotherapy notes, AIDS or substance abuse. To release a member’s PHI regarding sensitive conditions, participating providers must obtain prior, written authorization from the member (or authorized representative) that states information specific to the sensitive condition may be disclosed.

Interpreter services are available 24/7 at no cost to CalViva Health members and providers without unreasonable delay at all medical points of contact. The member has the right to file a complaint or grievance if linguistic needs are not met.

Provider guidelines

  • Providers may not request or require an individual with limited English proficiency (LEP) to provide their own interpreter.
  • Providers may not rely on staff other than qualified bilingual/multilingual staff to communicate directly with individuals with LEP.
  • Providers may not rely on an adult or minor child accompanying an individual with LEP to interpret or facilitate communication.
    • A minor child or an adult accompanying the patient may be used as an interpreter in an emergency involving an imminent threat to the safety or welfare of the individual or the public where there is no qualified interpreter for the individual with LEP immediately available.
    • An accompanying adult may be used to interpret or facilitate communication when the individual with LEP specifically requests that the accompanying adult interpret, the accompanying adult agrees to provide such assistance, and reliance on that adult for such assistance is appropriate under the circumstances.
    • Providers are encouraged to document in the member’s medical record the circumstances that resulted in the use of a minor or accompanying adult as an interpreter.

To obtain interpreter services, members and providers can contact Customer Contact Center (CalViva Health, Health Net) at the phone number located on the member’s ID card. Request in-person interpreters, including sign language interpreters, a minimum of 5 business days before the appointment during business hours.

Please allow for video remote or a phone interpreter if that is the only option available for the language, date and time of the appointment.

Last Updated: 07/29/2022