24-1253 Provider Communications Posted Online and Operations Manual Updates for November 2024
Date: 12/06/24
Access the Provider Library for the latest operational and Plan updates and changes to better service your patients
The tables below outline provider communications posted online and operations manual changes made in November 2024.
- Communications posted online: Includes the posting date, material number and title, type of notice, applicable audience and lines of business, and a summary of the communication.
- Provider operations manual changes (for physicians, participating physician groups (PPGs), hospitals, and ancillary providers): Includes the effective date of the change, document name (and path to section where document is located), audience, affected lines of business and URLs, and a summary of the change.
- Behavioral Health Provider Operations Manual: No changes were made to this manual for November 2024.
Communications posted online in November 2024
Date, number and title | Type of notice | Audience | Lines of business1 | Summary |
11/8/24 24-1162m, Complete Mandatory Training, Get Prop 56 Payments | Regulatory | Physicians PPGs | Medi-Cal (all counties) Molina | Learn how you can earn rewards for screening members for adverse childhood experiences (ACEs). |
11/12/24 24-1189m, Medical Policies – | Contractual | Physicians PPGs Behavioral Health providers | IFP (Ambetter HMO/PPO) Employer Group Medi-Cal (all counties) Molina | Review changes to medical policies for procedures and services for October 2024. Medical policies, available online at Health Net Medical Policies, offer guidelines for determining medical necessity for certain procedures, equipment and services. As a reminder, all services must be medically necessary, and member benefits, legal and regulatory mandates take precedence over content of medical policies and must be applied first. |
11/15/24 24-1129m (24-1131 – 2025 Covered Drug Alternatives flyer), 2025 Non-formulary Drug Alternatives Flyer is Available for Physicians and Other Providers | News & Announcements | Physicians PPGs Hospitals Ancillary providers | Medicare Advantage HMO/PPO | Access nonformulary drug alternatives for 2025 via a new resource flyer available on Health Net’s Pharmacy page at Pharmacy Information for Providers under “Drug information for Medicare plans.” |
11/18/24 24-1165m, Elevate Care: Help Your Patients Prevent the Onset of Type 2 Diabetes | Regulatory | Physicians PPGs ECM providers CS providers | Medi-Cal (all counties) | Learn how to help patients prevent the onset of type 2 diabetes by referring eligible members to the Medi-Cal Diabetes Prevention Program. Find out more about the program, including who is eligible and how to refer members. |
11/19/24 24-1220m, Find Out How AB 948 Affects Tiers on the Drug List | News & Announcements | Physicians PPGs | IFP (Ambetter HMO/PPO) Employer Group
| California Assembly Bill (AB) 948 introduces changes to drug formulary tier descriptions. This notice describes key changes and explains that, starting 1/1/25, the changes will cause some members to have a lower copay due to their drugs being classified at a lower tier, while others may have higher copay because their drugs are placed at a higher tier. |
11/20/24 24-1209m, Annual Medical Records Collection Begins January 2, 2025 | News & Announcements | Physicians PPGs | IFP (Ambetter HMO/PPO) Employer Group Medi-Cal (all counties) Molina Medicare Advantage HMO/PPO | Informs providers of the upcoming annual medical record collection. Medical records will be reviewed to ensure providers are complying with the HEDIS® Clinical Effectiveness of Care measures. |
11/26/24 24-1227m, 2023 Provider Appointment Availability and After-Hours Access Survey Results | News & Announcements | Physicians PPGs Hospitals Ancillary providers | Medi-Cal (all counties)
| Informs providers of the annual Provider Appointment Availability and After-Hours Access Survey results for 2023. The survey results are used to monitor provider compliance with timely access and after-hours regulations and evaluate the effectiveness of the network to meet the needs and preferences of members. |
11/27/24 24-1237m, Important 2025 Medicare Plan Changes | News & Announcements | Physicians PPGs Hospitals Ancillary providers Behavioral Health providers | Medicare Advantage HMO/PPO | Find out about changes for Medicare and Medicare D-SNP, effective 1/1/25. Includes information about a new vision vendor for 2025, 2025 plan code and service areas resource table and easy access to supplemental vendor contacts. |
11/27/24 24-1257m, Review Changes to Medicare Medical Policies – November 2024
| Contractual | Physicians PPGs Hospitals Ancillary providers Behavioral Health providers | Medicare Advantage HMO/PPO | Review changes to Medicare medical policies for procedures and services for November 2024. Medical policies, available online at Medicare Prior Authorization Medical Clinical Policies, offer guidelines for determining medical necessity for certain procedures, equipment and services. As a reminder, all services must be medically necessary, and member benefits, legal and regulatory mandates take precedence over content of medical policies and must be applied first. |
1 Medi-Cal (all counties) indicates that the communication applies to Medi-Cal Amador, Calaveras, Inyo, Los Angeles, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.
Provider Operations Manual changes (for physicians, PPGs, hospitals, and ancillary providers) in November 2024
Effective Date | Document name (and path) | Audience | Lines of business and URL | Summary |
11/18/24 | Language Assistance Program and Cultural Competency | Physicians PPGs Hospitals Ancillary | Updated links to the Interpreter Services form under “Provider Responsibilities” and renamed title of form. | |
11/18/24
| Access to Interpreter Services (under Contacts) | Physicians PPGs Hospitals Ancillary | Updated contact information for providers to access no-cost interpreter services. | |
11/19/24 | Facility Site Review (under Quality Improvement) | Physicians PPGs
| Updated following reference documents:
| |
11/22/24 | Bariatric Surgery | Physicians PPGs Hospitals | Updated Bariatric Center of Excellence list. | |
11/25/24 | PPG D-SNP Authorization and Claims topics | PPGs | Medicare PPGs' Responsibilities for Authorization (under Prior Authorization) (under Denial Notification) Authorization and Referral Timelines (under Provider Oversight > Service and Quality Requirements) Integrated Denial Notification (under Denial Notification) (under Utilization Management) (under Provider Oversight > Delegated Management) Medicare, Medi-Cal Claims Processing for DSNP in EAE Counties (under Claims and Provider Reimbursement) | Updated information to reflect that, for D-SNP members, PPGs must review both Medicare and Medi-Cal benefits to determine eligibility for services requested and not deny prior authorization as “not a covered benefit” without checking both Medicare and Medi-Cal covered services. Includes updates to prior authorization timelines for such services and how to submit a secondary claim. |
11/27/24 | Overview
Contacts | Physicians PPGs Hospital Ancillary |
American Specialty Health Plans
| Changes applied to add subheadings and replace Centene Vision with Premier Eye Care; also removed outdated information. |
Provider Services
Line of business | Phone number | |
Ambetter from Health Net IFP Ambetter PPO | ||
Ambetter HMO | ||
Health Net Employer Group HMO, POS, & PPO | ||
Medicare (Individual & Employer Group) (Wellcare By Health Net) | ||
Medi-Cal (including CS and ECM providers) | N/A | |
Behavioral Health providers | N/A |
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.