View
0
Download
0
Category
Preview:
Citation preview
1 | P a g e
Medi-Cal Administrative Manual Table of Contents
2 | P a g e
Medi-Cal Administrative Manual Table of Contents
Section Subject Page
100 ORGANIZATION Introduction 2
Board of Directors Roster and Board Committees 3
Committee Descriptions and Advisory Roster 4
Independent Practice (IPA) - Overview 8 Physician Rights and Responsibilities 9 Types of Practice 12
Management Service Organization (MSO) - Overview 13 Resources at a Glance 15
Administration and Departments 17 Education 20
200 PRIMARY CARE PHYSICIANS Primary Care Physician (PCP) - Overview 23 General Contract Information - Overview 24 PCP Assignment / Member Liability 25
300 SPECIALIST PHYSICIANS Specialist Overview 27
400 ANCILLARY PROVIDERS Ancillary Overview 29 Anthem Blue Cross 30 Health Net 39
3 | P a g e
Medi-Cal Administrative Manual Table of Contents
Section Subject Page
500 OPERATIONS Customer Service – Overview 48
Patient Billing Statements from Physician Offices 49
Waiver of Liability 49
Waiver of Liability Form 50
Language Assistance Program 51
Claims
Submission Guidelines 53
Claims Inquiry 53
Provider Inquiry 54
Provider Inquiry Request Form 55
Electronic Claims Submission Guidelines 56
Provider Dispute 57
Provider Dispute Resolution Request Form 58
Overpayments 59
Vaccines for Children 60
Assistant Surgeon Reimbursement 62
Third Party Liability (TPL) 67
California Children Services 68
Web Site
Access and Information 69
4 | P a g e
Medi-Cal Administrative Manual Table of Contents
Section Subject Page
600 UTILIZATION MANAGEMENT
Managed Care Coordinators 71
Case Managements 72
Referrals - Policy Guidelines 73
Retro Referrals 74
Global Care Referrals 75
Routine Eye Examination Policy 76
Unauthorized Referrals to Non-Plan Providers 76
Self-referrals - OB/GYN 77
Behavioral Health Referrals 77
Prior Authorization
Guidelines 78
Prior Authorization Form 80
Emergency Room Authorization 82
Hospital Observation Status 84
Criteria used to authorize, modify or deny 85
Appeals – Clinical 86
1 | P a g e
Medi-Cal Administrative Manual Table of Contents
Introduction
Board of Directors
Committee Descriptions
Advisory Rosters
Independent Practice Association (IPA)
Physician Rights and Responsibilities
Types of Practice
Management Service Organization (MSO)
Resources at a Glance
Administration and Departments
Education
2 | P a g e
Medi-Cal Administrative Manual Table of Contents
The purpose of this manual is to acquaint participating physicians of Santé Community
Physicians and their office staff with the basic policies and operating procedures as established
by Santé, the Management Service Organization (MSO) contracted to provide administrative
services. This manual is a living document. Santé updates this manual on a regular basis to
keep current with the changes that are part of our managed care environment.
The Administrative Manual is one of three manuals produced by Santé for the offices of our
physicians. The other two manuals are our Quality Standards Manual and our Outpatient Best
Practices Manual. The Quality Standards Manual contains policies and procedures designed to
keep your offices in compliance with state, local, and the National Committee for Quality
Assurance (NCQA) regulations and standards. The Outpatient Best Practices Manual contains
Best Practice guidelines and utilization parameters which can help physicians improve and
streamline the care of their patients. The Outpatient Best Practices Manual also contains the
preventative health guidelines our physicians must implement in order to maintain the health of
their assigned populations.
It is the hope of the Santé staff that all of our manuals will prove to be valuable tools as your
office works with us in the managed care environment. We welcome your comments and
suggestions of our products. Santé’s goal is to enhance your ability to function in the managed
care environment – your success will also be our success.
Introduction
3 | P a g e
Medi-Cal Administrative Manual Table of Contents
Board of Directors Roster and Board Committees
Board of Directors
Name Board Position Field of Practice
Mateo F. De Soto, M.D. President and Chief
Executive Officer Mental Health
Ren Imai, M.D. Chief Financial Officer Family Practice
Al Velasco, M.D. Secretary Family Practice
Ajit Arora, M.D. Director Gastroenterology
Mark Cunningham, M.D. Director General Surgery
Ali Fayed, M.D. Director Internal Medicine
John Lattin, M.D. Director Pediatrics
Stanley Louie, D.O., M.S.H.P.E Director Family Practice
Sukhbir S. Manjal, M.D. Director Internal Medicine
Frank Tamura, M.D. Director Radiology
Executive Committee
Mateo F. De Soto, M.D. Al Velasco, M.D.
Ren Imai, M.D.
Finance Committee
Ren Imai, M.D., Chairman Al Velasco, M.D.
Mateo F. De Soto, M.D.
4 | P a g e
Medi-Cal Administrative Manual Table of Contents
Advisory Committee Rosters
Credentials Committee
Kenneth Steinbach, M.D. Chairman Muhammad Sheikh, M.D.
Juergen Krauthammer, M.D. Ajit Singh, M.D.
Ali Fayed, M.D. Alan Kelton, M.D.
FHCA Committee
Juergen Krauthammer, M.D. David Slater, M.D.
R. Mendoza, M.D. Al Velasco, M.D.
Primary Care Strategy Council
Ren Imai, M.D., Chairman Mary Hill, M.D.
Al Velasco, M.D., Vice Chairman Sami Issa, M.D.
Marina Alper, M.D. Ronald Kleyn, M.D.
Leonel Apodaca, Jr., M.D. William Mochizuki, MD
Richard Berquist, M.D. Matthew Lozano, M.D.
Sharon Booth, M.D. Natalya Malley, M.D.
David Cardona, M.D. Sukhbir Manjal, M.D.
Nikki Donaldson, D.O. Mary Sadlek, M.D.
Jeffrey Gardner, M.D. Prem Singh, M.D.
Vivian Hernandez, M.D. Barbara Morlan, MD
5 | P a g e
Medi-Cal Administrative Manual Table of Contents
Advisory Committee Rosters
Quality Improvement Committee
Mark Cunningham, M.D., Chairman Janet Habegger, M.D.
Bill Dixon, P.A. Wagih Ibrahim, M.D.
David Dorough, M.D. Keith Carson, MD
Dominic Dizon, M.D. Mary Sadlek, M.D.
Denard Fobbs, M.D. Mario H. Gonzalez, Jr., MD
Michael Gromis, M.D.
Specialty Advisory Committee
Ajit Arora, M.D., Chairman Richard Moors, M.D.
Craig Aaronson, D.P.M. Paul Norwood, M.D.
A.M. Aminian, M.D. William Pitts, M.D.
Kevin Boran, M.D. Sanagaram Shantharam, M.D.
William Brown, Jr., M.D. Kenneth Steinbach, M.D.
Mel Froese, M.D. Frank Tamura, M.D.
Gene Kallsen, M.D. Karl Van Gundy, M.D.
Yuk Yuen Leung, M.D. Richard Weinberg, M.D.
Marketa Limova, M.D. Stephen Yeagle, M.D.
Utilization Management Committee
Al Velasco, M.D. Chairman Don Gaede, M.D.
Richard Berquist, M.D. Natalya Malley, M.D.
Kristopher George, M.D. Mary Sadlek, M.D.
Ahmad Emami, M.D. Frank Tamura, M.D.
6 | P a g e
Medi-Cal Administrative Manual Table of Contents
Committee Descriptions
Credentials Committee
The Credentials Committee reviews qualifications of each applicant and re-applicant to
Santé Community Physicians. Examples of credentialing issues are:
Sets standards for physician reviews
Maintenance of IPA’s credentialing status
Executive Committee
The Executive Committee, composed of the officers of the IPA, reviews the business needs
of the IPA. Examples of Executive Committee issues are:
Reviews reports from the Credentials Committee regarding physician panels
Reviews contracting issues regarding non-physician providers
Makes necessary decisions between meetings of the full Board of Directors
Finance Committee
The Finance Committee reviews issues and policies that affect financial performance of the
IPA, and also proposes financial policy for the IPA. This committee meets once a month
and is composed of board members only. Examples of Finance issues are:
Physician payment mechanisms
Physician contracts (including capitation contracts)
Fee-for-service withholds
Primary Care Strategy Council
The Primary Care Strategy Council serves as a discussion forum for Primary Care
Physicians, and advises the Board on issues relevant to PCPs. The committee meets every
month. Examples of Primary Care Strategy issues are:
PCP retention and recruitment
PCP compensation and incentives
PCP education
7 | P a g e
Medi-Cal Administrative Manual Table of Contents
Committee Descriptions
Quality Improvement Committee
The Quality Improvement Committee ensures that members of the IPA provide high quality
care. This committee meets every month. Quality Improvement Committee responsibilities
include:
Reviews and sets quality standards
Establishes projects to improve quality of care in the IPA
Responds to quality inquiries from health plans and members (patients)
Specialty Advisory Committee
The Specialty Advisory Committee serves as a discussion forum for Specialist Physicians
and advises the Board on issues relevant to Specialists. The committee meets every other
month. Examples of Specialty Advisory issues are:
Specialist compensation
Panel composition
Division of services between PCP’s and Specialists
Utilization Management Committee
The Utilization Management Committee establishes policies regarding the utilization of
health services for Santé Community Physicians, and reviews the performance of
physicians in all specialties. Examples of Utilization Management issues are:
Develops utilization policies and standards
Reviews system performance with regards to utilization
Reviews system case management performance
Responsible for maintaining Santé’s delegated status with regards to utilization
8 | P a g e
Medi-Cal Administrative Manual Table of Contents
INDEPENDENT PRACTICE ASSOCIATION (IPA)
Welcome to Santé Community Physicians!
We want to extend our welcome to you, our physicians and staff, who are part of Santé
Community Physicians. We hope to develop a lasting, rewarding partnership with you while
we work together to provide quality, cost-effective care for our patients.
We have developed this provider manual to help answer many of your questions about the
administrative policies of the IPA. This manual will work hand-in-hand with Santé’s Quality
Standards and Clinical Guidelines manuals in your office to help make your practice a
successful managed care physician office. We have made every attempt to make this
provider manual a valuable resource to you.
We encourage you to call any member of our staff (see the “Resources-at-a-Glance” page
in this section) if you need further assistance or have any questions about the enclosed
materials.
What is Santé Community Physicians?
Santé Community Physicians is the IPA associated with Community Medical Centers. Santé
Community Physicians is one of the largest IPAs in Central California, with over 1,300
physicians in all medical specialties. The primary function of the IPA is to organize
physicians effectively, enabling them to speak with a unified voice as a business
organization.
Santé Community Physicians is a shareholder organization. Shares are owned by Primary
Care Physicians and Specialist Physicians who are contracted to provide care to health
plan members.
9 | P a g e
Medi-Cal Administrative Manual Table of Contents
Physician Rights and Responsibilities
Santé Community Physicians (SCP) is a collaborative independent association of
physicians (IPA) and other licensed medical providers who have come together to promote
the health of their patients and the health of their community through the practice of
managed medical care. It is the primary responsibility of physicians in SCP to provide and
advocate the most appropriate medical care for each and every one of his or her patients.
Santé Community Physicians is also an organization designed to enhance the rewards and
joy of physicians in the practice of medicine. In order to improve the environment in which
medicine is practiced, Santé encourages physicians of all specialties to work together and
in doing so improve the outcomes for all enrolled members. It is a major goal of Santé to
enhance the communication between physicians and it is the responsibility of all SCP
providers to participate in this process.
Santé Community Physicians has joined a partnership with Community Medical Centers
and the other facilities, making up our integrated healthcare delivery system. It is a principal
of Santé to support the development of this integrated healthcare delivery system. The
physicians of SCP are committed to the success of our facility partners just as the facilities
are committed to the success of SCP.
Santé Community Physicians is mindful of the needs both physicians and members have in
a managed care environment. Therefore the following specific rights and responsibilities of
physicians and other providers are enumerated below.
RIGHTS
Physicians:
1. May hire physician assistants and nurse practitioners to provide services. 2. Must be given 30-day notice of changes in compensation formulas. 3. May bill for non-covered services if enrollee is given prior written notice and agrees. 4. May receive up to 100% of billed charges through coordination of benefits when
possible. 5. May request IPA to work with the health plan to enable them to reassign member
according to health plan criteria if physician for any reason is unable to provide adequate care.
6. May have access to dispute resolution mechanisms. 7. Who are PCPs may close practice with a minimum of 90 day written notice. Such
practice closure may not occur more than once a year. 8. May resign without cause by giving 90-day notice. 9. Who are PCPs may refer.
10 | P a g e
Medi-Cal Administrative Manual Table of Contents
Physician Rights and Responsibilities
RESPONSIBILITIES
Physicians:
1. Who are PCPs must provide “comprehensive” PCP services to any member who designates the physician as their PCP.
2. Must be available 24 hours a day/7 days a week or have appropriate call coverage. 3. May not discriminate in treating members. 4. Must submit claims or encounter information within ninety (90) days of date of
service. 5. Must carry own malpractice, $1,000,000/$3,000,000 minimum. Agrees to notify the
IPA of malpractice claims. 6. Must inform IPA of any changes in address, license, tax ID, hospital privileges, or
any other changes affecting ability to care for members. 7. Agrees to participate in Santé’s Utilization Management Program, Credentialing and
Quality Improvement program including serving on committees and serving as an advisor if asked.
8. Agrees that if he or she is terminated or resigns the physician will cooperate with IPA to ensure continuity of care for members.
9. Agrees to render all appropriate and necessary services to members. 10. Agrees to participate in peer review program and to allow access to patient records. 11. Agrees to secure a covering physician that accepts SCP compensation or will look to
the contracted physician for compensation and will not bill members. 12. Agrees to only admit patients to participating hospitals unless circumstances
preclude admission to a participating hospital. 13. Must be in good standing to practice medicine. 14. Must comply with state and federal regulations. 15. May collect third party liability. 16. Who serve as PCPs must keep practice open to minimum 500 enrollees. 17. Must supply own personnel, equipment and supplies. 18. Must buy worker’s compensation insurance for their own employees. 19. Must carry their own comprehensive insurance. 20. Must maintain skills, as demonstrated by continuing education, re-credentialing and
maintenance of privileges. 21. Maintain staff privileges at a contracted facility or designate another SCP physician
who will admit to a contracted facility on his/her behalf.
11 | P a g e
Medi-Cal Administrative Manual Table of Contents
Physician Rights and Responsibilities
22. Must cooperate with medical director to receive quality of care. 23. Agrees to grant IPA access to any and all profile information and other information
on physician performance held by plans, facilities and outside agencies. 24. Must continue to treat enrollee at term until member transferred to another physician
or until covered services rendered to enrollee “completed” and will be paid in accordance “with comparative methodology developed by IPA” period.
25. Agrees to treat members from any contracted Medi-Cal physician, if practice is open, to the type of business to which the members belongs.
26. Agrees not to defame Santé Community Physicians, Santé Health System, and Community Medical Centers and any of our contracted health plans or facilities.
27. Agrees to process uncontested overpayment refund requests within thirty (30) days and if not, is subject to offset by IPA from other amounts due.
12 | P a g e
Medi-Cal Administrative Manual Table of Contents
Types of Practice
An IPA is an Independent Practice Association made up of physicians who are contracted
to the entity for the purpose of providing managed medical care. These physicians may be
in individual or group practices or Federally Qualified Health Centers (FQHC).
Santé Community Physicians is an IPA of physicians who are dedicated to each other and
to Community Medical Centers to form an integrated delivery system. Santé Community
Physicians is composed of a variety of physician practice models:
Sole Practitioner
The individual physician contracts with Santé Community Physicians and is reimbursed
using either a modified fee-for-service or a capitation model.
Group Practice
Two or more physicians who utilize the same Tax ID Number
(For the purpose of PCP capitation, once the total group has 100 or more combined
members, all physicians within the group are reimbursed by capitation, including any non-
plan physicians practicing within the group.)
Two types of group practices are:
Independent Group – Individual physicians who jointly own their own practice, supply their own internal management, and are contracted as an entity with Santé Community Physicians. Vision Care is an example of an independent group.
Institutional Group – Physicians and other providers (such as Nurse Practitioners) who are employees of a group practice. The assets of the group and non-provider employees are controlled by an institution.
13 | P a g e
Medi-Cal Administrative Manual Table of Contents
MANAGEMENT SERVICE ORGANIZATION (MSO)
About Santé Working through a contract between Community Medical Centers and Santé Community Physicians, Santé is the Management Services Organization (MSO) that serves Santé Community Physicians. Santé works as a background organization to support the managed care efforts of the IPA. Santé provides services including, but not limited to, the following:
Contracting Wellness
Medical Affairs Marketing
Finance Claims Processing
Credentialing Customer Services
Physician Services/Communications Provider Relations
Quality Improvement Practice Management
Utilization Management
Serving Santé Community Physicians as its Management Services Organization, Santé integrates services with Community Medical Centers to provide an important piece in our developing healthcare system. The goal of Santé is to assist members of Santé Community Physicians in ways that best utilize the managed healthcare system. About Santé Community Physicians Santé Community Physicians Medical Group, Inc. is a California professional corporation organized as an Independent Practice Association (IPA). The IPA is intended to develop contractual agreements with, and negotiate on behalf of physicians who will provide medical services to patient subscribers or enrollees of programs offered by insurers, Health Maintenance Organizations (HMOs), Medi-Cal, competitive medical plans, and other third party payers. The Santé Community Physicians IPA is a physician-owned and primary care-driven network of over 1,300 physicians with a governing Board of Directors made up of both Primary Care and Specialist Physicians. Policies are developed by physician leadership through such committees as Primary Care Advisory, Utilization Management, Quality Improvement, Finance, and Executive Board. In a managed healthcare system, risk is shared throughout the delivery system. Individual physicians share in the risk assumed by the IPA by accepting fixed capitated payments for medical services. In order for Santé Community Physicians to provide the services necessary to drive a quality managed care organization, patient care must be managed effectively and efficiently.
14 | P a g e
Medi-Cal Administrative Manual Table of Contents
How to Make Managed Care Work for You
The previous world of fee-for-service healthcare was easy to understand. Today’s managed
care environment is more complex. However, managed care can benefit both providers and
patients when incorporated effectively into physician practice. The following guidelines will
assist you in this reimbursement system.
Be informed Our goal is to provide you with all available information and data to help you better
understand managed care. The administrative policies in this manual are provided
as guidelines for office functioning in a managed care environment. Please take
advantage of other literature, reports, seminars, and meetings offered by Santé for
physicians and office staff. In addition, the Physician Services Coordinator is
available to come to your office to provide personal assistance.
Provide excellent patient service The partners in this healthcare system must team up to deliver consistent quality to
its patients (members). It is paramount that our care, customer service and
communication with patients be consistently excellent. One of the major
responsibilities of providers is to guide patients through the new and different world
of managed care.
Embrace the wellness philosophy of preventive medicine Scientific research has indicated that as much as 70% of disease is preventable. We
can all benefit by educating our patients regarding healthy lifestyles that reduce
critical risk factors. The outcome of this education will be more appropriate utilization
of our healthcare system. The Santé Community Physicians/Community Medical
Centers Wellness Program invites you to become an integral part of that effort.
Santé Community Physicians was created by physicians who projected that the enormous
growth of managed care across the nation would soon impact central California. Santé
Community Physicians is an organization proactively meeting this changing healthcare
marketplace. Santé Community Physicians, your IPA, is dedicated to making you a part of
this system.
15 | P a g e
Medi-Cal Administrative Manual Table of Contents
Resources at a Glance
Administrative Address General Correspondence
Address Claims Mailing Address
Santé Community Physicians 7370 N. Palm, Suite 101 Fresno, California 93711
Santé Community Physicians P O Box 45021 Fresno, California 93718
Santé Community Physicians P O Box 45021 Fresno, California 9718
Main Telephone Numbers: (559) 228-4466 (844) 340-7955
Executive Administration
(559) 228-5418 - Scott Wells, Executive Director
(559) 228-5408 - Daniel Bluestone, M.D., Medical Director
(559) 228-5453 - Chris Cheney, Chief Financial Officer
(559) 228-5429 - Gloria Mullin, Executive Assistant
FAX: (559) 224-8461
Contracting & Network Development Physician Services & Education
Vicki Anderson, VP Managed Care 559) 226-6800 FAX: (559) 226-1651
Kelly Lilles, Director, Physician Services & Marketing (559) 228-5464
Marcus Watkins, Director Managed Care (559) 226-6800 FAX: (559) 226-1651
Sky Garcia, Manager, Physician Services & Marketing (559) 228-5441
Valentine Villaluz, Physician Services (559) 228-4308 FAX: (559) 228-2958
Customer Service-Claims All Providers & Members:
Education RSVP Line: (559) 228-5488
(559) 228-5410 FAX: (559) 224-2672
Quality Improvement & Credentialing
Robert Sarkisian, Director (559) 225-5432 FAX: (559) 224-2046
Electronic Claims Submission Tommie Poteet-Romagnoli, RN, CPC, Nurse Manager
Customer Service (559) 228-2405 FAX: (559) 224-2046
(559) 228-5410 FAX: (559) 224-2672 Cheryl Copeland, CPCS, Credentials Specialist (559)228-5484 FAX: (559) 224-2046 Pam Murphy, CPCS, Credentials Specialist (559) 228-5421 FAX: (559) 224-2046
Operations
Dianne Villanueba-McGraw, Supervisor, Quality Improvement (559) 228-5466 FAX: (559) 224-2046
Debbie Nephew, VP of Operations (559) 228-5409
Utilization/Case Management Dawn Dahl, Director (559) 228-4325 FAX: (559) 224-2693
Get Connected to the Santé Medi-Cal website @ www.medi-cal.santehealth.net
16 | P a g e
Medi-Cal Administrative Manual Table of Contents
Administration and Departments
Administration
This department represents the organizational leadership, physician recruitment and
business development areas of Santé. Your primary contacts are:
Scott B. Wells, Executive Director
Michael Synn, M.D., Medical Director
Chris Cheney, Chief Financial Officer
Vicki Anderson, Vice-President Managed Care
Gloria Mullin, Executive Assistant
The following are brief profiles of the various MSO departments: Claims, Contracting and
Network Development, Credentialing, Customer Services, Finance, Foundation Health Care
Administrators, Medical Affairs, Physician Services and Education, Quality Improvement,
Utilization/Case Management, and Wellness.
Claims
The claims department is responsible for processing claims and encounter information. This
department interprets the benefit levels as determined by the contracting Medi-Cal plan and
provider contracts when processing the claims, and is also accountable for the tracking of
utilization data. Your primary contact is:
Frank Lopez, Director
17 | P a g e
Medi-Cal Administrative Manual Table of Contents
Administration and Departments
Contracting and Network Development
Contracting negotiates agreements for capitation payments, exclusive agreements with
health plans and hospital partners, and serves the entire system in monetary agreements
with outside entities. Physician and ancillary contracting are also handled in this
department. Your primary contacts are:
Vicki Anderson, Vice President, Managed Care
Credentialing
The processes for application, credentialing and verification services have been integrated
by Santé Community Physicians and Community Medical Centers. The Credentialing
Department not only receives and processes initial applications, but also ensures
continuous quality through ongoing reviews and re-credentialing processes. Any changes in
demographic information (i.e. changes in address, phone, etc.) should be directed, in
writing, to the Credentialing Department. Your primary contacts are:
Sera Larsen, Director, Quality Improvement & Credentialing
Pam Murphy, CPCS, Credentials Specialist
Cheryl Copeland, CPCS, Credentials Specialist
Customer Service
The Customer Service Department is an integral part of our commitment to service both the
health plan member and the physician office. The Customer Services Department is
responsible for member advocacy, claims status, and ongoing education for the members.
Provider Relations Representatives for primary care and specialty offices support physician
office claims inquiries. Your primary contact is:
Nissa Lara, Customer Service Manager
Finance
The Finance Department develops and monitors the company’s operating budget, performs
financial analysis, and carries out the general accounting function. Additionally, Finance
administers the various capitation programs that support the system. Your primary contact
is:
Chris Cheney, Chief Financial Officer
18 | P a g e
Medi-Cal Administrative Manual Table of Contents
Administration and Departments
Foundation Health Care Administrators (FHCA, Inc.)
FHCA administers Santé Community Physicians’ broader PPO panel, including physicians
and facilities throughout Central California. This department handles Utilization
Management, Customer Service, pre-pricing of claims, and contract issues for this PPO
panel.
Medical Affairs
This department is responsible for assuring that Santé (the MSO) is serving its physician
provider members and their offices. It is also responsible for ensuring that high quality
medical service is rendered to health plan members. The Medical Affairs Department is
charged with ensuring compliance with health plan contracts in credentialing, quality
management, education, and utilization management. This department also works with
contracting and finance to ensure the needs of members are being met. Your primary
contact is:
Michael Synn, M.D., Medical Director
Physician Services
The Physician Services Department is dedicated to serving the IPA physician and office
staff. Physician Services is responsible for training, educating, communicating, and
supporting physicians while also advocating for physicians. This aids our physicians in the
operations and policies of the Medi-Cal business that Santé contracts. Additionally,
physician education programs are developed and implemented though Physician Services.
Your primary contacts are:
Kelly Lilles, Physician Services Director
Valentine Villaluz, Physician Services Supervisor
Quality Improvement
The purpose of Santé Quality Improvement is to ensure and monitor the delivery of high
quality medical services. This department uses a systematic and documented approach to
reviewing the quality of healthcare and outcomes. The program encompasses all physician
providers contracting with Santé Community Physicians.
Your primary contacts are:
Sera Larsen, Quality Improvements and Credentials Director
Tommie Romagnoli, Quality Improvements Manager
19 | P a g e
Medi-Cal Administrative Manual Table of Contents
Administration and Departments
Utilization/Case Management
The UM/Case Management department is staffed with clinicians and para-professionals
who play a key role in managing medical costs in this system. In consultation with the Santé
Vice President of Medical Affairs and Associate Medical Director, this department
determines medical necessity of procedures, length of hospital confinements, and
appropriateness of ancillary treatment. This department is responsible for providing
authorizations for treatment and monitoring treatment patterns and utilization trends. Your
primary contact is:
Dawn Dahl, Director, Utilization Management
Wellness
The Wellness Programs are designed to work in collaboration with the Primary Care
Physicians and Specialists to meet the health education needs of their members. Our
programs are designed to promote wellness and healthy lifestyles, reduce the risk of
disease and assist with disease management. The Wellness Department does this through
education and support of behavioral changes, with the goal of measurably improving the
health of the individuals we serve. Wellness embodies a proactive managed care strategy
and serves as a tool for enhancing the provider/patient relationship.
20 | P a g e
Medi-Cal Administrative Manual Table of Contents
Education
Santé Community Physicians will continue to provide opportunities for quality improvement of the healthcare system. To support this goal, a complete program of quality improvement through education has been developed. We believe that as these systems are put into place and utilized, the Santé managed care system will offer the best outcomes for both patients and physicians. Physician Profiles and Action Plans Using processed encounter information, Santé Community Physicians prepares and distributes a profile for each IPA physician. This profile shows the relative cost efficiency of each physician as compared to other physicians in his or her specialty. The report adjusts for medical complexity (severity) and ranks physicians by cost and quality indices. Protocol Development Outpatient Best Practice Protocols are developed for Primary Care Providers. Santé Specialist Physicians are instrumental to this process. All protocols are approved by the Santé UM Committee. Quality Improvement and Educational Audits Chart and administrative data set reviews are conducted by the Santé Quality Improvement Department as required by our contracted health plans. A feedback tool will make audited physicians aware of audit results and opportunities to improve their practices. Physician and Staff Education Santé Community Physicians offers many types of educational opportunities for its physicians and their staffs. The following types of educational programs are available:
PCP Education – Based on Santé Community Physicians’ Outpatient Best Practice guidelines, this continuing education program will ensure that Santé PCPs have the tools to manage their patients to meet increasingly stringent national quality standards.
Office Manager Meetings – Office managers are invited to educational presentations solely for office staff. Presentations include managed care, Quality Improvement access audits and how these can improve your practice, how to handle difficult patients, and other topics of interest.
Managed Care Symposium – “Focus” features leaders in managed care discussing issues of interest to the entire IPA.
Provider Workshop – Hands on educational training covering various physician practice operations.
Specialty Education – With the assistance of Community Medical Centers, Santé offers topical programs directed at Specialists and PCPs through Performance Improvement and various clinical departments of the integrated system.
21 | P a g e
Medi-Cal Administrative Manual Table of Contents
On-going Educational Features
Case Management – This effort focuses on matching patient’s needs to the most appropriate available resource.
Utilization Management – This is an on-going effort to balance the needs of the IPA with the needs of our patients in a managed care environment. The goal is to reduce the number of inappropriate or out-of-plan referrals. Using case management, Santé will appropriately match patient needs with system resources.
Administrative Provider Manual – This manual is your resource for Administrative Policies of Santé Community Physicians. The manual is updated and expanded to include contracting information and operational policies.
Quality Standards Provider Manual – This manual is your resource for meeting NCQA quality standards.
Clinical Guideline Manual – This manual contains out-patient evidence-based guidelines for primary care physicians.
Educational Communications – Additional educational communications are provided in the quarterly Provider Update Newsletter and through Policy Memorandums.
22 | P a g e
Medi-Cal Administrative Manual Table of Contents
Primary Care Physician (PCP) - Overview
General Contract Information – Overview
PCP Assignment/Member Eligibility
23 | P a g e
Medi-Cal Administrative Manual Table of Contents
PRIMARY CARE PHYSICIAN OVERVIEW
The main responsibility of the Primary Care Physician is to be health manager and
advocate for his or her members from the moment the member selects that physician as
Primary Care Physician. Primary Care Physicians must look after their members acute,
chronic, and preventative health needs, regardless of whether the PCP has previously seen
the member.
Primary Care Physicians should be able to personally meet most of their patients’ medical
needs. The Primary Care Physician has an obligation to refer the patient to another
physician or medical provider when that PCP cannot personally meet the needs of the
patient. Only Primary Care Physicians have the right and responsibility to refer their
patients.
SANTÉ COMMUNITY PHYSICIANS IPA IS RESPONSIBLE FOR DELIVERING TOTAL
HEALTHCARE FOR ALL MEMBERS WHO HAVE CHOSEN A PRIMARY CARE
PHYSICIAN FROM THE SANTÉ ROSTER.
24 | P a g e
Medi-Cal Administrative Manual Table of Contents
GENERAL CONTRACT INFORMATION
All contractual terms related to payment are contained in exhibits and addenda following
the main body of the physician contract. Specific contract provisions of interest include:
Contracting physicians with open practices must accept patients from any Managed Medi-Cal Plan with which Santé Community Physicians is contracted.
Physicians must admit patients to participating facilities except when emergency situations make admission to contracting facilities impossible.
Physicians must comply with utilization management and quality policies of Santé.
Physicians must maintain privileges at a participating hospital
Contracts are for 12 months and renew automatically unless otherwise terminated.
Contracts may be terminated by either party without stated cause with 90 days written notice.
Physicians must have coverage at all times. It is the responsibility of contracted physicians to ensure that the covering physician does not balance-bill the patient.
Encounter information for all services performed by the primary or by any covering physician must be submitted to SCP.
No fees / co-payments are to be charged to Managed Medi-Cal patients.
Open Practice Policy
It is in the best interest of Santé Community Physicians that its contracted physicians keep
their practices open. If a physician finds it necessary to close his or her practice to new
members, a written request within five (5) business days must be made to Santé Physician
Contracting Department fax (559) 226-1651. Guidelines for making this request are listed
below:
Primary Care Physicians must keep their practice open to new members until 500 members have been assigned to their practice.
If a physician, after reaching 500 members, wishes to close his/her practice to HMO, Medi-Cal, Medicare and/or Workers’ Compensation product lines; closure will be effective 90 days after the written request is received. Product line closure may apply to any or all product lines at the physician’s discretion, e.g., HMO, Medi-Cal, etc.
Physicians may request closure for their practices once in any calendar year.
Santé strongly encourages physicians to leave their practices open. When a physician is
able to re-open practice to new members, a written request should be sent to the Santé
Physician Contracting Department fax (559) 226-1651.
25 | P a g e
Medi-Cal Administrative Manual Table of Contents
PCP ASSIGNMENT/MEMBER ELIGIBILITY
Primary Care Physician Selection
If the member did not identify a Primary Care Physician (PCP) during the enrollment
process, they must do so as soon as possible. Each family member may have his/her own
PCP. The member must complete a PCP selection form provided by their Managed Medi-
Cal plan directly or through their employer. They may obtain assistance by calling the Santé
Customer Services Department for a list of primary care physicians or they may call the
plan directly to make their primary care selection. Health plan phone numbers are located
on the back of the member ID card. If the member makes no choice, the Managed Medi-Cal
plan will assign a Primary Care Physician to the member. MANAGED MEDI-CAL PLANS
ARE RESPONSIBLE FOR ASSIGNING MEMBERS TO PRIMARY CARE PHYSICIANS.
How to Change Primary Care Physicians
When a member wants to change from one PCP to another, notification must be made through
the plan’s Customer Service Department. Toll-free numbers are listed on the member’s ID card.
Eligibility Reports
Eligibility reports are available to download from Santé’s website at www.medi-
cal.santehealth.net.This report combines Medi-Cal plans into one alphabetized list of members
for easy reference. A secure log-in is required to obtain this information. If you do not have a
log-in, please go to www.medi-cal.santehealth.net and click on “Providers/Administrators” then
click on “Sign-Up”.
Eligibility Verification
On occasion, new patients who are not listed on the Eligibility Report may come to a PCP office
seeking care. The provider office should ask patients to provide a current identification card.
It is recommended the provider collect the most current insurance ID card. Most ID cards
indicate PCP assignment. However, the provider office should verify the member’s PCP
assignment, eligibility by calling plan office at the phone number located on the back of the
member’s ID card or by obtaining log-in access to the health plan websites for quick verification.
26 | P a g e
Medi-Cal Administrative Manual Table of Contents
Specialist - Overview
27 | P a g e
Medi-Cal Administrative Manual Table of Contents
SPECIALIST OVERVIEW
The Specialist’s main responsibility is to be the clinical expert for patients referred to him or
her by the member’s Primary Care Physician. Specialists are responsible for all or part of a
health plan member's medical care (acute, chronic and preventative) from the time a
member is referred until the member is returned to the care of their Primary Care Physician.
All care provided to members must be provided in the most efficient manner to maximize
the effectiveness of the system.
Specialists have two primary obligations: 1) to meet their patient’s medical needs in the
area of their medical expertise, and 2) to communicate diagnostic and therapeutic
information for the referred patient to the referring Primary Care Physician.
When a Specialist cannot personally meet the needs of their patient, he or she must request
that the Primary Care Physician refer the patient to another physician or medical provider.
Specialists should not make such referrals themselves; only Primary Care Physicians have
the right and responsibility to refer their patients to other physicians.
Santé Community Physicians IPA is responsible for delivering healthcare to all members
who have chosen Primary Care Physicians from the Santé Community Physicians roster.
The Specialist must be an advocate for the needs of his or her patients and see that these
patients receive adequate and appropriate care.
28 | P a g e
Medi-Cal Administrative Manual Table of Contents
Ancillary Intro
Ancillary Service Provider Listing
Anthem Blue Cross Medi-Cal
Health Net Medi-Cal
29 | P a g e
Medi-Cal Administrative Manual Table of Contents
ANCILLARY OVERVIEW
Welcome to the Ancillary Section. Ancillary Services are services over and above physician services, including, but not limited to laboratory, radiology, physical therapy, home health and skilled nursing facilities. Ancillary services fall into three broad categories: diagnostic, therapeutic and custodial. In this section you can find the contracted Ancillary providers for Anthem Blue Cross Medi-Cal and Health Net Medi-Cal. It is the contracted Santé Community Physician’s (primary care physician or specialist----whoever is requesting the service) responsibility to direct the patient to an in-plan ancillary provider when needed. Please be sure to refer to the Prior Authorization list in the Utilization Management Section for services that may require prior authorization.
30 | P a g e
Medi-Cal Administrative Manual Table of Contents
ANCILLARY SERVICE PROVIDER LISTING
Anthem Blue Cross Medi-Cal
ACUPUNCTURE (Health Plan Risk effective 11/01/17)
ACUTE INPATIENT REHABILITATION FACILITY (Health
Plan Risk)
Leon S. Peters Rehabilitation Center
2823 Fresno Street Fresno 93721 (559) 459-6405
San Joaquin Valley Rehab
7175 N. Sharon Avenue Fresno 93720 (559) 436-3600
AMBULANCE / TRANSPORTATION (Health Plan Risk)
American Ambulance
911 Santa Fe Avenue Fresno 93721 (559) 443-5900
Logisticare Solutions Fresno (887) 440-7433
Pistoresi Ambulance Service Madera (559) 673-8004
ANESTHESIA (Santé Risk) Dental ONLY
Fresno Dental Surgery Fresno 93721 (559) 263-9648
CARDIAC MONITORING (Santé Risk)
AMI Cardiac Monitoring (800) 785-4354
CardioNet (866) 426-4402
Lifewatch, Inc. (877) 774-9846
CHEMICAL DEPENDENCY (Health Plan Risk)
See Mental Health
CHIROPRACTIC (Verify if a benefit- typically not
covered (If Covered, Santé Risk)
See Specialist Roster
DIABETIC EDUCATION (Santé Risk)
Community Diabetes Care Center
1925 E. Dakota, Suite 111 Fresno 93726 (559) 459-1763
DIALYSIS (Health Plan Risk)
Community Medical Center – Clovis
2755 Herndon Avenue Clovis 93611 (559) 324-4000
Community Regional Medical Center
2823 Fresno Street Fresno 93721 (559) 459-9301
Da Vita, Inc./Fresno Dialysis
1111 E. Warner, Suite 101 Fresno 93710 (559) 439-1845
31 | P a g e
Medi-Cal Administrative Manual Table of Contents
Da Vita, Inc./ Total Renal Care/Fresno At Home Center
568 E. Herndon Avenue, Suite 301 Fresno 93720 (559) 448-0127
Da Vita, Inc./Healthcare Renal Care/Hanford Dialysis
402 W. 8th Street Hanford 93230 (559) 582-4339
Da Vita, Inc./Healthcare Renal Care/Selma Dialysis
2001 High Street Selma 93662 (559) 891-2750
Da Vita, Inc./ Total Renal Care/Almond Wood Dialysis
501 E. Almond Avenue Madera 93637 (559) 673-1900
Da Vita , Inc./ Total Renal Care/Ash Tree Dialysis
2666 N. Grove Industrial Fresno 93727 (559) 252-1932
Da Vita, Inc./Renal Healthcare, Inc./Fresno Palm Bluffs
770 West Pinedale Fresno 93711 (559) 438-8512
Fresenius/BMA Fresno
3636 N. First Street, Suite 144
Fresenius Airport East:
1899 N. Helm Ave. Fresno 93727 (559) 452-1480
Sanger Sequoia Dialysis
2517 Jensen Avenue Bldg. B Sanger 93657 (559) 876-3852
DURABLE MEDICAL EQUIPMENT (DME) (Santé Risk)
180 Medical
8516 NW Expressway Oklahoma City 73162 (877) 688-2729
5 Medical
4656 E Dakota Ave #103 Fresno 93726 (559) 353-2954
Academy Medical Equipment
230 W. Fallbrook Ave. Ste. 107 Fresno 93711 (559) 261-9641
Advanced Home Medical, Inc. (Breast Pump)
312 Paseo Tesoro Walnut 91789 (909) 569-9013
Ashli Healthcare, Inc.
323 W. Cromwell Ave. #117 Fresno 93711 (888) 831-7977
ATG Rehab Specialist Inc. dba Numotion
4010 N. Chestnut Ave. #108 Fresno 93726 (559) 431-2035
Byram Healthcare
5302 Rancho Road Huntington
Beach 92647 (877) 902-9726
DJO Global Inc. dba DJO LLC
1247 E. Alluvial Ave. #103 Fresno 93720 (559) 261-1300
Express Rx Inc.
1711 W. Temple St. 100 Los Angeles 90026 (855) 392-9308
General Home Medical Supply, Inc.
717 Lakefield Road, Suite D Westlake
Village 91361 (805) 449-1559
32 | P a g e
Medi-Cal Administrative Manual Table of Contents
Guardian Sleep, LLC
315 Piercy Rd. San Jose 95138 (559) 334-3242
Hygeia Baby II Medical Group, Inc.
6241 Yarrow Dr. Ste. A Carlsbad 92011 (714) 515-7571
MedCare Health, Inc.
1205 11th Street Reedley 93654 (559) 435-7865
Medequip, Inc.
27 Brookline Aliso Viejo 92656 (949) 443-4414
Medsupply
5850 E. Shields Ave #105 Fresno 93727 (559) 292-1540
Mountain Medical Supply
35344 Highway 41 Suite D Coarsegold 93614 (559)377-3099
My Best Homecare
420 Hillview Ave. Milpitas 95035 (800) 959-9503
North Coast Medical Supply dba Advanced Diabetes Supply
2544 Campbell Place Ste. #150 Carlsbad 92009 (877) 869-1298
National Seating & Mobility
4980 E. University Ave. Suite 114 Fresno 93727 (559) 252-4396
Pacific Medical
1700 N. Chrisman Rd. Tracy 95304 (800) 726-9180
Respicare
5470 W. Spruce Ave. #104 Fresno 93722 (559) 432-4455
Sanger Medical Supply
1348 7th St. Sanger 93657 (559) 876-2551
Shield Healthcare
423 W. Fallbrook Ave. #101 Fresno 93711 (800) 675-8842
Simply Mama
2705 McMillan Ave. #130 San Luis
Obispo 93401 (866) 364-7113
Valley Medical Supplies Fresno (559) 478-4691
FAMILY PLANNING (Santé Risk)
Family Planning Associates
165 N. Clark Fresno 93701 (559) 233-8657
Family Planning Associates
125 E. Barstow Avenue Fresno 93710 (559) 225-5180
Family Planning Associates
500 E. Almond Avenue Madera 93637 (559) 675-1133
Planned Parenthood
5727 N. Fresno Street, Suite 101 Fresno 93710 (559) 446-1515
Planned Parenthood
633 N. Van Ness Fresno 93725 (559) 488-4900
Planned Parenthood
33 | P a g e
Medi-Cal Administrative Manual Table of Contents
500 E. Almond Madera 93637 (559) 675-1133
FERTILITY DRUGS (Not Covered)
GENETIC COUNSELING (Santé Risk)
Cynthia Curry, M.D.
2210 E. Illinois Ave, Suite 308 Fresno 93701 (559) 268-8307
HEARING AIDS (Santé Risk)
Hearing For Life Hearing Aids
4836 N. First St. # 102 Fresno 93726 (559) 225-2211
1205 Evergreen Selma 93662 (559) 225-2211
724 Medical Center Dr. #06 Clovis 93611 (559) 225-2211
1592 11th St. #D Reedley 93654 (559) 225-2211
HOME HEALTH (Health Plan Risk)
Adventist Health Home Care Services
4620 Kings County Drive, Suite 101 Hanford 93230 (559) 585-3425
Avance Home Health, Inc.
1350 “O” Street, Suite 303 Fresno 93721 (559) 266-8300
Children’s Home Care
7555 N. Del Mar Avenue, Suite 101 Fresno 93711 (559) 353-7125
Community Home Care
1925 E. Dakota Avenue, Suite 108 Fresno 93726 (559) 459-1615
Crescent Healthcare
(800) 879-4844
HealthCare California
5709 N. West Avenue Fresno 93711 (559) 243-9990
Interim Healthcare, Inc.
1320 E. Shaw Avenue, Suite 110 Fresno 93710 (559) 224-0560
Matria Healthcare, Inc. (High Risk OB)
3130 Tisch Way, Suite 510 San Jose 95128 (800) 999-2457
Rehab Focus
295 W. Cromwell, Suite 103 Fresno 93711 (559) 432-2257
HOME INFUSION (Santé Risk)
Community Home Infusion
(559) 459-1646
Integrated Care System
7140 W. Pershing Ct. Visalia 93291 (559) 734-2896
NuFactor Specialty Pharmacy
41093 County Center Dr. Ste. B Temecula 92591 (800) 323-6832
HOSPICE (Health Plan Risk)
Adventist Health Home Care Services
(559) 582-5273
Community Home Care Services (Palliative Care) (559) 459-1608
Community Living Center – Fresno (Inpatient) (559) 222-7416
34 | P a g e
Medi-Cal Administrative Manual Table of Contents
Hinds Hospice (Inpatient & Outpatient)
(559) 226-5683
Optimal Hospice Care
(559) 320-4000
LABORATORY PROVIDERS (Santé Risk)
Quest Diagnostics
Clarient Diagnostic Services – Molecular Diagnostics, Cytopathology/Cytometry/Cytogenic Testing, Surgical Pathology
(888) 443-3311
Progenity, Inc. (Genetic Testing)
5230 S. State Road Ann Arbor, MI 48108 (855) 293-2639
Veracyte (Contract Pending)
6000 Shoreline Court, Suite 300 San Francisco 94080 (650)243-6300
LITHOTRIPSY (Health Plan Risk)
Urology Associates of Central California, Inc.
7014 N. Whitney, Suite B Fresno 93720 (559) 322-2600
NUTRITIONAL COUNSELING (Santé Risk)
Brooks Healthcare, Inc.
5070 N. 6th Street, Suite 160 Fresno 93710 (559) 224-8646
Fresno Nephrology Medical Group
568 E. Herndon Avenue, Suite 201 Fresno 93720 (559) 228-6600
Sang Pediatrics
1122 S Street #102 Fresno 93721 (559) 268-1737
OCCUPATIONAL THERAPY (Santé Risk if outpatient clinic or non-hospital. Health Plan Risk if Hospital
setting – CORC is Hospital setting since it’s billed by a Hospital)
Community Outpatient Rehabilitation Center (CORC)
1925 E. Dakota, Suite 120A Fresno 93726 (559) 459-1842
Hand Therapy of Fresno, Inc. (Term 10/1/19)
7120 N. Whitney Ave. Ste. 102 Fresno 93720 (559) 323-4831
ORTHOTICS (Santé Risk)
Capstone Orthopedic
7015 N. Chestnut Ave., Ste. 103 Fresno (559) 298-0321
Central Orthotic and Prosthetic
2039 N. Fine Ave. Fresno 93727 (559) 251-5557
Central Valley Medical Supplies Fresno (559) 478-4691
KMY Prosthetic & Orthotic
7210 N. Milburn Ave. #105 Fresno 93722 (559) 277-3909
Silhouette Post-Surgical
7055 N. Maple Ave. #108 Fresno 93720 (559) 432-7199
OUTPATIENT SURGERY Facility (Health Plan Risk)
California Colon and Rectal Cancer Screening Center
35 | P a g e
Medi-Cal Administrative Manual Table of Contents
7121 N. Whitney Ave. Fresno 93720 (559) 299-9396
Community Outpatient Surgery Center
1045 Fresno St. Fresno 93706 (559) 256-2150
ENT Facial Surgery Center
1351 E. Spruce Ave. Fresno 93720 (559) 432-3303
Fresno Endoscopy Center
7405 N. Fresno St. Fresno 93720 (559) 438-8400
Gastroenterology & Liver Disease Medical Center Inc.
7215 N. Fresno St. #101 Fresno 93720 (559) 449-0309
Lags Surgery Center of Fresno
5771 N. Fresno St. #101 Fresno 93720 (559) 272-1295
Madera Surgery Center
1015 W. Yosemite Ave. Madera 93637 (559) 673-0700
North Point Surgery Center
1332 W. Herndon Ave. #102 Fresno 93711 (559) 435-2435
Pristine Surgery Center
7085 N. Maple Ave. Fresno 93720 (559) 325-7100
Richburg Valley Eye Institute Association
1680 E. Herndon Ave. Fresno 93720 (559) 432-4200
University Surgery Center
1390 E. Yosemite Ave. Ste. B Merced 95340 (209) 580-3400
Urology Associates of Central California, Inc. Surgery Center
7014 N. Whitney Ave. Ste. B Fresno 93720 (559) 650-1020
Vision Care Surgery Center
7075 N. Sharon Ave. Fresno 93720 (559) 486-2000
PROSTHETICS (Health Plan Risk)
Abilities Unlimited Prosthetics
(559) 243-1234
Advanced Prosthetics & Orthotics dba Capstone
7015 N Chestnut Ave, #103 Fresno 93720 (559) 298-0321
Apria Healthcare, Inc.
512 E. Fountain Way Fresno 93727 (888) 492-7742
(559) 221-2251
Central Orthotic & Prosthetic (559) 268-5433
Fresno Prosthetics, Inc.
4832 N. First Street, Suite 102 Fresno 93726 (559) 225-2400
Hanger Prosthetics & Orthotics West (Includes Breast Prosthesis / Bras) (559) 431-7045
Ortho Supply (800) 944-3422
Reedley Medical Supply (559) 638-8004
Silhouette (Mastectomy Bras and Breast Prosthesis)
5610 N. Palm, Suite 105 Fresno 93704 (559) 432-7199
Synergy Prosthetics
735 Sunrise Ave. #101 Roseville 95661 (510) 770-9010
36 | P a g e
Medi-Cal Administrative Manual Table of Contents
Valley Orthopedics (Madera & Fresno Counties) (559) 221-1933
PHYSICAL THERAPY (Santé Risk)
Bacci & Glinn Physical Therapy, Inc.
331 N. 11th Ave. Hanford 93230 (559) 582-1027
CCFMG Physical Therapy
Compass Physical Therapy
921 G. Street Reedley 93654 (559)638-9200
Dakota Physical Therapy (559) 227-8437
Dynamics Kids Physical Therapy
1360 E. Spruce Ave. Ste. #103 Fresno 93720 (559) 433-4700
Eric Verheul PT
401 W Lacey Blvd. Hanford 93230 (559) 582-2781
Eric Verheul PT
234 C. Street Lemoore 93245 (559) 924-0514
Hand Therapy of Fresno, Inc. (Term 10/1/19)
7120 N. Whitney Ave. Ste. 102 Fresno 93720 (559) 323-4831
McGuire Physical Therapy, Inc.
1700 E. Bullard Ave. #102 Fresno 93710
PhysMed Physical Therapy
7033 N. Fresno St. #202 Fresno 93720 (559) 438-4300
Rebound Physical Therapy (559) 271-3100
Terrio Physical Therapy (559) 322-4103
Troxell & Mohr Physical Therapy
2351 W. Cleveland Ave. Madera 93637 (559) 661-1611
PRENATAL GENETICS (Santé Risk)
Quest Diagnostics
PSYCHIATRIC FACILITY (Non-Secured Unit) (Health Plan Risk)
Community Behavioral Health Center
7171 N. Cedar Avenue Fresno 93720 (559) 449-8000
PSYCHIATRIC FACILITY (Secured Unit) (Health Plan Risk)
Community Regional Medical Center
2823 Fresno Street Fresno 93721 (559) 459-6000
RADIOLOGY (Outpatient) (Santé Risk)
Advanced Medical Imaging
California Imaging Institute
Community Medical Center – Clovis
Community Regional Medical Center
Community Medical Imaging
Mitchell Imaging (Mobile Diagnostic Ultrasound)
(Effective Date: 07/01/2018)
37 | P a g e
Medi-Cal Administrative Manual Table of Contents
P.O. Box 647 Clovis 93613 (559) 269-9437
Tri County Medical Imaging, Inc.
590 W. Putnam Ave. Suite 2B Porterville 93258 (559) 782-1973
SELF INJECTABLES (Santé Risk)
University Medical Center Pharmacy
290 N. Wayte Lane 1st Floor Fresno 93701 (559) 459-4592
SKILLED NURSING FACILITIES (Health Plan Risk)
Avalon Health Care
1700 Howard Rd. Madera 93637 (559) 673-9278
Care Meridian - Fresno
6385 N Marks Avenue Fresno 93711 (559) 431-8594
Care Meridian - Weber
2020 N Weber Avenue Fresno 93705 (559) 264-0535
Community Living Center – Fresno
3003 N. Mariposa Fresno 93703 (559) 222-7416
Delta Nursing and Rehabilitation Center
514 N. Bridge St. Visalia 93291 (559) 732-8614
Golden Living Center – Fresno Behavioral Care
1715 S Cedar Avenue Fresno 93702 (559) 237-8377
Golden Living Center - Clovis
111 Barstow Avenue Clovis 93612 (559) 299-2591
Golden Living Center – Country View Alzheimer
925 N Cornelia Avenue Fresno 93706 (559) 275-4785
Golden Living Center - Fowler
1306 East Sumner Fowler 93625 (559) 834-2542
Golden Living Center - Fresno
2715 Fresno Street Fresno 93721 (559) 486-4433
Golden Living Center - Hillcrest
3672 N. First Street Fresno 93726 (559) 227-5383
Golden Living Center - Hy-Lond
3408 E. Shields Avenue Fresno 93726 (559) 227-4063
Golden Living Center – Hy-Pana
3510 E. Shields Avenue Fresno 93726 (559) 222-4807
Horizon Health & Subacute Center
3034 E. Herndon Avenue Fresno 93720 (559) 237-0883
Kingsburg Center
1101 Stroud Avenue Kingsburg 93631 (559) 897-5881
Madera Rehabilitation & Nursing Center
517 South “A” Street Madera 93638 (559) 673-9228
Pacific Gardens Nursing and Rehab Center
577 S. Peach Avenue Fresno 93727 (559) 251-8463
San Joaquin Valley Rehabilitation Hospital
7173 N. Sharon Avenue Fresno 93720 (559) 436-3600
38 | P a g e
Medi-Cal Administrative Manual Table of Contents
The Rehabilitation Center of Fresno
1665 “M” Street Fresno 93721 (559) 268-5361
Tulare Nursing and Rehabilitation Center
686 E. Meritt Ave. Tulare 93274 (559) 686-8581
Valley Healthcare Center
4840 E. Tulare Avenue Fresno 93727 (559) 251-7161
Willow Creek Healthcare Center
650 W. Alluvial Avenue Clovis 93611 (559) 323-6200
SLEEP STUDIES (Santé Risk)
American Home Diagnostics, Inc. (In Home)
7575 N. Cedar Ave. Suite 103 Fresno 93720 (559)916-4433
Guardian Sleep, LLC
4848 N. First St. Fresno 93726 (559) 334-3242
The Pulmonary & Sleep Disorder Center
6311 N. Fresno Street, Suite 106 Fresno 93710 (559) 435-4700
Schapansky Sleep & Wellness Center (In Home)
5660 N. Fresno St. Suite 102 Fresno 93710 (559)776-7066
Sleep Quest, Inc. (In Home)
5475 N. Fresno St. #112 Fresno 93710 (559) 436-8800
SPEECH and HEARING SERVICES (Non-Therapy) (Santé Risk)
Miracle Ear Central California
7391 N. Palm Ave. #104 Fresno 93711 (559) 244-6060
SPEECH THERAPY (Santé Risk)
Community Outpatient Rehabilitation Center (CORC)
1925 E. Dakota, Suite 120-A Fresno 93726 (559) 459-1842
WOUND CARE (Santé Risk)
Community Medical Center
1925 E. Dakota Avenue, Suite 208 Fresno 93726 (559) 459-6000
39 | P a g e
Medi-Cal Administrative Manual Table of Contents
ANCILLARY SERVICE PROVIDER LISTING
Health Net Medi-Cal
Member Assignment Anticipated 03/01/2019
ACUTE INPATIENT REHABILITATION FACILITY (Health
Plan Risk)
San Joaquin Valley Rehab
7175 N. Sharon Avenue Fresno 93720 (559) 436-3600
AMBULANCE / TRANSPORTATION (Health Plan Risk)
Logisticare Solutions Fresno (887) 440-7433
ANESTHESIA (Health Plan Risk)
Fresno Dental Surgery Fresno 93721 (559) 263-9648
CARDIAC MONITORING (Santé Risk)
AMI Cardiac Monitoring (800) 785-4354
CardioNet (866) 426-4402
Lifewatch, Inc. (877) 774-9846
CHIROPRACTIC (Santé Risk – Covered in FQHC or
RHC setting only. See MCL roster)
DIABETIC EDUCATION (Santé Risk)
Community Diabetes Care Center
1925 E. Dakota, Suite 111 Fresno 93726 (559) 459-1763
DIALYSIS (Santé Risk)
Community Medical Centers – Clovis
685 Medical Center Drive #105 Clovis 93611 (559) 324-4905
Community Regional Medical Center
285 N. Fresno St. Fresno 93701 (559) 459-9301
DaVita Ash Tree
2666 N. Grove Industrial Dr., Suite 106 Fresno 93727 (800)424-6589
DaVita Herndon Dialysis
560 E. Herndon Ave, Suite 101 Fresno 93720 (800)424-6589
DaVita Fresno Dialysis
4308 W. Shaw Ave, Suite 101 Fresno 93722 (800)424-6589
DaVita Fresno Palm Bluffs Dialysis
770 W. Pinedale Ave Fresno 93711 (800)424-6589
DaVita Sanger Sequoia Dialysis
2517 Jensen Ave, Bldg B Sanger 93657 (800)424-6589
40 | P a g e
Medi-Cal Administrative Manual Table of Contents
DaVita Selma Dialysis
2711 Cinema Way, Suite 111 Selma 93662 (800)424-6589
DaVita Almond Wood Dialysis
501 E. Almond Ave Madera 93637 (800)424-6589
DaVita North Madera Dialysis
720 N. I St. Madera 93637 (800)424-6589
DaVita Lemoore Dialysis
1345 W. Bush St. Lemoore 93245 (800)424-6589
DaVita Hanford Dialysis
402 W. 8th St. Hanford 93230 (800)424-6589
DaVita Sequoia Dialysis
440 N. 11th Ave Hanford 93230 (800)424-6589
DURABLE MEDICAL EQUIPMENT (Health Plan Risk)
5 Medical
4656 E Dakota Ave. #103 Fresno 93726 (559) 353-2954
Adventist Health Oxygen & Medical Equipment
440 Greenfield Ave. Ste. A Hanford 93230 (559) 537-2695
Apria Healthcare - Fresno
5712 East Fountain Way Fresno 93727 (559) 221-2251
Brooks Health Care
5070 N. Sixth St., #164 Fresno 93710 (877) 889-3424
Byram Healthcare (Preferred Provider for Ostomy)
5302 Rancho Road Huntington
Beach 92647 (877) 902-9726
California Home Medical
7946 N. Maple Ave. #111 Fresno 93720 (559) 226-5215
Central Valley Medical Supplies Fresno
(559) 478-4691
5153N N. Blackstone Ave. Fresno 93710 (559) 478-4691
Edgepark Medical Supplies
1810 Summit Commerce Park Twinsburg, OH 44087 (888)394-5375
Ivanhoe Medical Supply
7944 N. Maple Ave. #109 Fresno 93720 (559) 323-3998
KCI USA, Inc. – Fresno
1155 East North Ave. #105 Fresno 93725 (800) 275-4524
Lincare, Inc. - Fresno
7545 N Del Mar Ave #102 Fresno 93711 (559) 435-6379
Lincare, Inc. - Hanford
308 West Lacey Blvd. Hanford 93230 (559) 585-3500
Madera Medical Pharmacy
402 South Madera Ave. #A Madera 93637 (559) 674-8553
MedCare Health, Inc.
1205 11th Street Reedley 93654 (559) 435-7865
Medsupply
5850 East Shields Ave. #105 Fresno 93727 (559) 292-1540
41 | P a g e
Medi-Cal Administrative Manual Table of Contents
National Seating – Fresno
4980 E. University Ave. #114 Fresno 93727 (559) 252-4396
North Coast Medical Supply/Advanced Diabetes
2544 Campbell Place #150 Carlsbad 92018 (877) 869-1298
Numotion – Fresno
4010 N. Chestnut Ave. #108 Fresno 93726 (559) 431-2035
Pacific Pulmonary Services – Fresno
340 W Fallbrook Ave. # 109 & 110 Fresno 93711 (559) 449-7500
Respicare
5470 W. Spruce Ave. #104 Fresno 93722 (559) 432-4455
Respiratory Care Plus
2594 N. Fordham Ave. #B Fresno 93727 (559) 252-0100
Sanger Medical Supplies
1348 7th Street Sanger 93657 (559) 876-2551
West Side Drugs
1101 O Street Firebaugh 93622 (559) 659-2159
FAMILY PLANNING – Contraception Only (Santé Risk)
Family Planning Associates
165 N. Clark Fresno 93701 (559) 233-8657
Family Planning Associates
125 E. Barstow Avenue Fresno 93710 (559) 225-5180
Family Planning Associates
500 E. Almond Avenue Madera 93637 (559) 675-1133
Planned Parenthood
5727 N. Fresno Street, Suite 101 Fresno 93710 (559) 446-1515
Planned Parenthood
633 N. Van Ness Fresno 93725 (559) 488-4900
Planned Parenthood
500 E. Almond Madera 93637 (559) 675-1133
GENETIC COUNSELING (Santé Risk)
Cynthia Curry, M.D.
2210 E. Illinois Ave, Suite 308 Fresno 93701 (559) 268-8307
HEARING AIDS (Health Plan Risk)
Gillett Hearing Aid Center
1150 N Douty St. Hanford 93230 (559) 582-5266
Hear for Life – Fresno
5100 N. 6th St. #120 Fresno 93710 (559) 225-2211
Miracle - Ear Central CA Fresno
7391 N. Palm Ave. #104 Fresno 93711 (559) 244-6060
Miracle - Ear Central CA Hanford
1413B Bailey St. Hanford 93230 (559) 583-8393
42 | P a g e
Medi-Cal Administrative Manual Table of Contents
HOME HEALTH (Health Plan Risk)
Compassionate Care Home Health Agency
7545 N Del Mar Ave. #103 Fresno 93711 (559) 432-2003
Focus Health – Fresno
377 West Fallbrook Ave. #206 Fresno 93711 (559) 432-2257
HealthCare California
5709 N West Ave. Fresno 93711 (559) 243-9990
Healthpoint Home Health
3120 Willow Ave. #102 Clovis 93612 (559) 412-7953
Healthy Living at Home-Fresno
1318 E. Shaw Ave. #100 Fresno 93710 (559) 369-6473
Interim Healthcare of the Central Valley
1843 E Fir Ave. #101 Fresno 93720 (559) 224-0560
Maxim Healthcare Services, Inc. – Fresno
6051 N Fresno St. #102 Fresno 93710 (559) 224-9078
Omnia Healthcare LLC
755 N. Peach Ave. #G3 Clovis 93611 (559) 772-4673
Remedy Home Care
3447 W. Shaw Ave. #101 Fresno 93711 (559) 742-7000
Saint Agnes Home Health And Hospice
6729 N Willow Ave. #103 Fresno 93710 (248) 305-7985
Sequoia Home Health
900 Pollasky Ave. Clovis 93612 (559) 765-4315
St. Mary's Home Health Services, Inc.
3180 E. Shields Ave. #105 Fresno 93726 (559) 221-9919
Therapeutic Home Healthcare
5150 N 6Th St. #110 Fresno 93710 (559) 224-8585
Valley Home Health
2511 W. Shaw Ave. #101 Fresno 93711 (559) 222-4060
Valley Regional Home Health
7498 N. Remington Ave. Fresno 93711 (559) 554-9772
Vida Care Home Health
5100 N 6Th St. #112 Fresno 93710 (559) 248-0277
Wilshire Home Health
5105 E. Dakota Ave. Fresno 93727 (559) 248-0131
HOME INFUSION (Health Plan Risk)
HOSPICE (Health Plan Risk)
AseraCare Hospice – Fresno
650 W. Alluvial Ave. Fresno 93711 (559) 447-2540
Bright Horizon Hospice Services
3649 W. Beechwood Ave. #106 Fresno 93711 (559) 443-0303
Hinds Hospice
2490 W. Shaw Ave. Fresno 93711 (209) 225-7875
43 | P a g e
Medi-Cal Administrative Manual Table of Contents
Optimal Hospice Care – Fresno
6780 N. West Ave. #101 Fresno 93711 (661) 410-3000
Oyuna Hospice, Inc.
5067 N. Mariposa St. #104 Fresno 93711 (559) 374-2726
INPATIENT DETOX FACILITY (Sante Risk)
True North Detox
22051 Oak Hill Lane. Clovis 93619 (559)746-7202
21877 Oak Hill Lane. Clovis 93619 (559)746-7202
21870 Oak Hill Lane. Clovis 93619 (559)746-7202
2121 Herndon Ave. Clovis 93611 (559)746-7202
LABORATORY PROVIDERS (Santé Risk)
Quest Diagnostics
Clarient Diagnostic Services – Molecular Diagnostics, Cytopathology/Cytometry/Cytogenic Testing, Surgical Pathology
(888) 443-3311
Progenity, Inc. (Genetic Testing)
5230 S. State Road Ann Arbor, MI 48108 (855) 293-2639
Veracyte (Contract Pending)
6000 Shoreline Court, Suite 300 San Francisco 94080 (650)243-6300
LITHOTRIPSY (Health Plan Risk)
NUTRITIONAL COUNSELING (Santé Risk)
Brooks Healthcare, Inc.
5070 N. 6th Street, Suite 160 Fresno 93710 (559) 224-8646
Fresno Nephrology Medical Group
568 E. Herndon Avenue, Suite 201 Fresno 93720 (559) 228-6600
Sang Pediatrics
1122 S Street #102 Fresno 93721 (559) 268-1737
OCCUPATIONAL THERAPY (Santé Risk)
Community Outpatient Rehabilitation Center (CORC)
1925 E. Dakota, Suite 120A Fresno 93726 (559) 459-1842
Hand Therapy of Fresno, Inc. (Term 10/1/19)
7120 N. Whitney Ave. Ste. 102 Fresno 93720 (559) 323-4831
ORTHOTICS AND PROSTHETICS (Santé Risk)
Capstone Orthopedic
7015 N. Chestnut Ave., Ste. 103 Fresno (559) 298-0321
Central Orthotic and Prosthetic
2039 N. Fine Ave. Fresno 93727 (559) 251-5557
Central Valley Medical Supplies Fresno (559) 478-4691
KMY Prosthetic & Orthotic
44 | P a g e
Medi-Cal Administrative Manual Table of Contents
7210 N. Milburn Ave. #105 Fresno 93722 (559) 277-3909
Silhouette Post-Surgical
7055 N. Maple Ave. #108 Fresno 93720 (559) 432-7199
OUTPATIENT SURGERY Facility (Health Plan Risk)
Comprehensive Pain Management Center, Inc.
7152 N. Sharon Ave., #104 Fresno 93720 (559) 447-4898
Eye-Q Vision Care
7075 N. Sharon Ave. Fresno 93720 (559) 486-2000
Fresno Dental Surgery Center, Inc.
2828 Fresno St., #100 Fresno 93721 (559) 263-9648
Fresno Endoscopy Center
7405 N. Fresno St. Fresno 93720 (559) 438-8400
Gastroenterology & Liver Disease Medical Center Inc.
7215 N. Fresno St. #101 Fresno 93720 (559) 449-0309
Herndon Surgery Center
1843 E Fir Ave. #104 Fresno 93720 (559) 323-6611
Kings Eye Center Medical Group
1395 W. Lacey Blvd. Hanford 93230 (559) 585-3937
Ky Advanced Surgical Center, Inc.
3796 N. Fresno St. #103 Fresno 93726 (559) 221-9905
Lags Surgery Center of Fresno
5771 N. Fresno St. #101 Fresno 93720 (559) 272-1295
LDAC Surgery Center, Inc.
6153 N. Thesta Ave. Fresno 93710 (559) 446-1065
Madera Ambulatory Endoscopy Center
451 E. Almond Ave. #105 Madera 93637 (559) 673-8111
North Point Surgery Center
1332 W. Herndon Ave. #102 Fresno 93711 (559) 435-2435
Pristine Surgery Center
7085 N. Maple Ave. Fresno 93720 (559) 325-7100
Urology Associates of Central California, Inc. Surgery Center
7014 N. Whitney Ave. Ste. B Fresno 93720 (559) 650-1020
Therapy Physical and Rehab Outpatient (Santé Risk)
Bacci & Glinn Physical Therapy, Inc.
331 N. 11th Ave. Hanford 93230 (559) 582-1027
CCFMG Physical Therapy
Compass Physical Therapy
921 G. Street Reedley 93654 (559)638-9200
Dakota Physical Therapy (559) 227-8437
Dynamics Kids Physical Therapy
1360 E. Spruce Ave. Ste. #103 Fresno 93720 (559) 433-4700
45 | P a g e
Medi-Cal Administrative Manual Table of Contents
Hand Therapy of Fresno, Inc. (Term 10/1/19)
7120 N. Whitney Ave. Ste. 102 Fresno 93720 (559) 323-4831
PhysMed Physical Therapy
7033 N. Fresno St. #202 Fresno 93720 (559) 438-4300
Rebound Physical Therapy (559) 271-3100
Terrio Physical Therapy (559) 322-4103
Troxell & Mohr Physical Therapy
2351 W. Cleveland Ave. Madera 93637 (559) 661-1611
PRENATAL GENETICS (Santé Risk)
Quest Diagnostics
PSYCHIATRIC FACILITY (Non-Secured Unit) (Not Covered)
PSYCHIATRIC FACILITY (Secured Unit) (Not Covered)
RADIOLOGY (Outpatient) (Santé Risk)
Advanced Medical Imaging
California Imaging Institute
Community Medical Center – Clovis
Community Regional Medical Center
Community Medical Imaging
Mitchell Imaging (Mobile Diagnostic Ultrasound)
(Effective Date: 07/01/2018)
P.O. Box 647 Clovis 93613 (559) 269-9437
Tri County Medical Imaging, Inc.
590 W. Putnam Ave. Suite 2B Porterville 93258 (559) 782-1973
SELF INJECTABLES (Santé Risk)
University Medical Center Pharmacy
290 N. Wayte Lane 1st Floor Fresno 93701 (559) 459-4592
SKILLED NURSING FACILITIES (Health Plan Risk)
Avalon Health Care
1700 Howard Rd. Madera 93637 (559) 673-9278
Community Subacute & Transitional Care Center
3003 N. Mariposa Fresno 93703 (559) 222-7416
Delta Nursing and Rehabilitation Center
514 N. Bridge St. Visalia 93291 (559) 732-8614
Fresno Post-Acute Care, LLC
1233 A St. Fresno 93706 (559) 268-6317
Golden Living Center – Chowchilla
1010 Ventura Ave. Chowchilla 93610 (559) 665-4826
Golden Living Center - Clovis
111 Barstow Avenue Clovis 93612 (559) 299-2591
46 | P a g e
Medi-Cal Administrative Manual Table of Contents
Golden Living Center – Country View Alzheimer
925 N Cornelia Avenue Fresno 93706 (559) 275-4785
Golden Living Center - Fowler
1306 East Sumner Fowler 93625 (559) 834-2542
Golden Living Center – Fresno
2715 Fresno Street Fresno 93721 (559) 486-4433
Golden Living Center - Hillcrest
3672 N. First Street Fresno 93726 (559) 227-5383
Golden Living Center - Hy-Lond Center - Fresno
3408 E. Shields Avenue Fresno 93726 (559) 227-4063
Golden Living Center – Reedley
1090 E. Dinuba Ave. Reedley 93654 (559) 638-3578
Golden Living Center – Sanger
2550 Ninth St. Sanger 93657 (559) 875-6501
Hacienda Rehabilitation & Health Care Center, Inc.
361 E. Grangeville Blvd. Hanford 93203 (559) 582-9221
Hanford Nursing & Rehabilitation Hospital
1007 W. Lacey Blvd. Hanford 93230 (559) 582-2871
Healthcare Centre of Fresno
1665 M St. Fresno 93721 (559) 268-5361
Horizon Health & Subacute Center
3034 E. Herndon Avenue Fresno 93720 (559) 237-0883
Kings Nursing & Rehabilitation Center
851 Leslie Ln Hanford 93230 (559) 582-4414
Kingsburg Care Center
1101 Stroud Ave. Kingsburg 93631 (559) 897-5881
Madera Rehabilitation & Nursing Center
517 South “A” Street Madera 93638 (559) 673-9228
Manning Gardens Care Center, Inc.
2113 E Manning Ave. Fresno 93725 (559) 834-2586
Oakhurst Healthcare and Wellness Center
40131 Highway 49 Oakhurst 93644 (559) 683-2244
Oakwood Gardens Care Center
3510 E. Shields Ave. Fresno 93726 (559) 222-4807
Pacific Gardens Nursing and Rehab Center
577 S. Peach Avenue Fresno 93727 (559) 251-8463
Palm Village Health Care Center
703 W. Herbert Ave. Reedley 93654 (559) 638-6933
Sierra View Homes
1155 E. Springfield Ave. Reedley 93654 (559) 638-9226
Sierra Vista Healthcare
1715 S. Cedar Ave. Fresno 93702 (559) 237-8377
Sunnyside Convalescent Hospital
2939 S. Peach Ave. Fresno 93725 (559) 233-6248
Terraces at San Joaquin Gardens
47 | P a g e
Medi-Cal Administrative Manual Table of Contents
5551 N. Fresno St. Fresno 93710 (559) 439-4770
Tulare Nursing and Rehabilitation Center
686 E. Meritt Ave. Tulare 93274 (559) 686-8581
Twilight Haven
1717 S Winery Ave Fresno 93727 (559) 251-8417
Valley Healthcare Center
4840 E. Tulare Avenue Fresno 93727 (559) 251-7161
Willow Creek Healthcare Center
650 W. Alluvial Avenue Clovis 93611 (559) 323-6200
SLEEP STUDIES (Santé Risk)
American Home Diagnostics, Inc. (In Home)
7575 N. Cedar Ave. Suite 103 Fresno 93720 (559)916-4433
Guardian Sleep, LLC
4848 N. First St. Fresno 93726 (559) 334-3242
The Pulmonary & Sleep Disorder Center
6311 N. Fresno Street, Suite 106 Fresno 93710 (559) 435-4700
Schapansky Sleep & Wellness Center (In Home)
5660 N. Fresno St. Suite 102 Fresno 93710 (559)776-7066
Sleep Quest, Inc. (In Home)
5475 N. Fresno St. #112 Fresno 93710 (559) 436-8800
SPEECH and HEARING SERVICES (Non-Therapy) (Santé Risk)
Miracle Ear Central California
7391 N. Palm Ave. #104 Fresno 93711 (559) 244-6060
SPEECH THERAPY (Santé Risk)
Community Outpatient Rehabilitation Center (CORC)
1925 E. Dakota, Suite 120-A Fresno 93726 (559) 459-1842
48 | P a g e
Medi-Cal Administrative Manual Table of Contents
Customer Service Overview
Patient Billing
Waiver of Liability
Language Assistance Program
Submission Guidelines
Claims Inquiry
Provider Inquiry
Provider Inquiry Request Form
Electronic Claims
Provider Dispute
Provider Dispute Resolution Request Form
Overpayments
Vaccine for Children
Processing Guidelines
Assistant Surgeon Reimbursement
Third Party Liability
California Children Services (CCS)
Website/Access and Information
49 | P a g e
Medi-Cal Administrative Manual Table of Contents
CUSTOMER SERVICE
The Customer Service Department is an integral part of the Santé Community Physicians’
commitment to service. This department services three types of customers: Members,
Physicians and their office staff/ billing services.
Members
Examples of the role of the Santé Customer Service Department for Medi-Cal members are:
1. To provide members with physician rosters. 2. 3. To assist in claim inquiries, ancillary provider selection, and current physician roster information. 4. To facilitate prompt payment of claim problems. 5. To educate as needed. 6. Redirect eligibility inquiries to member’s designated health plan. 7. Redirect PCP assignment inquiries to member’s designated health plan.
The Customer Service telephone number for members is listed below.
For: Call:
Members (559) 228-4466
Physicians, Office Staff, Billing Services
Examples of the role of the Santé Customer Service Department for physicians, office staff, and billing
services are:
1. To provide verification of PCP assignment as received from the member’s Medi-Cal health plan. 2. To facilitate prompt payment of claim problems. 3. To educate as needed. 4. Redirect eligibility inquiries to member’s designated health plan. 5. Redirect PCP assignment inquiries to member’s designated health plan.
Customer Service telephone number for Physician Offices is listed below.
For: Call:
All PCP and Specialty Offices (559) 228-4466
50 | P a g e
Medi-Cal Administrative Manual Table of Contents
Patient Billing Statements from Physician Offices or Surcharges
Santé’s Managed Medi-Cal contracts authorize patient billings to be limited to the following:
Non-covered services due to ineligibility
Patient statements are not authorized and should not be sent. Surcharges of any kind are also
prohibited. If a physician office is sending patients a statement showing full charges or a
surcharge has been imposed, they will be considered out of compliance with both the managed
Medi-Cal contract and the Knox-Keene Health Care Service Plan Act.
(Please check eligibility at least 5 days prior to date of service. If you have been notified that a
patient is not eligible, you may bill the patient at that time.)
For any claim issue, physician offices should work directly with Santé’s Customer Service
Department, where our staff is dedicated to working with both PCP and Specialty Physician
offices.
Waiver of Liability
Medi-Cal members must be properly informed in advance and in writing of services or procedures that are not covered by their benefit plan. If they choose, have the member sign a waiver agreeing to pay for non-covered services. If the provider does not obtain a signed waiver of liability, and the care is unauthorized by Santé, the provider is expected to accept full liability for the cost of the service or procedure. (Non-covered services maybe verified with patients health plan)
In the event the member chooses to upgrade a product or service, by signing the waiver the
member is agreeing to pay the difference between the billed and allowed amount. If the provider
does not obtain a signed waiver of liability, the provider is expected to accept the allowed
amount as payment in full.
You may choose to use your own form with similar language. Once signed, this form is to
remain in the patient file and it is not necessary to mail to Santé with the claim. Following is an
example Waiver of Liability form:
51 | P a g e
Medi-Cal Administrative Manual Table of Contents
Santé Community Physicians
WAIVER OF LIABILITY FORM
MEMBER NAME: ________________________________ DOB: _______________ SUBSCRIBER ID: _______________________ GROUP NO: ______________________ PROVIDER: ___________________________________________________________
Provider: This form is to be used for Santé members who wish to receive health care services from you that may not be covered by their Benefit Plan.
Member: Your signature on this form acknowledges that you agree to bear financial
responsibility for all services provided as listed below if:
the service(s) is not covered under your benefit plan, or,
the service(s) has not been otherwise approved for payment by your health plan, or
the service(s) is not medically necessary, or
the service(s) is primarily for comfort and convenience, or,
You choose to upgrade a product or service above the level otherwise covered under your health plan (you will pay the difference between the billed and allowed amount)
Services: (Any service not described as a covered benefit in the member's Evidence of Coverage Disclosure Form)
Date of Service Service, Product, or Upgrade
Total Cost Member’s (patient’s) Responsibility*
*In addition to being responsible for this amount, I understand that I will be billed and held responsible for any applicable copayment or deductible.
______________________________ Patient Name
__________________________________ _____________
Signature of Patient/Guardian Date
__________________________________ _____________ Signature of Witness Date
52 | P a g e
Medi-Cal Administrative Manual Table of Contents
LANGUAGE ASSISTANCE PROGRAM
SB853
Language Assistance Program
The Language Assistance Program is designed to meet the growing needs of our state’s
population as well as the health membership of each of the plans.
The following is an outline of what the Language Assistance Program entails:
Language Assistance Program
Service Offered Guidelines
Interpreter services provided
at all points of contact
Professional interpreters are proficient in health care terminology
Professional interpreters receive training regarding HIPPA (confidentiality) and ethical standards
Points of contact include administrative, clinical, and related services
Written materials that are
provided in the threshold
languages
Materials translated prospectively include enrollment, eligibility and membership information, EOBs, and notices of language assistance.
Members must indicate their preferred written language to receive prospectively translated materials
Written materials are
translated into a threshold
language upon request
Materials that are member-specific (e.g., denial, delay or claims letters) are sent in English with the offer of translation upon request
Translated materials are sent to the member no later than 21 days from the request date
Translators are proficient in health care terminology
Translators received training regarding HIPAA (confidentiality) and ethical standards
53 | P a g e
Medi-Cal Administrative Manual Table of Contents
What is a threshold language?
A threshold language is a language other than English that is spoken by the proportion of the
health plan’s enrollees. The health plans are required to provide interpretation and translation
services for their identified threshold languages at a minimum.
Plan Threshold Languages
Plan Languages
Anthem Blue Cross Chinese (traditional), Korean, Spanish, Tagalog, Vietnamese
Health Net Chinese (traditional), Spanish
Please note: Some plans may provide interpreter services for more languages than their identified threshold languages. Just ask when you call the above numbers. Accessing Interpreter Services by Plan
Plan Type of Interpretation Plan Interpreter Access
Anthem Blue Cross Telephonic ………………. 1-800-407-4627
Health Net Telephonic ………………. 1-888-893-1569
When utilizing the Health Plan Interpretation Services:
1. Give the customer care associate the member’s ID number.
2. Explain the need for an interpreter and state the language.
3. Wait on the line while the connection is made
4. Once connected to the interpreter, the associate or nurse introduces the
member, explains the reason for the call and begins the dialogue.
For Information on Face-to-Face Interpretation services, please inquire with the Health Plans
Interpretation Service Line.
54 | P a g e
Medi-Cal Administrative Manual Table of Contents
CLAIMS Submission Guidelines
Claim Form Use of the HCFA -1500 form (sample follows) is required to process your claim.
Indicate the Medi-Cal plan on the top of the claim form;
Identify the member’s name, address, and identification numbers, and/or include
a copy of the member’s plan identification card;
Include any other insurance information so that we may coordinate benefits;
If appropriate, indicate on the claim document if you were providing services for
another physician on an “on-call” basis, for proper benefit determination.
Identify services rendered using CPT codes;
For injections use J codes, specifying units provided.
Claims Submission Timeline: Claims must be submitted promptly to avoid the possibility of forfeiture of payment for services. Please note that the Santé Managed Medi-Cal contract specifies if a claim is denied due to late provider claims submission, the charges are not the financial responsibility of the patient.
Medi-Cal claims must be received within 180 days of the date of service.
For claims in which SCP Medi-Cal is secondary, claims must be submitted within
180 days from the “processed date” as noted on the explanation of benefits from the
primary carrier.
Submit claims to:
Santé Community Physicians (Managed Medi-Cal Plan name here, example: Anthem Medi-Cal) P.O. Box 45021 Fresno, California 93718
Claims Inquiry The follow-up process should be initiated if claim notification (payment, denial, or explanation) is not received from Santé within 60 days of initial claim submission:
PCP and Specialty offices may call the Customer Service Department for claims inquiries at (559) 228-4466.
Claims inquiry can be made via the Santé web site at www.medi-cal.santehealth.net (office manager or provider access is required.)
File a Provider Inquiry
55 | P a g e
Medi-Cal Administrative Manual Table of Contents
Provider Inquiry Request Form The Provider Inquiry form on the following page may be used to:
Check status of claim(s)
Request clarification on calculation of payment
Submit corrected billing
Resubmit a contested claim, submitting missing information
Submit Provider Inquiry Request form to: Santé Managed Medi-Cal P.O. Box 45021 Fresno, CA 93718 or Fax to: (559) 228- 4465
56 | P a g e
Medi-Cal Administrative Manual Table of Contents
PROVIDER INQUIRY REQUEST
Send to:
Provider Inquiry Santé Community Physicians – Managed Medi-Cal Plans
P.O. Box 45021 Fresno, CA 93718
Sent by: (provider name/facility)
Provider Tax ID #:
Provider Address:
Patient Name:
Date of Birth:
Member ID Number:
Claim Number (if known):
Service “From – To” Date:
Original Claim Amount Billed: Original Submission Date:
INDICATE REASON FOR INQUIRY AND PROVIDE A DETAILED DESCRIPTION:
Inquiry Type: Resubmission of “contested” claim with missing information. (documentation attached) Status of Claim (i.e., no receipt of payment) Clarification on calculation of payment Assistance in determining member responsibility
__________________________ ______________________ ________________
Contact Name (Print) Title Phone Number
__________________________ ______________________ Signature Date
57 | P a g e
Medi-Cal Administrative Manual Table of Contents
Electronic Claims Submission Guidelines
Submission Guidelines Claims must be submitted promptly to avoid the possibility of forfeiture of payment for services. Please note that the Santé Managed Medi-Cal contract specifies if a claim is denied due to late provider claims submission, the charges are not the financial responsibility of the patient.
Claims must be received within 180 days of the date of service. When Santé Medi-Cal is Secondary For claims in which Santé Medi-Cal is secondary, claims must be submitted with 180 days from the “processed date” as noted on the explanation of benefits for the primary carrier. These claims must be submitted hardcopy on a HCFA- 1500 form with the primary carrier’s explanation of benefits.
Santé encourages all paper submitters to submit claims electronically by either using the direct format or through a clearinghouse. You can submit all claims directly to Santé by obtaining an application through our website at www.Medi-Cal.santehealth.net How to sign up for direct electronic submission with Santé:
Go to www.Medi-Cal.SanteHealth.net
Click on the Provider/Administrator link
Click on Sign Up button
Select: Use This Link To Print The Office Manager Access Request Form.
Print the Request Form
Fill-out and fax Request Form to (559) 228-2958 Santé is partnered with clearing houses including Office Ally, Change Health Care and ENS (Electronic Network Systems) to assist you in billing claims using existing billing software. Contact your clearinghouse to discuss further and provide them the payer ID below. Payer ID: SNTMC Claims that require supporting documentation should be sent by mail to the address above. To submit your claims electronically, please contact Santé’s Customer Service at (559) 228-4466
58 | P a g e
Medi-Cal Administrative Manual Table of Contents
Provider Dispute
A provider dispute is a written notice challenging, appealing or requesting reconsideration of a claim
that has been denied, adjusted, contested, or seeking resolution of a billing determination or other
contract dispute.
Each provider dispute must contain at a minimum the following information:
The providers name, address and phone number
Providers identification number
A clear identification of the disputed item including date of service
A complete and accurate explanation of the issue
If the provider dispute is not about a claim, a clear explanation of the issue and the
provider’s position on such issue
Provider disputes for medical inappropriateness will be reviewed by the Medical Director or the Associate
Medical Director.
Time Limitations for Submission of Provider Disputes
The physician has 365 calendar days from the date of denial notification to submit a provider dispute.
Provider Dispute Address
Provider disputes must be submitted with a formal written letter explaining the circumstances as to why
the denial should be reviewed for reconsideration. The use of the following Provider Dispute Resolution
Request form may be used in lieu of a letter.
Submit Provider Disputes to:
Attention: Santé Medi-Cal Customer Service/Appeals
Via Mail: P.O. Box 45021, Fresno, CA 93718
Via Physical Delivery: 7370 N. Palm Ave. #101, Fresno, CA 93711
Or
Via Fax: (559) 224-4465
59 | P a g e
Medi-Cal Administrative Manual Table of Contents
PROVIDER DISPUTE RESOLUTION REQUEST
Send to:
Santé Managed Medi-Cal Customer Service/ Appeals
P.O. Box 45021, Fresno, CA 93718
Or
Fax to: (559) 224-4465
Provider Name: Provider Tax ID #:
Provider Address:
Contracted?
Yes No
Patient Name:
Date of Birth:
Health Plan Name:
Subscriber ID #: Claim Number:
Service “From – To” Date:
Original Billed Amount: Claim Amount Paid:
Claim Information: Single Claim Multiple “LIKE” claims (attach spreadsheet)
Dispute Type: claim Appeal of Medical Necessity Contract Dispute Seeking Resolution of a Billing
Determination Disputing a Request for Reimbursement of Overpayment Other
Description of Provider Dispute:
Expected Outcome:
___________________________ _____________________ ________________ Contact Name (Print) Title Area code & Phone Number
_________________________________________ ________________________________ ________________________ Signature and date Email Address Fax Number
60 | P a g e
Medi-Cal Administrative Manual Table of Contents
Overpayments
Santé’s policy on Claims Overpayments is to “take back” overpayments from future charges. Full
itemization will be reflected on the remittance advice.
According to California Law, Santé has 365 days from date of payment to recover an overpayment. Santé
is not restricted by the 365-day time limit if the overpayment was caused in whole or in part by fraud or
misrepresentation on the part of the provider.
If the provider contests the overpayment “take back”, the provider, within 30 business days of the date of
the remittance advice, must submit a written notice stating the basis upon which the provider believes that
the claim was not overpaid. In this case, Santé treats the claim overpayment dispute as a provider dispute.
Please reference previous page for the Provider Dispute Resolution Request form.
61 | P a g e
Medi-Cal Administrative Manual Table of Contents
Vaccines for Children (VFC) Program
Billing Guidelines updated 9/7/2018
Santé will not reimburse for the cost of the provider-purchased vaccines that are available through
the VFC program and administered to Santé Managed Medi-Cal children through the age of 18 years
old, except when justified (ex: documented vaccine shortage, disease epidemic, etc.) A provider’s
non-enrollment in the VFC program is not a justified exception.
Reminder: The federal VFC program supplies free vaccines to enrolled physicians. Every Medi-
Cal-eligible child 18 years of age and under may receive vaccines supplied by the
VFC program. To participate, providers must enroll in VFC even if already enrolled
with Medi-Cal or the CHDP program. Providers billing VFC procedure codes are
reimbursed for vaccine administration costs only.
Billing Procedure:
In order to avoid claims processing delays or denial of payment, providers must bill
the valid VFC immunization CPT(s) with modifier SL to report the VFC vaccine
administration charge. Please do not bill administration CPTs (ex. 90471, 90472,
90640, etc.) in conjunction with the vaccine and modifier SL. Please note, this billing
procedure ONLY applies to the administration of VFC vaccines (CPTs listed on the
table below)
Vaccines not available through VFC should be billed to Santé without the SL
modifier and with the appropriate administration CPT code.
The following CPT codes are used to bill the administration fee for the vaccines supplied by the
VFC program and require modifier SL (used for program recipients 18 years of age and younger.)
Bill CPT with modifier SL When administering this VFC vaccine
90620 Meningococcal vaccine serogroup B (Bexsero)
90621 Meningococcal vaccine serogroup B (Trumenba)
90630 Influenza virus vaccine, quadrivalent, split virus, preservative free, for intradermal
use
90633 Hepatitis A vaccine/pediatric/adolescent (Vaqta , Havrix )
90644 Meningococcal conjugate vaccine, serogroups C & Y and Haemophilus influenza
type B vaccine (Hib-MenCY), 4 dose schedule, when administered to children 6
weeks − 18 months of age, for intramuscular use
90647 Haemophilus influenzae b (Hib) vaccine (PedvaxHIB )
90648 Haemophilus influenza b (Hib) vaccine (ActHIB )
90649 Human papillomavirus (HPV) vaccine (Gardasil )
90650 Human papillomavirus (HPV) vaccine, types 16, 18, bivalent, for intramuscular
use
90651 Human papillomavirus (HPV) vaccine, types 6, 11, 16, 18, 31, 33, 45, 52, 58,
monovalent, for intramuscular use
90655, 90656 Influenza vaccine (preservative-free Fluzone )
90657 Influenza vaccine (Fluzone )
90658 Influenza vaccine (Fluvirin )
90660 Influenza virus vaccine, live, for intranasal use (FluMist )
62 | P a g e
Medi-Cal Administrative Manual Table of Contents
90670 Pneumococcal conjugate vaccine, 13 valent, for intramuscular use
90674 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit,
preservative and antibiotic free, 0.5 mL dosage, for intramuscular use
90680 Rotavirus vaccine, oral (RotaTeq) (3 dose schedule)
90681 Rotavirus vaccine, oral (2 dose schedule)
90682 Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA,
hemagglutinin (HA) protein only, preservative and antibiotic free, for
intramuscular use
90685 Influenza virus vaccine, quadrivalent, split virus, preservative free, 0.25 ml dosage
90686 Influenza virus vaccine, quadrivalent, split virus, preservative free, 0.5 ml dosage
90688 Influenza virus vaccine, quadrivalent, split virus 0.5 ml dosage
90696 Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine,
inactivated (DTap-IPV)
90698 Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza
Type B, and poliovirus vaccine, inactivated (DTaP-Hib-IPV) for intramuscular use
(Pentacel)
90700 DTaP Vaccine (Tripedia, Daptacel, Infarix)
90707 MMR Vaccine (MMR II)
90710 MMRV Vaccine (ProQuad)
90713 Inactivated Polio Vaccine (IPOL)
90714 Diphtheria and Tetanus Toxoids adsorbed, preservative free (7 years of age and
older) (Decavac)
90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), (7 years of age
and older) (Boostrix, Adacel)
90716 Varicella Vaccine (Varivax)
90723 DTaP-HepB-IPV Vaccine (Pediarix)
90734 Meningitis Vaccine (Menactra® or Menveo®)
90743 Hepatitis B Vaccine (Recombivax HB)
90744 Hepatitis B Vaccine (Engerix B)
90748 Hepatitis B and H. Influenza b (Hep B-Hib) (Comvax)
90756 Influenza virus vaccine, quadrivalent, subunit, antibiotic free, 0.5 ml dosage
Example of Correct Billing Procedure Qty Billed Amount
90633SL 1 $9.00 <=Santé will reimburse the admin fee
when the vaccine code is billed with -SL
Example of Incorrect Billing Procedure Qty. Billed Amount
90633SL 1 $9.00
90471 1 $9.00
63 | P a g e
Medi-Cal Administrative Manual Table of Contents
Processing Guidelines
Claims that are the risk of Santé Community Physicians are processed utilizing the National Correct
Coding Initiative (NCCI) guidelines. Additionally, claims payment determination is in accordance
with Medi-Cal guidelines unless specified otherwise in the provider contract agreement.
Assistant Surgeon Reimbursement
Surgeons are required to utilize Santé contracted providers as surgical assistants. With the exception
of emergency surgeries, prior authorization is required if a non-contracted provider must be utilized
as a surgical assistant. In addition to prior authorization, the surgeon will explain the Santé Assistant
Surgeon Reimbursement policy to the prospective assistant and affirm the assistant’s adherence to
that policy. Non-contracted assistant surgeons will not be permitted to balance bill Santé patients;
such unpaid balances will be considered a matter between the surgeon and the surgical assistant. If
the Non-contracted assistant surgeon balance bills a Santé Medi-Cal patient, Santé will be obligated
to pay the balance of the charges. In this case, reimbursement will be debited from the surgeon’s
future reimbursements, not to exceed $1000.
Contracted Physician Surgical Assistants shall be reimbursed at a rate of 16% of the allowable
surgical units based upon contract type. The patient may not be balanced billed for the difference
between billed amount and paid amount.
Contracted non-physician Surgical Assistants, who are not reimbursed by the surgeon as employees,
shall be reimbursed at a rate of 8% of the allowable surgical RBRVS units or units based upon
contract type. The patient may not be balance billed for the difference between billed amount and
paid amount.
Prior authorization is not required for non-physician Surgical Assistants who are reimbursed by the
surgeon as employees. However, the surgeon will not bill Santé for the reimbursement of these
assistant surgeon fees.
64 | P a g e
Medi-Cal Administrative Manual Table of Contents
Assistant Surgeon Reimbursement
Assistant surgeon fees ARE ALLOWABLE on the following procedures and do NOT REQUIRE prior
authorization when utilizing a Santé contracted assistant surgeon:
12018 20955 - 20973 21552-21554 23420-23472 24301
12047 20975 21557 - 21750 23485 - 23491 24320 - 24331
12057 21011-21014 21810 23515 24340 - 24346
14301 21016 21825 23530 - 23532 24360 - 24470
14302* 21034 21931-21933 23550 - 23552 24498
15734 21044 - 21045 21936 23585 24515 - 24516
15738 21047 22100 - 22226 23615 - 23616 24545 - 24546
15750 - 15758 21049 22318 - 22328 23630 24575
15770 21060 22526* - 22905 23660 24579
15830 - 15832 21121 - 21180 21552-21554 23670 24586 - 24587
15841 - 15850 21182 - 21206 21557 - 21750 23680 24615
15922 21209 23000 - 23020 23800 - 23920 24635
15935 21240 - 21247 23035 - 23040 23929 24665 - 24666
15952 21255 - 21275 23071-23073 24006 24685 - 24802*
19260 - 19272 21339 23077 - 23100 24071-24073 24900 - 24931
19302 - 19318 21343 - 21344 23105 24079-24102 24940
19357 - 19369 21347 - 21348 23107 - 23125 24115 - 24116 25071 - 25073
20100 21360 -21395 23145 24125 - 24126 25078 - 25085
20150 21401 - 21408 23150 - 23156 24134 25107
20251* 21422 - 21436 23172 - 23174 24138 - 24140 25119
12018 20955 - 20973 23182 -23220 23420-23472 25126
20692 21445 23332 23485 - 23491 25135 -25145
20696 - 20902 21462 - 21470 23000 - 23020 23515 25151 -25170
20922 -20924 21490 - 21495 23035 - 23040 23530 - 23532 25215
20937 - 20938 21502 23395 - 23412
24149 - 24155
25250 - 25251
25263 - 25265 26372 - 26392 27065 - 27080 27438 - 27472 27687 - 27692
25300 - 25335 26420 27087 - 27091 27479 27698 - 27703
25350 - 25426 26434 27097 - 27100 27486 - 27495 27705
25431 - 25444* 26474 27105 - 27170* 27498 - 27499 27709 - 27725
25446 - 25449 26479 27176 - 27181 27506 - 27507 27727
65 | P a g e
Medi-Cal Administrative Manual Table of Contents
25490 - 25492 26483 - 26485 27187 27511 - 27514 27740 - 27745
25515 26492 - 26494 27202-27218* 27519 27756 - 27759
25525 - 25526 26497 - 26499* 27226 - 27228 27524 27814
25545 26502* 27236 27535 27822 - 27823
25574 - 25575 26517 - 26518 27244 27536 27826 - 27829
25607 - 25609 26530 - 26531 27245 27540 27832
25628 26541 27248 27556 - 27558 27846 - 27848
25645 26546 27253 - 27254 27566 27870 - 27881
25670 26550 - 26565 27258 - 27259 27580 - 27592 27888*
25676 26568 - 26590 27267 - 27269 27598 - 27599 27894
25685 26596 27280 - 27299 27602 28039
25695 - 25830* 26686 27303 - 27306 27612 28047*
25905-25915* 26820 27310 27620 - 27626 28086
25922 - 25924 26842 - 26844 27325 27632- 27634 28100 - 28107
25929 26852 27326 27637 - 27638 28114
26111 - 26113 26862-26862* 27329 27645 - 27647 28118
26118 27001 - 27006 27331 - 27339 27650 28122
26125* 27030 - 27036 27345 - 27365 27654 - 27659 28130
26185 27045 27380 - 27390* 27665 - 27676 28171
26260-26262 27048 - 27049 27392 - 27415 27685 28202
26352 27052 - 27054 27418 - 27424 27438 - 27472 27814
26357 - 26358 27059 27427 - 27435 27479 27822 - 27823
28210* 30160 33300 - 33417 37660 42961
28238 30410 33422 - 33502 37761 42971 - 42972
28250 - 28260 30430 - 30462* 33504 - 33530* 37788 43020 - 43135
28262 - 28264 30540 - 30545 33533 - 33960 38100 - 38129 43279 - 43415
28289 31075 - 31087 33970 38204 43425
28292 - 28306 31205 - 31230 33973 38207-38215* 43496
28308 31295 - 31296 33975 - 34451 38308 - 38382 43500 - 43659
28320 - 28322 31300 34501 - 35206 38530 - 38542 43753-43757*
28360 31360 - 31420 35211 - 35390 38555 - 38780 43770 - 43775*
28415-28420* 31580 35450 - 35458 38900 43800 - 43888
28445 - 28446 31584 - 31595 35500 - 35539 39000 - 39220 44005 - 44055*
28555 31601 35556 - 35681* 39499 - 39599 44110-44310*
28585 31611 35685 - 35870 40701 - 40702 44314 - 44322
66 | P a g e
Medi-Cal Administrative Manual Table of Contents
28615 31634 35876 - 36000* 40799 44345 - 44346
28705 - 28740 31750 - 31786* 36147-36148* 40840 44602 - 44721
28760 - 28800 31805 36261 40843-40844* 44800 - 44900
29804 32035 - 32200 36460 42120 44950 - 44979
29820 - 29828 32215 - 32320 36818 - 36821 42200 - 42260 45110 - 45136
29834 - 29837 32440 - 32540 36825 - 36833 42299 45160 - 45172
29843 - 29845 32553 36838 42409 - 42440 45395 - 45499
29847 32561 - 32562 37145 - 37181 42507-42508* 45540 - 45825
29851 - 29863 32650 - 32940* 37207 42510 46705
29884 - 29885 32998 37216* 42699 46710 - 46751
29887 - 29892 33020 - 33141 37600 - 37606 42725 46760 - 46762
29894-28499* 33243 37615 - 37619* 42810-42815* 47010
29904 - 29916 33250 - 33261* 33300 - 33417 42844 - 42845 42961
30125* 32265 - 33266 33422 - 33502 42890 - 42894 42971 - 42972
47015 - 47381 51040 55535* 59350 62192
47400 - 47480 51050 - 51060 55550 - 55559 59514 62200
47550 51080 55650* 59525 62220 - 62223
47562 - 47620 51500 - 51597 55706 - 55845 59620 62230
47700 51800 - 51992 55862 - 55866 59866 - 59870 62256 - 62258
47711 - 47900 53085 56620 - 56700 59898 - 59899 62351
48000 - 48100 53210 56800 - 56810 60200 - 60281* 63001 - 63308
48105 - 48155 53215 57106 - 57130 60500-60699* 63620-63621*
48500 - 48510 53230 - 53235 57200 - 57335 61140 63655 - 63685
48520 - 49020 53400 - 53415 57423 - 57426 61154 63700 - 63744
49040* 53425 - 53449* 57530 - 57556 61156* 64490 - 64495
49062 53500* 57720 61250 - 61315* 64580
49203 - 49220 53505 - 53515 58140 - 58294 61320 - 61322 64704 - 64716
49255 - 49329 54110 - 54135* 58300* 61330 - 61516 64722
49425 54205 58345 61518 - 61524 64732
49435 - 49436 54300 - 54390 58356 - 58554 61531 - 61576 64736 - 64742
49491 - 49900 54405 - 54430 58560 61582 - 61592 64746 - 64772
49905 54440 58570 - 58662 61596 - 61619 64786
50010 54522 - 54560 58672 - 58770 61630 - 61708 64792*
50045 - 50075 54650 58805 - 58822 61711 64802 - 64818
50081 - 50135 54680 - 54690 58825 - 58960* 61796-61800* 64835 - 64840
67 | P a g e
Medi-Cal Administrative Manual Table of Contents
50205 - 50380 54699 58974-58976* 61850 - 61880 64857 - 64911
50400 - 50549 55150 59070* 62005 - 62147 65105 - 65114*
50562 55400* 59074 - 59121 62161 - 62164 65260 - 65265*
50593 - 50660 55520 59136 - 59151 62180* 65710 - 65756
50700 - 50949 51040 55535* 59350 62192
51020 51050 - 51060 55550 - 55559 59514 62200
65770 67121* 67973 -67974 69670
65781 67255 68720 - 68750 69711*
65900 67340* 69155 69725 - 69745
66165 - 66220 67399 69320 69805
67027 67413 - 67414 69530 69820 - 69840
67036 - 67043 67420 - 67450* 69550 - 69554 69915
67107 - 67108 67570 - 67599 69605 69950 - 69979
67112 - 67113 67121* 67973 -67974 69670
Assistant surgeon fees ARE ALLOWABLE on the following procedures and do NOT REQUIRE
prior authorization when utilizing a Santé contracted assistant surgeon:
Prior authorization is REQUIRED to utilize an assistant surgeon for procedures NOT on the above
list. Determination for authorization will be based on the surgeon’s documented complexity of the
individual case.
68 | P a g e
Medi-Cal Administrative Manual Table of Contents
Third Party Liability
Contracted physicians may not refuse to see an assigned Medi-Cal patient who may have been in a
motor vehicle accident (MVA), or other Third Party Liability (TPL) injury (excluding workers’
compensation). Additionally:
o The physician should always follow Santé policies and procedures (authorizations, referrals,
plan providers) to ensure coverage if the TPL denies coverage.
o At no time should a Medi-Cal patient be billed full charges, and only when appropriate
should a patient be billed copay.
This policy is in line with contractual, legal and regulatory requirements.
Physicians who are paid fee for service for some or all services rendered to a Santé
Medi-Cal patient have the following options:
■ Physician may bill TPL only
Physician may get more reimbursement from the TPL carrier than from Santé
If TPL denies coverage, Santé must be billed, not the patient. Include the TPL denial letter
to avoid untimely filing denial by Santé.
■ Physician may bill Santé only, supplying Santé with TPL information and indicating TPL NOT
BILLED on claim form
Physician will be reimbursed by Santé. No additional money will be paid to physician if
Santé collects from TPL carrier.
69 | P a g e
Medi-Cal Administrative Manual Table of Contents
California Children Services (CCS) California Children Services (CCS) is a statewide program that treats children with certain physical limitations and chronic health conditions or diseases. CCS can authorize payment for specific medical services and equipment provided by CCS-approved specialists. The California Department of Health Care Services (DHCS) manages the CCS program which is administered as a partnership with the county health department. CCS-eligible patients should be referred to CCS for case management and authorization of treatments. The program is open to anyone who:
is under 21 years old;
has or may have a medical condition that is covered by CCS;
is a resident of California; and
has a family income of $40,000 or less as reported as the adjusted gross income on the state tax form; or
the out-of-pocket medical expenses for a child who qualifies are expected to be more than 20% of family income.
CCS covered conditions In general CCS covers medical conditions that are physically disabling, or require medical, surgical, or rehabilitative services. There may also be certain criteria that determine eligibility. For a complete list of medical conditions visit www.dhcs.ca.gov/services/ccs CCS claims processing CCS case related claims must be billed directly to California Children Services for processing. Claims not related to a CCS case may be billed to Santé Managed Medi-Cal within 180 days from the date of the denial notice from CCS. Please ensure the denial notice is submitted with the claim.
70 | P a g e
Medi-Cal Administrative Manual Table of Contents
WEBSITE Access and Information Internet access enables physician practices to streamline operational processes.
As an Office Manager or staff member of a Santé Community Physician, access to the following time saving features is available: √ Authorization Status √ Quality Improvement Manual On-Line √ Claims Inquiry √ Downloadable Forms and Tools √ Specialty Roster for Referrals √ Education Calendar for Office Managers/Staff √ Administrative Manual On-Line √ Pay for Performance Tool Kit √ The Latest HIPAA Information As a Santé Community Physician, access to all of the above features plus the following tools and information is available: √ Disease Registry Reports for Primary Care Physicians √ Cost and Utilization Reports √ SCP Education Events √ SCP Annual Report & Financials To Receive a Password
Step 1: Go to www.medi-cal.santehealth.net Step 2: Click on the “Sign-up” link Step 3: Choose Provider Access or Office Manager/Staff Access Step 4: Print Form, Fill Out, and Fax to (559) 224-2958 Note: Regarding Office Manager/Staff Access - If the request is for a group practice,
provide the group name and list the name and license number of each physician in the group. This will enable Santé to provide access to all files related to the group practice. The lead physician in the group practice must authorize the request.
71 | P a g e
Medi-Cal Administrative Manual Table of Contents
Managed Care Coordinators
Case Management
Referrals – Policy Guidelines
Retro Referrals
Global Care Referrals
Routine Eye Examination Policy
Unauthorized Referrals to Non-Plan Providers
Self-referrals – OB/GYN
Behavioral Health Referrals
Prior Authorization
Guidelines
Emergency Room Authorization
Hospital Observation Status
Prior Authorization Form (Master)
Appeals – Clinical
72 | P a g e
Medi-Cal Administrative Manual Table of Contents
MANAGED CARE COORDINATORS
The Utilization Management (UM) Department has Managed Care Coordinators whose role is to provide
utilization information (referrals, prior authorization, benefit determination, etc.), and to serve as principal
staff support for medical offices. Telephone calls should be directed to a Managed Care Coordinator as
shown below.
The UM department representatives work with physician office staff only. If a patient has a question regarding prior authorization or referrals, please give them the phone number of the Santé Managed Medi-Cal Customer Service Department (559) 228-4466. These two departments work closely on patient issues.
UM Department Main Line (559) 228-4488
MANAGED CARE
COORDINATOR
TELEPHONE
NO.
Aziz Tohme 559-228-4289
RoseAnn Florez 559-228-4380
73 | P a g e
Medi-Cal Administrative Manual Table of Contents
CASE MANAGEMENT
Contact persons: Telephone: Fax:
Chameka Howell, R.N., Certified Case Manager 559-228-5313 559-224-2405
Case Management The purpose of the Case Management program is to ensure that medically necessary care is delivered in a
high-quality, cost-effective setting for members who require extensive or ongoing services. Case
Managers coordinate individual services for members whose needs include ongoing medical care, home
health, hospice care, rehabilitation services and preventative services. To meet identified member’s
needs, case managers work with all members of the healthcare team including physician, patient, and
family members.
Community Case Management Community Case Management is a community-based model that assists identified members with
healthcare needs. Members of all ages are followed by a specific case manager who plans and
coordinates the member's care throughout the healthcare continuum. The Community Case Manager,
using a “team approach,” acts as a consultant and advocate for members served. The goal is to maintain
the member on their wellness path. Members who may benefit include members with:
Chronic condition/illness
Chronic/ reoccurring medical problems
Multiple hospital admissions/ER visits
Functional or emotional impairment
Frail elderly
Poor support system at home
Potential for complications due to multiple health/social problems.
High risk pregnancy
Referral to Case Managers
Physicians or physician offices are encouraged to refer patients who fit the description of members
requiring case managers. Contact persons are listed above.
74 | P a g e
Medi-Cal Administrative Manual Table of Contents
REFERRALS – POLICY GUIDELINES Primary Care Physicians (PCPs) act as managers of their patients' health and are responsible for ensuring that their patients in need of medical care beyond their scope of practice are referred to appropriate Specialist Physicians, designated services or providers. Referral forms are to be used by PCPs when directing patients to these providers. (Note: radiology services do not require a Referral Form. See prior authorization guidelines for some procedures.)
Note: This policy will not apply in situations where patients are seen on an emergent basis or when utilizing one of the self-referring options.
Referral Process 1. A referral form template is provided to each PCP office to refer Santé Medi-Cal members to a specialist.
The PCP may use the template provided by Santé or use his/her own referral form. If the PCP opts to use
his/her own referral form, the referral form must contain, at a minimum, all information contained in the
Santé referral form template. Additionally, specialist offices may not impose a practice specific referral
form to replace the approved referral form template.
NOTE: Effective January 1, 2008, within 5 days before the actual date of service, providers must
confirm that the member’s health plan coverage is still in effect. 2. Complete a referral form in its entirety when referring to an in-plan physician specialist, designated service or
provider. (Do not complete a referral form for routine services, such as x-rays or lab work.) Specialist Providers must contact the PCP to send the referral for Specialty services/providers
3. Referrals must include dates, diagnoses and diagnosis codes. Specify “Consult Only” if you wish the
specialist to consult with you before treating the patient. Otherwise, mark the number of visits you wish to
authorize during the 180-day referral period *.
4. Fax or mail a copy of the referral form to the Specialist Provider, as well as a copy to Santé within two
working days. Santé’s mailing address is P.O. Box 45021, Fresno, California, 93718. The Fax number is
(559) 228-4465.
NOTES:
Please contact Utilization Management for authorization of any non-plan provider. This ensures benefit compliance, use of
contracted facilities, and negotiation of rates. DO NOT FILL OUT A REFERRAL FORM to a non-plan provider. This will
obligate Santé to pay in full, and the referring physician will be monetarily penalized. (See Authorizations)
75 | P a g e
Medi-Cal Administrative Manual Table of Contents
Retro Referrals Retro Referrals are referrals written after the date of service. The Utilization Management Committee has
directed that Retro Referrals will be deemed invalid and claims for these services will be denied. (It
should be noted that all denials may be appealed.)
Specialty Physicians should require that each patient they see have a valid referral from the patient’s
Primary Care Physician at the time they are seen. If the patient is seen on an urgent basis or presents
himself/herself without a valid referral, Specialty Physicians should immediately contact the Primary
Care Physician to receive a valid referral.
A fax copy of a valid referral is acceptable proof that a referral was issued. When the specialist’s office
contacts the Primary Care Physician’s office, the specialist’s office should obtain the name of the person
with whom they spoke and the control number of the referral, which the Primary Care Physician’s office
has committed to send. In a situation where a fax copy is unavailable, the control number of the referral
may be submitted with the billing for the service rendered.
The above policy will not apply in situations where patients are seen on an emergent basis, or when
utilizing one of the self-referring policies in a plan provider's office.
76 | P a g e
Medi-Cal Administrative Manual Table of Contents
Global Care Referrals
A Primary Care Physician may refer to a specialist for "global" care, effective for six months care (or as
specified below) without limitations on number of visits allowed, for ONLY the following types of care:
NOTE: See self-referral section for patient options.
1. "Global Oncology," to a hematologist/oncologist or a radiologist/oncologist ONLY for ongoing
chemotherapy or radiation therapy for malignancy.
2. "Global Allergy Treatment," to an allergist ONLY for allergy immunotherapy or desensitization by
injection.
3. Dialysis.
4. “Obesity Management Program,” to a weight management specialist ONLY (see page 703.1). Please
include ICD9 code 278.01 on all referrals to this program.
5. “HIV/AIDS”, to a HIV/AIDS specialist.
In this case, the PCP should leave the number of visits on the referral blank and specify the type of care
and the diagnosis. However, the specialist must communicate with the Primary Care Physician, and the
PCP must concur with the treatment plan.
If the Primary Care Physician wishes the number of visits to be limited, he/she must indicate the number
of visits desired.
77 | P a g e
Medi-Cal Administrative Manual Table of Contents
Routine Eye Examination Policy
When they are a benefit of the members' health plan, routine eye examinations will only be available from
SCP Ophthalmologists. If a non-contracted ophthalmologist provides routine eye examinations without
prior authorization from Santé, no payments will be made.
Note: See self-referral section for patient options.
Process for Routine Eye Examinations:
Health plans are responsible for making members aware of eye care coverage, including benefits (such as
examinations) that are not covered.
If a member does have the routine eye examination benefit, the member - not the PCP - is responsible for
calling and scheduling the examination with a SCP Ophthalmologist; no PCP referral is required.
If pathology is discovered during a routine eye examination, the SCP Ophthalmologist will notify the
member's PCP in writing. This notification will include a description of the pathology discovered and
request a referral for on-going therapy. The SCP Ophthalmologist will also keep the member's Primary
Care Physician informed of the member's response to treatment and will inform the PCP when the course
of therapy is completed.
If the SCP Ophthalmologist determines the member to be ineligible for routine eye exam, the member must be informed. If the member agrees in writing prior to routine eye examination being performed, the SCP Ophthalmologist may bill the member for the service provided.
If a secondary referral to a non-SCP provider is required, the SCP Ophthalmologist will inform the
member's PCP of the necessity and ask the member's PCP to obtain authorization for the services.
Unauthorized Referrals to Non-Plan Providers Non-authorized elective services rendered by a non-plan provider, as a result of a Santé contracted
physician referral, shall be approved for payment according to the following protocol:
Services will be paid to the non-plan provider at 100% of Medi-Cal Rates.
The referring Santé physician’s future reimbursements will be debited the amount equal to the
difference between payment made to the non-plan provider and the Santé contract reimbursement
rate, not to exceed $1000 for each unauthorized referral.
Note: Self-referral option is the only exception.
78 | P a g e
Medi-Cal Administrative Manual Table of Contents
Self-referrals – OB/GYN A Medi-Cal female member has the option of seeking obstetrical and gynecological physician services directly from a Santé OB/GYN or from a participating family practice physician, surgeon, or internist designated as providing OB/GYN services. Additionally, self-referral patient information must be communicated back to the patient’s PCP of record. This includes:
OB/GYN preventive care
Pregnancy
Gynecological complaint
OB/GYNs and other specialists treating a Santé Medi-Cal patient under this policy must remember to
mark SELF-REFERRAL in box 19 of your HCFA form in lieu of submitting a Santé referral number and
form.
Behavioral Health Referrals
A referral from the Primary Care Physician is not necessary for members to access services. The
provider office can direct the member to contact the behavioral health administrators at the following
numbers:
(Please keep in mind that the PCP may also contact the administrator)
The County Department of Mental Health
(559) 600-9180
Health Net (Managed Health Network - MHN)
1-888-426-0030
Anthem Blue Cross Medi-Cal (Carve Out)
1-888-831-2246
79 | P a g e
Medi-Cal Administrative Manual Table of Contents
PRIOR AUTHORIZATION GUIDLINES Selected services require prior authorization in order to:
ensure benefit compliance, use of contracted providers and review of medical necessity;
provide timely involvement of Medi-Cal corporate resources;
allow contracting of rates when using non-plan providers. Please request services as soon as ordered by the physician in order to allow adequate time for the authorization process. All routine authorizations should be submitted by fax. See sample and master fax form. Do not schedule appointments prior to authorization approval. Elective services must be requested a minimum of 48 hours or two full working days prior to scheduled service. If the requesting physician determines that the patient’s medical condition requires emergent medical service, the provider must ensure the patient receives timely service and then proceed with the authorization process. However, should review of the information determine that the service was not medically indicated and authorization would not have been given, the service will be denied and the contracted provider(s) must write off all services. Please note that, from time to time, the Santé Utilization Management Committee will require prior authorization for services other than those listed on the Prior Authorization Form. Pre-authorization requirements may vary by provider or specialty. The Santé Utilization Management Committee will notify you of these requirements.
Prior Authorization Not Obtained Claims for non-emergent services that require prior authorization which are rendered by contracted providers without prior authorization will be denied. Such services will not be the liability of the member. These determinations are subject to appeal.
Prior Authorization Fax Number
559-228-4521
80 | P a g e
Medi-Cal Administrative Manual Table of Contents
Services Requiring Prior Authorization
* Aqua Therapy
* Breastfeeding Medicine Referral
* Balance & Dizziness Referral
* Colonoscopy; EGD
* Cosmetic/Reconstructive Surgery
* Durable Medical Equipment purchases over $200 (Per line item)
* Durable Medical Equipment (All rentals, regardless of cost)
* Endocrinologist Visit (Type ll Diabetes)
* Genetic Testing
* Home Health / Home IV
* Intensity Modulator Radiation Therapy (IMRT)
* Infusions – Ambulatory
* Injections: Self–Injectables; in-office Injectables listed on back of authorization form
* M2A Video Capsule Endoscopy
* MRI, MRA, CT and Pet scans
* Nutrition Consult for Chronic Disease (CMC)
* Obesity – Referral to General Surgeon
* Obesity Surgery
* Out of Plan Provider
* Plastic Surgery Referral
* Sleep Studies
* Transplants (In conjunction with Health Plan programs)
* Weight Management Program Referral
* Wound Care – Facility Based
NOTE: Emergency services never require prior authorization and will be reviewed retrospectively.
81 | P a g e
Medi-Cal Administrative Manual Table of Contents
82 | P a g e
Medi-Cal Administrative Manual Table of Contents
83 | P a g e
Medi-Cal Administrative Manual Table of Contents
Emergency Room Authorization When possible, Medi-Cal members should call their Primary Care Physician for urgent care needs or
before seeking emergency services. The Primary Care Physician may refer the member to his/her
office, another PCP, an in-plan specialist, or to a Santé contracted emergency room facility, as the
situation requires.
Medically necessary emergency services cannot be denied for lack of authorization. Services are to
be considered an emergency if; “…in the judgment of any prudent layperson the absence of
immediate medical attention could reasonably be expected to result in one of the following, placing
the patient’s health in serious jeopardy; serious impairment to bodily functions; serious dysfunction
of any body, organ or part.”
GENERAL CRITERIA
Time of Day
(in conjunction with
condition severity)
Before 0800, or after 1700 weekdays
Services during standard working hours, if PCP referral
Week-end or holidays
Condition Acute (<6 hours), Sudden (<24 hours), severe onset
Condition or symptoms are life-threatening or have
significant potential for chronic disability; i.e., a reasonable
person would believe it was life-threatening or disabling
Symptoms developed during non-office hours, despite
duration (e.g., over weekend/holiday time), and patient has
not been seen within the past 12 months for this same
diagnosis or condition
L&D Checks Approved
84 | P a g e
Medi-Cal Administrative Manual Table of Contents
Emergency Room Authorization
Examples of non-emergent conditions more appropriately treated in office or Urgent Care (unless
associated with unstable vital signs or physical findings as above):
Allergic reactions without dyspnea
Animal bites that do not require suturing
Asthma responding to single inhalation or parenteral treatment
Back pain without recent acute trauma or associated recent neurological complaints or
findings
Bronchitis
Checks and rechecks of burns, casts, test results or wounds
Colds or cold sores
Conjunctivitis without presence of contact lens, foreign body or trauma
Cough
Dermatitis, itching, rash
Diarrhea without bleeding or dehydration in older children and adults
Dressing change
Extremity injury without deformity or injury (might be appropriate for urgent care if level of
pain requires rule-out fracture)
Flu symptoms
Foley catheter replacement
Genital discharge or pain without abdominal pain
Headache unless sudden onset, unprecedented severity or associated with fever or recent
trauma
Human bites without tissue disruption
Ingrown toenails
Insect bites with only local symptoms
Lacerations that do not involve nerves or tendons, do not require suturing or are more than 24
hours old
Localized infections
Medications administration or refills
Musculoskeletal pain not associated with recent trauma
Needle sticks or puncture wounds
Otitis media unless associated with a temp>103 or ear drainage
Routine administration of parenteral medications
Paronychia
Sinusitis
Sore throat
Sty
Suture removal
Toothache without facial swelling or lymphadenopathy
Urinary burning, frequency or infection
85 | P a g e
Medi-Cal Administrative Manual Table of Contents
Hospital Observation Status
Patients who have been evaluated either in a physician’s office or in an emergency room and found to be too ill to be sent home should be admitted to the hospital and not listed on observation status. Santé Community Physicians has established the following policy:
Patients admitted directly to the hospital will always be listed under ADMIT status. Patients considered to be unstable for discharge but observed outside the emergency room will be admitted as inpatients and NOT listed on observation status.
86 | P a g e
Medi-Cal Administrative Manual Table of Contents
Criteria used to authorize, modify or deny
When a prior authorization request is authorized, modified, or denied a copy of guideline, protocol or
other similar criteria, on which the decision was based, can be requested, by calling Santé Managed
Medi-Cal at (559) 228-4466 or at the following Health Plans websites:
Anthem Blue Cross
https://www.anthem.com/wps/portal/ca/culdesac?content_path=provider/f1/s0/t0/pw_a111722.htm&root
Level=0&name=onlinepolicies&label=Overview
Health Net
https://www.healthnet.com/portal/provider/content/iwc/provider/unprotected/working_with_HN/cont
ent/medical_policies.action
87 | P a g e
Medi-Cal Administrative Manual Table of Contents
APPEALS - CLINICAL
When a prior authorization request is denied, the physicians or members have the opportunity to
appeal the decision. This form of denial is known as prospective denial, one that is given prior to
service rendered.
UM appeals must address the reason given for denial for services requested.
Common UM Denials
1. Cosmetic
2. Not a plan benefit
3. Inadequate medical justification
4. Services can be provided by an in-plan provider
5. Alternate service recommended
6. Does not comply with UM guidelines
Submission of Appeals
For all plans, providers or members are to contact the Medi-Cal corporate office directly to submit an appeal. Use the mailing address or telephone number listed in the body of the Santé denial letter. Be sure to include additional information for authorization reconsideration.
To request an appeal by telephone or in writing contact the Health Plan at the following locations:
Anthem Blue Cross Health Net
Phone Contact Anthem Blue Cross between 7 a.m. and 7 p.m. Pacific time Monday through Friday by calling 1-800-407-4627. Or, if you cannot hear or speak well, please call 1-888-757-6034
Contact CalViva Health 24 hours a day, 7 days a week by calling 1-888-893-1569. Or, if you cannot hear or speak well, please call TTY: 711.
Mail Anthem Blue Cross Attn: Grievance Coordinator P.O. Box 60007 Los Angeles, CA 90060-0007
In writing: Fill out an appeal form or write a letter and send it to:
Medi-Cal Appeals Unit P.O. Box 419086 Rancho Cordova, CA 95741-9086
Electronic Visit your health plan’s website. Go to provider.healthnet.com
Recommended