medi-cal administrative manual manual/working/med… · introduction 2 board of directors roster...

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Medi-Cal Administrative Manual Table of Contents

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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

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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

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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

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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

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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

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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.

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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

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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.

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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

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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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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

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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

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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

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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

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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.

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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.

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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.

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Primary Care Physician (PCP) - Overview

General Contract Information – Overview

PCP Assignment/Member Eligibility

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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.

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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.

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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.

http://www.medi-cal.santehealth.net/



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Specialist - Overview

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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.

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Ancillary Intro

Ancillary Service Provider Listing

Anthem Blue Cross Medi-Cal

Health Net Medi-Cal

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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.

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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


Da Vita, Inc./Fresno Dialysis

1111 E. Warner, Suite 101 Fresno 93710 (559) 439-1845

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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

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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


125 E. Barstow Avenue Fresno 93710 (559) 225-5180



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

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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

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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


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

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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


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

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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



McGuire Physical Therapy, Inc.

1700 E. Bullard Ave. #102 Fresno 93710

PhysMed Physical Therapy


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)



RADIOLOGY (Outpatient) (Santé Risk)

Advanced Medical Imaging

California Imaging Institute



Community Medical Imaging

Mitchell Imaging (Mobile Diagnostic Ultrasound)

(Effective Date: 07/01/2018)

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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


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


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


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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


Schapansky Sleep & Wellness Center (In Home)

5660 N. Fresno St. Suite 102 Fresno 93710 (559)776-7066

Sleep Quest, Inc. (In Home)


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)


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

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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


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



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

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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


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


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

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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)


165 N. Clark Fresno 93701 (559) 233-8657


125 E. Barstow Avenue Fresno 93710 (559) 225-5180



Planned Parenthood


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

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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

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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



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


Sang Pediatrics

1122 S Street #102 Fresno 93721 (559) 268-1737

OCCUPATIONAL THERAPY (Santé Risk)


1925 E. Dakota, Suite 120A Fresno 93726 (559) 459-1842



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

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7210 N. Milburn Ave. #105 Fresno 93722 (559) 277-3909

Silhouette Post-Surgical


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


Gastroenterology & Liver Disease Medical Center Inc.


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.


Lags Surgery Center of Fresno


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

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PhysMed Physical Therapy


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 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

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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


Golden Living Center - Hillcrest

3672 N. First Street Fresno 93726 (559) 227-5383

Golden Living Center - Hy-Lond Center - Fresno


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

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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


Schapansky Sleep & Wellness Center (In Home)

5660 N. Fresno St. Suite 102 Fresno 93710 (559)776-7066

Sleep Quest, Inc. (In Home)


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)


1925 E. Dakota, Suite 120-A Fresno 93726 (559) 459-1842

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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

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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

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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:

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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

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LANGUAGE ASSISTANCE PROGRAM

SB853


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:


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

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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.

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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


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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

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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

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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



http://www.santehealth.net/SignUp/Web_Access_Request_Form.Asp

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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

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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

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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.

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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 )

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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

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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.


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.

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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

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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

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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

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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.

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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.

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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.

http://www.dhcs.ca.gov/services/ccs

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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.

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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

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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

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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.

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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)

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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.

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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.

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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.

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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

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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

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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.

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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

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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

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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.

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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

https://www.anthem.com/wps/portal/ca/culdesac?content_path=provider/f1/s0/t0/pw_a111722.htm&rootLevel=0&name=onlinepolicies&label=Overview

https://www.anthem.com/wps/portal/ca/culdesac?content_path=provider/f1/s0/t0/pw_a111722.htm&rootLevel=0&name=onlinepolicies&label=Overview

https://www.healthnet.com/portal/provider/content/iwc/provider/unprotected/working_with_HN/content/medical_policies.action

https://www.healthnet.com/portal/provider/content/iwc/provider/unprotected/working_with_HN/content/medical_policies.action

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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

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