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 provider website.

The Plan's 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.

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 September 2023—September 2026. The projects currently in process are:

PIPs require frequent reporting to DHCS and Health Services Advisory Group (HSAG) including:

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 PIP AIM Statement, 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 Healthcare Effectiveness Data and Information Set (HEDIS^®) performance measures for care and service, Consumer Assessment of Healthcare Providers and Systems (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 18 measures:

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.

Health Net, on behalf of CalViva Health, 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.

Overall, members and providers may receive live calls from the 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 psychotropic medication management and timely follow-up care after an emergency department (ED) visit or hospital stay for mental illness and/or substance use. The Plan conducts telephonic outreach to members about highlighting the importance of coordination of care between medical and behavioral health care providers.

Practitioners and providers may refer members for behavioral health services or members can self-refer by calling 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.

Overall, members and providers may receive live calls from the 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 vary and include psychotropic medication management and timely follow-up care after an emergency department (ED) visit or hospital stay for mental illness and/or substance use, and coordinating referrals and care. Below is a summary of the potential collaborative quality improvement projects:

Telephonic outreach to –

CalAIM is a multi-year initiative led by the Department of Healthcare Services (DHCS) to improve the quality of life for medical and social outcomes for Medi-Cal beneficiaries, especially for those with the most complex needs. Providers can refer to the CalAIM Resources for Providers page for tools and information to help easily navigate the different CalAIM programs, including those described below to support Medi-Cal members.

Enhanced Care Management (ECM)

ECM is a benefit that is being implemented statewide in phases. This program provides a whole-person approach to care that addresses the clinical and non-clinical circumstances of high-need Medi-Cal members. ECM is a collaborative and interdisciplinary approach which provides intensive and comprehensive care management services to population of focus.

The following seven core services are provided at the point of care:

The overall goal of the ECM benefit is to provide comprehensive care and achieve better health outcomes for the highest need beneficiaries in Medi-Cal. The health plan is required to contract with community-based ECM providers who have experience serving the ECM population of focus and expertise providing the core ECM services to eligible members under the Medi-Cal ECM benefit.

Community Supports (CS)

CS is an initiative to address social determinants of health and improve health equity statewide. CS services are medically appropriate and cost-effective alternatives to state plan services. DHCS has pre-approved 14 CS services to address the needs of members – including those with the most complex challenges effecting health, such as homelessness, unstable and unsafe housing, food insecurity, and/or other social needs.

The following CS services are optional and available to members.

The key goal of the pre-approved CS services is to allow members to receive care in settings where they feel most comfortable and to keep them in their home or the community, as medically appropriate.

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.

Providers should complete and fax or email a copy of the Fit Families for Life 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 Information Line.

The Home Edition resource is a member-based offerings under the Fit Families for Life program. It is a five-week, self-paced, home-based family intervention resource 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. Online workouts are available to members with easy-to-follow short exercise videos. These videos are designed for different levels of physical activity. Program materials are available in English and Spanish, which providers can request for CalViva Health members (regardless of weight status).

The Healthy Habits for Healthy People is a self-paced intervention resource guide for older adults aimed to improve food choices and physical activity. 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. Online workouts are available to members with easy-to-follow short exercise videos. These videos are designed for different levels of physical activity. Materials extended to all participants at no cost are available in English or Spanish.

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 Health Pregnancy Program is a care management program for members who are pregnant.

The program can help members:

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.

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  at 800-300-8086, Monday–Friday, 7 a.m.–9 p.m., and Saturday from 9 a.m.–5 p.m., or online. 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 Information Line.

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.

Members have access to a heart health prevention or management toolkit (educational booklet) to learn how to prevent and manage heart disease for themselves and their loved ones. The resource package also includes the ‘Know Your Numbers' brochure which can help members track blood pressure numbers and other measures (cholesterol, A1C and BMI) to maintain a healthy heart.

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.

Powered by findhelp, 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.

To search for and make referrals to Community Supports (CS) providers and services, go to CalViva Health ECM CS, log into your account, and complete and submit the CalViva CalAIM Assessment. Based on the results, a list of available CS services will appear to make a referral.

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.

Providers should complete and fax or email a copy of the Fit Families for Life Program Referral form to the 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 Education Information line.

The Home Edition resource is a member-based offering under the Fit Families for Life program. It is a five-week, self-paced, home-based family intervention resource 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. Online workouts are available to members with easy-to-follow short exercise videos. These videos are designed for different levels of physical actvity. Program materials are available in English and Spanish, which providers can request for members (regardless of weight status).

The Healthy Habits for Healthy People is a self-paced intervention resource guide for older adults aimed to improve food choices and physical activity. 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. Online workouts are available to members with easy-to-follow short exercise videos. These videos are designed for different levels of physical actvity. Materials extended to all participants at no cost are available in English or Spanish.

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:

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

The Kick It California tobacco cessation program (formerly known as the California Smokers' Helpline) is available to 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.

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  at 800-300-8086, Monday–Friday, 7 a.m.–9 p.m., and Saturday from 9 a.m.–5 p.m. 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 Education Department.

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.

Members have access to a resource package that can include heart health prevention or management toolkits (educational booklet) to learn how to prevent and manage heart disease for themselves and their loved ones. The resource package also includes the ‘Know Your Numbers' brochure which can help members track their blood pressure numbers and other measures (cholesterol, A1C and BMI) to maintain a healthy heart.

myStrength^®, a personalized website and mobile application, is available to help members deal with depression, anxiety, stress, substance use, pain management, postpartum depression and more. The Plan also provides members with Adverse Childhood Experiences (ACEs) education and resources. Members can request ACEs education and resources by contacting the toll-free Health Education Information line or requesting them through their doctor.

Powered by findhelp, 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.

To search for and make referrals to Community Supports (CS) providers and services, go to Health Net ECM CS, log into your account, complete and submit the Health Net CalAIM Assessment. Based on the results, a list of available CS services will appear to make a referral.

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

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.

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 Plan's 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. The Plan 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.

This program supports 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:

Providers can refer a member to the Case Management Department by email or fax. The Case Management Referral Form (CalViva Health) is available in the Provider Library. Members may self-refer to the program by calling the Member Service Department's (CalViva Health) 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.

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:

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.

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.

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:

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 websites 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.

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.

New members must receive an IHA, which includes an age-appropriate history, preventive care services and physical examination 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 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.

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 physicain 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.

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.

The Plan 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.

The Plan 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 Provider Services Center (Health Net) 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 .

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 .

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).

Results of the PARS are made available in the provider directory, Health Plan website and to Member Services Department (CalViva Health, Health 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:

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

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.

Providers should submit prior authorization requests for items under the pharmacy benefit by fax to 800-869-4325. Providers 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.

Member rights and responsibilities are available in the Medi-Cal Provider Manual .  Providers can request copies by contacting the Provider Services Center (CalViva Health, Health 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 responds 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:

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 physicians and other 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 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.

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.