Transcription
Medi-Cal Provider ManualJanuary 2020blueshieldca.comblueshieldca.com/promise
Blue Shield Promise Health Plan Medi-Cal Provider ManualTable of ContentsSECTION 1: INTRODUCTIONSECTION 2: MISSION STATEMENTSECTION 3: BENEFITS3.1: Covered Benefits .1SECTION 4: MEMBER RIGHTS AND RESPONSIBILITIES4.1: Member Rights and Responsibilities.1SECTION 5: ENROLLMENT5.1: Eligibility.15.2: Member Enrollment.15.3: Member Health Plan Selection .15.4: Coverage.25.5: Newborn Coverage.25.6: Change of Primary Care Physician .25.6.1: Member Initiated Change .25.6.2: Primary Care Physician Initiated Change.35.7: Eligibility List .45.8: Eligibility Verification.45.9: Identification Cards .55.10: Disenrollment .55.11: Plan Initiated Disenrollment.65.12: Transportation.65.13: Translation Services/California Relay Services .6SECTION 6: GRIEVANCES, APPEALS AND DISPUTES6.1: Member Grievances.16.2: Member Appeals Requests .36.2.1: Expedited Appeal .46.3: Independent Medical Review.46.4: Provider Disputes – Claims Processing .66.4.1: Provider Questions, Concerns and Disputes .66.4.2: Reconsiderations.66.4.3: Provider Disputes Policy and Procedure.76.4.4: First Level Appeal .86.4.5: Second Level Appeal .86.5: Attachments .9Blue Shield of California Promise Health PlanMedi-Cal Provider ManualJanuary 2020TOC Page 1
Blue Shield Promise Health Plan Medi-Cal ManualSECTION 7: UTILIZATION MANAGEMENT7.1: Utilization Management Program .17.1.1: Physician, Member, and Provider Responsibilities .17.1.2: Organization of Health Care Delivery Services .27.1.3: Medical Services Structure Membership .27.1.4: UM Review Process for Appropriateness of Care.37.1.5: Review Criteria .47.2: Complex Case Management Program.67.2.1: The Role of the Case Manager .77.2.2: Case Management in the Ambulatory Setting.77.2.3: Case Management in the Inpatient Setting. 107.3: Primary Care Physician (PCP) Scope of Care . 107.4: Authorization and Review Process . 157.4.1: Authorization Time Frames . 157.4.2: Authorization Validity. 237.4.3: Specialty Referrals . 237.4.4: Ancillary Referrals . 247.4.5: Outpatient Services . 247.4.6: Elective Admission Requests. 257.5: Emergency Services and Admission Review . 257.5.1: Emergency Services . 257.5.2: Urgent/Emergent Admissions. 277.5.3: Concurrent Review. 287.5.4: Discharge Planning . 297.5.5: Retrospective Review . 297.6: Authorization Denials, Deferrals and Modifications . 307.7: Referrals . 327.7.1: Second Opinion . 327.7.2: Self-Referable Services (Medi-Cal) . 337.7.3: Direct OB/GYN Access . 337.7.4: Independent Medical Review. 347.7.5: Continuity of Care . 347.7.6: Reconstructive Surgery . 357.7.7: Standing Referral. 367.8: Carve-Out Benefits: Public Health, Linked Services and Special BenefitInformation . 387.8.1: California Children Services (“CCS”). 387.8.2: Child Health and Disability Prevention Program (“CHDP”) . 387.8.3: Early Prevention, Screening, Diagnosis and Treatment. 417.8.4: Women, Infants and Children (“WIC”) Program . 427.8.5: Comprehensive Perinatal Services Program (CPSP). 437.8.6: Family Planning . 45TOC Page 2Blue Shield of California Promise Health PlanMedi-Cal Provider ManualJanuary 2020
Blue Shield Promise Health Plan Medi-Cal Provider Manual7.8.7: Sensitive Services. 467.8.8: Sexually Transmitted Disease . 477.8.9: Mental Health (Medi-Cal Managed Care) . 477.8.10: Vision . 497.8.11: Dental . 507.8.12: Organ Transplant . 507.8.13: Long Term Care. 517.8.14: Alcohol and Drug . 527.8.15: Tuberculosis . 537.8.16: Waiver Program. 537.8.17: Phenylketonuria (PKU). 537.8.18: Cancer Screening . 557.8.19: Cancer Clinical Trials. 557.8.20: AIDS Vaccine Coverage. 557.8.21: Services Under the End of Life Options Act (ABx2-15) for Medi-CalMembers . 567.9: Delegated UM Reporting Requirements (Participating Provider Group “PPG”Only . 567.10: Managed Long-Term Support Services (MLTSS). 58SECTION 8: ENCOUNTER DATA8.1: Encounter Data - Medi-Cal .18.2: Encounter Data Contact Requirement .2SECTION 9: QUALITY IMPROVEMENT9.1: Quality Improvement Program .19.1.1: Program Structure Governing.59.1.2: Standards of Practice .79.1.3: Quality Improvement Process .89.1.4: Communication of Information . 109.2: Policies and Procedures . 119.2.1: Confidentiality of Quality Improvement Information. 119.3: Quality of Care Focused Studies. 139.4: Practitioner/Provider and member Satisfaction Surveys . 169.5: Clinical Practice Guidelines. 169.6: Initial Health Assessment (“IHA”) . 169.7: Facility Site Review. 219.7.1: FSR Evaluation Tools. 219.7.2: Facility Review Tool Purpose. 239.7.3: Physical Accessibility. 249.7.4: Medical Equipment . 259.7.5: Fire and Earthquake Safety. 269.7.6: Emergency Equipment and Medications. 28Blue Shield of California Promise Health PlanMedi-Cal Provider ManualJanuary 2020TOC Page 3
Blue Shield Promise Health Plan Medi-Cal Manual9.7.7: Infection Control . 289.8: Medical Records . 349.8.1: Policy. 349.8.2: Procedure. 359.8.3: Guidelines. 369.9: Access to Care. 429.9.1: Access to Care Standards . 429.9.2: Monitoring Process . 439.10 Broken/Failed Appointments . 449.10.1: Broken/Failed Appointment Follow-up. 449.11: Advance Directives. 459.12: Clinical Telephone Advice. 469.13: HEDIS Measurements. 469.14: Credentialing Program. 519.14.1: Minimum Credentials Criteria . 539.14.2: Credentials Process for Participating Provider Group “PPG” . 57SECTION 10: PHARMACY AND MEDICATIONS10.1: Drug Formulary Policy.110.2: Continuity of Care for Medications .510.3: Prior Authorizations and Exceptions.510.4: Emergency Supply of Drugs Policy .610.5: Requirements for Hospital Emergency Rooms to Furnish Emergency Drugs .710.6: Drug Storage and Dispensing in Provider Offices .710.7: Pharmaceutical Utilization Management .910.8: Non Legend/Over the Counter (OTC) Drug Benefit . 1010.9: Member Charges for Pharmacy Services . 1010.10 Pharmacy Interpreter Service Requirement . 1110.11: Access to Emergency Contraception Therapy . 1110.12: Access to Pharmaceutical Care and Services . 1210.13: Drug Use Review . 1210.14: Specialty Pharmaceuticals . 1410.15: Reporting. 16SECTION 11: HEALTH EDUCATION11.1: Health Education Program .111.2: Scope of Health Education (HE) Program.111.2.1: Member Education.111.2.2: Mandated Health Education Topics .411.2.3: Selection of Health Education Materials.511.2.4: Provider Education .611.3: Member Education Contractual Requirements .6TOC Page 4Blue Shield of California Promise Health PlanMedi-Cal Provider ManualJanuary 2020
Blue Shield Promise Health Plan Medi-Cal Provider Manual11.3.1: Provider’s Responsibility to Health Education.611.3.2: PPG Provision of Health Education.711.3.3: Monitoring Provisions of Health Education.711.4: Staying Healthy Assessment (SHA) Tool .811.5: Program Recources .
Thank you for being a Blue Shield of California Promise Health Plan network provider. As a network provider, you play a very important role in the delivery of healthcare services to our members. The Blue Shield Promise Health Plan Medi-Cal Provider Manual is intended for network provider
