24-176 Provider Operations Manual Updates for January 2024
Date: 02/09/24
Access the Provider Library for the latest operational and Plan updates and changes to better service your patients
The tables below outline provider operations manual changes made in January 2024.
- 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: Includes the effective date of the change, operations manual section, topic and summary of the change.
Provider operations manual changes (for physicians, PPGs, hospitals, and ancillary providers) in January 2024
Effective Date, Document name (and path) | Audience | Lines of business and URL | Summary |
|---|---|---|---|
1/1/24 Ambetter HMO Ambetter PPO
| Physicians PPGs Hospitals Ancillary | Updated to include reference to Ambetter HMO in Imperial County, effective January 1, 2024, and revised product names, as necessary. | |
1/1/24 Overview Infertility Treatment
| Physicians PPGs Hospitals Ancillary | HMO PPO | Applied changes to align information with existing medical policies and upcoming changes to diagnosis criteria related to coverage for infertility treatment.
|
1/1/24 Schedule of Benefits or Summary of Benefits (SOB) | Physicians PPGs Hospitals Ancillary | HMO, PPO, Medicare Advantage, Medi-Cal
| ‘Summary of Benefits’ has been added to ‘Schedule of Benefits’ in all instances of the operations manuals where Schedule of Benefits is used. This change is a result of the Summary of Benefits replacing the Schedule of Benefits for select Medicare Advantage plans as of January 1, 2024. |
1/1/24 Prescription Mail Order Program Coverage Explanation Health Net Mail Order Prescription Drug Program
| Physicians PPGs Ancillary | HMO, PPO Prescription Mail Order Program Medicare HMO, PPO | Updated the pharmacy benefit manager from CVS to Express Scripts for the following plans in California, effective January 1, 2024: On- and off-exchange Ambetter HMO/Ambetter PPO; Wellcare By Health Net, including D-SNP and Employer Group Waiver Plans (exception: Retiree Drug Subsidy Medicare plans); and Wellcare. |
1/1/24 Minor’s Consent for Services
| Physicians PPGs Hospitals Ancillary |
| Updated existing information in Medi-Cal manual to advise that minors ages 16 or older can consent to narcotic replacement therapy without parent or guardian consent, per Assembly Bill 816. This same information was added to the HMO and PPO manuals as a new content. |
1/1/24 Notification of Hospital Admissions
| Physicians PPGs Hospitals Ancillary |
| Updated to include reference to the new Transitions of Care Management (TRC) worksheet, which can be used to help support transitions of care and ensure appropriate documentation and reconciliation of discharge medications to improve care coordination. |
1/1/24 Dental and Vision | Physicians PPGs Hospitals Ancillary | Medicare
| Updated to reflect dental and vision vendor changes for Medicare Advantage, effective January 1, 2024. Changes include the removal of the optional supplement benefit package for dental and vision, and EyeMed Vision replacing Envolve Vision. |
1/1/24 Access to Care and Availability Standards
| Physicians PPGs Hospitals Ancillary | Updated to reflect access and availability standards as of January 1, 2024. This also include the addition of behavioral health access standards. | |
1/1/24 Palliative Care Services
| Physicians PPGs Hospitals Ancillary | Updated requirements for submitting prior authorization for palliative care services. This included updating the form that providers use to submit requests for palliative care for Medi-Cal members to the Outpatient Medi-Cal Prior Authorization Form, and mandatory information that must be entered on the form before submitting it. | |
1/1/24 Member Rights & Responsibilities Overview | Physicians PPGs Hospitals Ancillary providers |
| Updated member rights and responsibilities according to information included in members’ Evidence of Coverage for 2024. |
1/1/24 Autism Spectrum Disorders | Physicians PPGs Ancillary |
| Updated according to information and requirements of Senate Bill 805, Health Care Coverage: Pervasive Developmental Disorders or Autism, effective |
1/1/24 Confidentiality of Medical Records | Physicians PPGs Hospitals Ancillary |
| Added section that specifies requirements for a valid authorization for release of a member’s medical information. Also added a ‘medical information’ glossary term. |
1/5/24 Financial Statements Financial Survey Filing Requirements | PPGs Hospitals
| HMO, Medi-Cal, Medicare | Updated Financial Statements to remove financial solvency review standard benchmarks that no longer apply and add process information specific to PPGs with sub-delegating risk arrangements. Financial Survey Filing Requirements was updated with information and requirements that apply to PPGs and now hospitals. |
1/19/24 Access to care and availability standards | Physicians PPGs Hospitals Ancillary |
| Added requirements when a deferral is needed for routine and expedited authorizations (pre-service). This change was made in accordance with the Department of Health Care Services All Plan Letter 20-011, CA Health and Safety Codes 1367.01, 1367.03(a)(5)(H) and 42 CFR 438.210(d) 438.404). |
1/26/24 Palliative Care Services
| Physicians PPGs Hospitals Ancillary |
| Updated requirements for submitting prior authorization for palliative care services. This included updates to the Care Management Referral Form and mandatory information that must be entered on the form before submitting it. |
1/31/24 Confidentiality of Medical Records
| Physicians PPGs Hospitals Ancillary |
| Added information specific to entities that are allowed to exchange real-time information, per California Assembly Bill 352. This includes entities for which the exchange of health information does not apply, as well as services that are excluded. |
1/31/24 Dental Screening and Services
| Physicians PPGs Hospitals Ancillary |
| Updated information about coverage for intravenous moderate sedation and deep sedation/general anesthesia services provided by a physician in conjunction with dental services for members in hospitals, ambulatory medical surgical settings or dental offices, and other related requirements, per DHCS APL 23-028. |
Behavioral Health Provider Operations Manual changes in January 2024
Effective Date | Section | Topic | Summary |
|---|---|---|---|
1/18/24 | Applies to entire manual | Claims submission address and payer ID change | Updated claims submission address and payer ID in all applicable sections of manual. |
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.
For Medi-Cal, this information applies to Amador, Los Angeles, Calaveras, Sacramento, Inyo, Mono, San Joaquin, Stanislaus, Tuolumne, and Tulare counties.