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MANAGEMENT SERVICES ORGANIZATION (MSO)Provider ManualThis document contains information for San Francisco Health Plan (SFHP) NEMS (Medi-Cal Beneficiaries), andNEMS Health Net Medicare Advantage program requirements. Additional information is available on the SFHPwebsite (www.SFHP.org/providers) and the Health Net Medicare Advantage website(https://ca.healthnetadvantage.com/). Please make sure to distinguish the contents and apply the information tothe program with which you are affiliated. If you have any questions regarding the contents of the document,contact NEMS MSO Provider Relations at 1(415) 352 - 5186 Option 3

Table of ContentsOur Mission: . 8HISTORY AND WHO WE ARE . 8Contact Information. 9Provider Relations . 9Utilization Management . 9Claims . 9OUR PROGRAMS . 9Medi-Cal Managed Care Program. 9Medi-Cal and Health Care Options; Fee-for-Service vs. Medi-Cal Managed Care. 10Health Care Options (HCO): . 10Dual Eligible. 10VERIFYING MEMBER ELIGIBILITY . 10How to Check Eligibility. 10PCP SELECTION, ASSIGNMENT, AND CHANGE . 11Members Rights and Responsibilities . 12San Francisco Health Plan members have the responsibility to: . 13PCP Assignments . 13PCP Initiated Member Reassignment or Member Dismissal from Practice . 14PCP Responsibilities . 14Services for Members with Disabilities . 15UTILIZATION MANAGEMENT . 15Utilization Management Staff Availability . 16General UM Information. 16Sensitive Services . 17Out-of-Network Services. 17Prior Authorization. 17General Provisions . 18Prior Authorization Turnaround Time. 18Authorization Approval/ Denial . 18Appeal of UM Decisions . 19

Case Management and Care Coordination . 19Quality Improvement . 20SBIRT . 21Long-Term Care . 21Care Transition . 21Health Homes Program . 21Provider Appointment Availability Survey . 22PROVIDER RELATIONS, PROVIDER POLICIES AND CREDENTIALING . 22Practitioner Credentialing/ Re-credentialing . 22Specialists Responsibilities . 23Provider Changes to Practice . 23Provider Network . 23Provider Roster Requirements and Verification Process . 23Additions to the Provider Network . 24Provider Information Changes or Terminations . 24Provider Orientation and Training . 24Provider Access, Availability and Appointments . 25Access to Care and Access Standards . 25Appointment Availability . 25After-Hours . 26Emergency Services and Urgent Care . 26Appointment Access Procedures . 26Access Standards. 26Procedures for Ensuring Access . 28Telephone Triage Procedures . 28Provider Satisfaction Survey . 28CLAIMS AND ENCOUNTER DATA. 29Claims Overview. 29Claim Requirements . 29Electronic Data Interchange (EDI) . 29Timely Filing Timeframes . 29General Claims Processing Guidelines . 30Acknowledgement of Claims . 30

Claim Processing Time . 30Clean Claim. 30Unclean Claim . 30Interest on Claims . 30Misdirected Claims. 30Billing Members . 30Overpayment and Recoupments . 31Coordination of Benefits (COB) . 31Provider Dispute Resolution Mechanism . 32NEMS MSO WEBSITE AND PROVIDER PORTAL . 33Member Education . 33Provider Portal and Registration. 33User ID and Password . 34Forms and Resources . 34CULTURAL AND LINGUISTIC SERVICES AND TRAINING . 35Cultural and Linguistic Training . 35Linguistic Services Terms . 36Why is Linguistic Access Important? . 36Linguistic Access Reduces Health Disparities . 36Business Value Linguistic Access . 36DHCS Medi-Cal Interpreter Services Requirements . 36Asking about language preference and working with LEP patient . 37Avoid using family, friends, or minors as interpreters. 37Working with Interpreters On-site. 37Working with Interpreters by Phone . 37What is Culture? . 38Tips to consider for effective cross-cultural communication . 38Other strategies for cross-cultural communication . 38Cultural Awareness . 38What is Cultural Competence in Health Care? . 39Key Steps Towards Cultural Competence . 39Caring for LGBTQ Communities . 39Tips for Working with Transgender Patients . 39

Caring for Seniors and Persons with Disabilities (SPDs) . 40Accommodations: What Patients May Need. 40Interacting with Seniors . 40Interacting with People with Physical Disabilities . 40Interacting with People with Speech Disabilities. 40Interacting with People with Cognitive, Intellectual, or Psychiatric Disabilities. 41Interacting with People with Visual Disabilities . 41HEALTH NET MEDICARE ADVANTAGE . 42ELIGIBILITY. 42To Verify Eligibility for Health Net Medicare Advantage: . 42PCP Selection for Health Net Medicare Advantage . 42Provider Portal and Registration. 43UTILIZATION MANAGEMENT . 43General UM Information. 43Out-of-Network Services. 43Prior Authorizations . 44General Provisions . 44Authorization Turnaround Time . 44UM APPEALS . 44Access Standards. 44Provider Appointment Availability Survey . 45CLAIMS AND ENCOUNTER DATA – HEALTH NET MEDICARE ADVANTAGE . 46Claims Submission. 46Mandatory Items for Claims Submission . 46Electronic Data Interchange (EDI) . 47Acknowledgement of Claims . 48Definition of Clean Claim and Unclean Claim . 48Timely Filing of Claims. 49Date of Receipt . 49Timely Reimbursement of Claims . 49Interest Payment on Clean Claims Not Paid Timely. 50Balance Billing . 50Billing Medicare-Medi-Cal Members Prohibited . 50

Denial of Claims . 51Contested Claims . 52General COB Information. 52Payment Processing for Medicare/Medi-Cal Crossover Claims. 52Overpayment Reimbursement/Member Cooperation . 52Provider Dispute . 53Medicare Non-Contracted Provider Appeals (Waiver of Liability) . 53Medicare Advantage Non-Participating Provider Disputes . 53Determination of the Dispute . 54Second Level Dispute . 54Retention of Provider Disputes Record . 54MEDICARE MANAGED CARE PROVIDER APPEALS . 55BENEFITS AND CARE COORDINATION. 56Pharmacy Benefits . 56Behavioral Health Services. 56Chiropractic and Acupuncture . 56Vision Benefit . 57Dental Services . 57Fluoride Varnish . 57Sensitive Services . 58Sterilization Services . 58Abortion . 58Minor Consent Services . 58Family Planning – Adult Sterilization and Consent . 58Health Assessments . 59Initial Health Assessment (IHA) . 59Staying Healthy Assessment (SHA) . 59Child Health and Disability Program (CHDP) . 60Coordination of Care for Medi-Cal Members . 60Golden Gate Regional Center (GGRC) . 60Early Start Program (ES) . 61Women, Infants, Children Program (WIC) . 61California Children’s Services (CCS) . 62

Comprehensive Perinatal Services Program (CPSP) . 62Local Education Agency (LEA) . 62DHCS Waiver Programs . 63Health Education. 64Major Organ Transplant . 65Second Opinions . 66Standing Referral to Specialty Care . 67Non-Covered Services . 67Member Liability . 67

provide medical services for Medi-Cal patientsfrom the San Francisco Health Plan.Our Mission: To provide affordable,comprehensive, compassionate, and qualityhealth care services in a linguistically competentand culturally sensitive manner to improve thehealth and well-being of our community.To meet the growing demands for its services,we opened its first satellite clinic in SanFrancisco’s Visitacion Valley in 2000. Additionalclinics throughout San Francisco, Daly City, andSan Jose followed between 2004 and 2012.Today, we operate 12 clinics throughout theSan Francisco Bay Area.NEMS MSO PROVIDER MANUALNEMS MSO provides periodic updates to theprovider network using provider bulletins,memorandums, and through the providermanual. The provider manual describes yourresponsibility as a provider to our members,and it is a resource for providers and staff toassist with providing our members with the bestpossible care. In this manual, the term“provider(s)” includes practitioners, medicalgroups, hospitals, ancillary providers, and othernon-hospital facilities. All contracted providersare required to fulfill the relevant specifiedresponsibilities explained in this providermanual. If you have any questions about ourprovider network, the provider manual, or ourmembers, please contact Provider Relations at1 (415)-352-5186 Option 3.NEMS MSO as a Federally Qualified HealthCenter (FQHC), is eligible to contract withManaged Care plan as a Risk BearingOrganization (RBO) to take full or partial risk toprovide services in a managed care system forresidents who qualify for Medi-Cal and haveenrolled in the San Francisco Health Plan.NEMS MSO is an internally developedManagement Services Organization, whichperforms administrative services for themanaged care members enrolled in the SanFrancisco Health Plan and have selected NEMSas the primary care clinic/provider.In 2000, we collaborated with California PacificMedical Center (CPMC), and togethercontracted with San Francisco Health Plan(SFHP) and formed the first full risk managedcare network - NEMS network. Participatingprimary care providers/clinics include:HISTORY AND WHO WE ARENorth East Medical Services (NEMS) wasfounded in 1968 and began serving patients in1971 in response to the lack of adequate healthcare services for uninsured and underprivilegedAsians in San Francisco, taking part in anationwide movement to establish communitybased health centers. For more than 42 years,NEMS has grown from a small primary careclinic to a large, comprehensive health careorganization, serving an estimated 250,000people since its creation. We became afederally qualified health center (FQHC) in 1992,and since inception, we have received federalfunding through the Community Health Centers(CHC) program. In 1999, NEMS formed a managed careManagement Services Organization (MSO) to 8NEMS San Francisco ClinicsCPMC Family Health CenterCPMC Pediatric Care Center1100 Van Ness Avenue Clinic2100 Webster Street Clinic350 Rhode Island Street Clinic3838 California Street Clinic45 Castro Street Clinic899 Valencia Street ClinicMission Neighborhood HealthCenterPrivate community PCPs

In 2015, we collaborated with Zuckerberg SanFrancisco General Hospital (ZSFG) to contractwith SFHP and formed the second full-riskmanaged care network known as NMSNetwork. The NEMS Clinics in the San Franciscoand San Mateo Counties are the participatingprimary care clinics in this network.ClaimsIn 2019, we expanded our services and addedan additional program to the network andcontracted with Health Net MedicareAdvantage to offer members the Health NetSeniority Plus Sapphire Premier II (HMO) plan.This plan gives our members access to ournetworks of highly skilled medical providers inour area. The Health Net Seniority Plus SapphirePremier II (HMO) plan also includes Part Dcoverage, which provides members with theease of having both their medical andprescription drug needs coordinated through asingle convenient source. The NEMS Clinics inSan Francisco and San Mateo Counties are theparticipating primary care clinics in thisnetwork.OUR PROGRAMSHours of operation: Monday to Friday,8:00am – 5:30pmPhone: 1(415) 352-5186 Option 2Contact the Claims Department for anyquestions related to claims and reimbursement.Medi-Cal Managed Care ProgramMedi-Cal provides free and low-cost health carecoverage services to low-income adults, familieswith children, pregnant women, seniors, peoplewith disabilities, children in foster care, andadults formerly in foster care up to age 26.Certain populations that include adults, familieswith children, seniors, and people withdisabilities, are required to enroll in Medi-Calmanaged care. Other Medi-Cal enrollees, suchas those with a Share of Cost, do not receivetheir Medi-Cal services through a managed careplan and remain in Fee-for-Service Medi-Cal.San Francisco Health Plan (SFHP) is one of twoMedi-Cal managed care plans authorized by theCalifornia Department of Health Care Services(DHCS) to serve Medi-Cal members in SanFrancisco.Contact InformationProvider RelationsHours of operation:

contracted with Health Net Medicare Advantage to offer members the Health Net Seniority Plus Sapphire Premier II (HMO) plan. This plan gives our members access to our networks of highly skilled medical providers in our area. The Health Net Seniority Plus Sapphire Premier II (HMO) plan also