23-389 Arrange for Covered Services When Services Are Not Available from Contracted Providers

Date: 04/27/23

Plans or delegated entities must ensure members have access to care

California Department of Managed Health Care All Plan Letter (APL) 22-030 requires CalViva Health or the entity delegated for financial risk to arrange for medically necessary treatment from noncontracted physicians and other providers when services are not available through contracted providers within timely access requirements. This will ensure members have access to the care that is appropriate to treat them.

The Plan or the delegated entity is responsible for:

• Contacting noncontracted physicians or other providers on behalf of the member to find out when appointments are available for medically necessary services.
• Scheduling any initial and follow-up appointments for the member with an out-of-network provider.

Providing members with names of noncontracted physicians and other providers who might be available does not fulfill these requirements. These additional steps ensure the member has access to services within geographic and timely access standards.

Additional Information

Relevant sections of the provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library. 

Providers are encouraged to access the provider portal online for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.

 

This information applies to Participating Physician Groups (PPGs).

This information applies to Medi-Cal in Fresno, Kings and Madera counties.