25-164 Get Ready: The Medi-Cal Subnetwork Certification Assessment Starts in April
Date: 02/28/25
Join an upcoming webinar for tips on how to prepare
From April through September 2025, we will be assessing and certifying our participating physician groups (PPGs) for network adequacy. This assessment considers PPGs’ scope of at-risk services for which they are contracted to provide based on their service area.
Health Net, on behalf of CalViva Health, is required to assess and certify our PPGs for network adequacy in accordance with regulatory requirements from the Department of Health Care Services (DHCS).
Prepare for the assessment
To prepare for the assessment, refer to provider update 25-158m, Follow Access to Care Standards to Ensure Patients Get Timely Care (PDF). The update is available on the Provider Library > select line of business > Updates and Letters > search for 25-158m. It covers topics such as medical appointment access standards, required specialties and time and distance to care.
We encourage PPGs to review their network and ensure provider information is correct when rosters are sent to the Plan. This includes the correct adult and pediatric provider types and the patient age range. This information displays in the online and hard-copy provider directories for members.
Join a webinar
Register for one of our upcoming webinars listed below to learn about access requirements and get tips on how to meet performance goals.
Date | Time (Pacific) | Registration |
|---|---|---|
Wednesday, March 19, 2025 | 1 p.m. | |
Wednesday, March 26, 2025 | 1 p.m. |
What does this assessment include?
Capitated, delegated PPGs must make evident that they maintain a network adequate to service adult and pediatric members within the PPG’s service area based on the following categories:
- Provider-to-Member Ratios – PPGs must meet provider-to-member ratios for primary care physicians (PCPs) and total network physicians.
- Time and Distance – PPGs must meet time and distance standards for adult and pediatric primary care and specialty care.
- Timely Access – PPGs must meet appointment access standards for primary care, specialty care, and after-hours access and instruction as relevant to provider types.
PPGs are required to ensure that members receive timely appointments per state requirements. They must also ensure members can obtain services within suitable time and distance standards. In areas where the network may not be adequate, the PPG must allow members to access services out of network for any deficient network components. If deficiencies exist, physicians or providers cannot restrict members’ access to practitioners within their own provider network and must authorize services for out of network providers when medically necessary.
Impacts for not meeting standards
PPGs are subject to a corrective action plan and network participation eligibility if one or more network adequacy standards are not met. PPGs can work with their designated provider engagement network specialist if they have questions or concerns about their ability to meet these standards.
Additional information
Providers are encouraged to access the provider portal 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.