Provider Manual
Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) is pleased to have you as part of our provider network. We recognize that the strength of our health care programs depends upon strong collaboration and communication with our providers, practitioners and their staff. The Provider Manual is intended to be a useful guide for participating providers/practitioners with Health Plan.
For the purposes of the Provider Manual, “provider” refers to health care practitioners and providers including any physician, nurse, other health care practitioner, hospital, ancillary provider, or other person or institution that furnishes Covered Services.
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Section 1: Introduction
- About Health Plan of San Joaquin and Mountain Valley Health Plan
- Mission, Vision and Values
- Governance and Committees
- Intent of Provider Manual
- How to Use Provider Manual
Section 2: Benefit Program
- Health Plan Medi-Cal Managed Care (HMO)
- Obtaining Coverage and Exclusions Information
- Services Covered by Health Plan
- Services Not Covered by Health Plan
- Enhanced Care Management (ECM)
- Community Supports
- Major Organ Transplants
- Medi-Cal Rx: Transition
Section 3: Provider Credentialing
- Credentialing
- Obtaining a Credentialing Application
- Requirements for Network Participation
- The Credentialing Process
- Initial Credentialing
- Recredentialing
- Provider’s Rights during the Credentialing Process
- Credentialing a New Group Provider
- Delegated Credentialing
- Facility Site Review
- Facility/Ancillary Credentialing
Section 4: Provider Contracting
- Becoming a Participating Provider
- Adding a New Provider to an Existing Agreement
- Terminating Providers
- Continuing Care Obligations of Terminating Providers
- Facility/Ancillary Contracting
Section 5: Provider Services
- Provider Rights and Responsibilities
- Provider Directory Maintenance Responsibility
- Provider Communication
- Provider Education and Training
- Doctor’s Referral Express (DRE)
Section 6: Eligibility, Enrollment, and Disenrollment
- Medi-Cal Eligibility
- Member Identification Cards
- Verification of Eligibility
- Primary Care Physician (PCP) Assignment
- Group/Clinic Assignment
- Primary Care Physician (PCP) Auto-Assignment
- Member Disenrollment
Section 7: Provider–Member Relationship
- Member Rights and Responsibilities
- Advance Directives
- Role of Primary Care Providers (PCPs)
- Role of Non-Physician Medical Practitioners (NPMPs)
- Role of Specialists
- Supporting Members in Self Care
- Social Services Support for Members
- Participation in Community Initiatives
- Provider Panel Capacity
- Open and Closed Panel Status
- Timely Access to Care
- Provider Request for Reassignment or Dismissal
- Interpreter Services
- HealthReach 24-Hour Nurse/Physician Advice
- Transportation Services
Section 8: Utilization Management
- Utilization Management Program Overview
- Counseling Members on Treatment Options
- Availability of Medical Review Criteria
- Inpatient Care
- Hospital Care
- Utilization Management Staff Availability
- Referrals to In-Network/Out-of-Network Providers
- Continuity of Care
- Obtaining a Second Opinion
- Covered Services that Don’t Need Prior Authorization/Referral
- Standing/Extended Referrals
- Affirmative Statement on Incentives
- Submitting Requests for Authorizations
- Advantages of Submitting Authorizations Online vs. Fax
- Turnaround Time for Prior Authorizations
- Emergency/Urgent Care Services
- Inpatient Admissions
- Inpatient Concurrent Review
- Initial Health Assessments
- Adult Preventive Guidelines
- Pediatric Preventive Guidelines
- Blood Lead Screening of Young Children
- Early Periodic Screening, Diagnostic Treatment (EPSDT) and California Health and Disability Program (CHDP)
- Vaccines for Children (VFC)
- Developmental Disabilities Services (DDS)
- Regional Centers
- California Children’s Services (CCS)
- Children with Special Health Care Needs (CSHCN)
- Family Planning Services
- Sensitive and Confidential Services for Adolescents and Adults
- Facility/Ancillary Referrals and Authorizations
Section 9: Care Coordination
- Provider Responsibilities for Care Coordination
- Integrated Care Coordination
- Complex Case Management (CCM)
- Disease Management Programs
- Transgender Services
- Social Services
- Centers of Excellence
Section 10: Claims Submission
- Claims Management
- Requirements for a Complete Claim
- Complete Claim Submission Options
- Claim Submission Timelines
- Claims Determination Notification
- Claim Reimbursement
- Claim Overpayment
- Personal Care Services (PCS) and Home Health Care Services (HHCS)
- Ancillary Claims
- Required Fields; CMS1500
- Required Fields; UB04
- Important Billing Tips
- Claims Status and Questions
- Member Billing
Section 11: Provider Payments
- Forms
- Capitation Payments
- Fee-for-service Payment (FFS)
- Street Medicine Payments
- Electronic Funds Transfer (EFT)
- Check Tracers
- Payment Delays Related to Provider Directory
- Encounter Data Submission
- Coordination of Benefits (COB)
- Third Party Liability (TPL)
- Facility Payments
- High-Cost Pharmacy (drugs)
Section 12: Dispute Resolution
- Grievances and Appeals
- Provider Dispute Resolution (PDR)
- Type of Disputes
- Requirements for Complete PDR
- PDR Submission Timelines
- PDR Determination Notification
- Other Information
Section 13: Quality Improvement and Health Equity (QIHE)
- Quality Improvement and Health Equity (QIHE) Overview
- Definition of Quality
- Scope of QMI Program
- Quality Management and Improvement (QMI) Process
- QMI Committees and Subcommittees
- Quality Management and Utilization Management (QMUM) Committee
- Quality Operations Committee (QOC)
- Peer Review and Credentialing Committee (PR&CC)
- Grievance and Appeals (G&A) Committee
- Health Education Committee (HEC)
- Compliance Committee (CC)
- Community Advisory Committee (CAC)
- Pharmacy and Therapeutics Advisory (P&TA) Committee
- Network Provider Committee Participation
- Quality of Care Issues
- Monitoring of Quality of Care Issues
- Reporting Potential Quality of Care Issues (PQI)
- Health Care Effectiveness Data and Information Set (HEDIS)
- Tips for Improving HEDIS Scores
- Clinical Practice Guidelines
- Member Experience Survey
- Provider Satisfaction Survey
- Patient Safety
