Provider Manual: Section 1

1.1 How to Use the Plan Provider Manual top

The Central Coast Alliance for Health (the Alliance) Provider Manual has been prepared for your use by the Provider Services Department. The manual sets forth operational policies and procedures including but not limited to, authorization, approval, referral, cultural and linguistic services, utilization management, quality assurance and improvement, notification and transfer, health assessment and screening, member grievances, billing, coordination of benefits, reporting, credentialing, and dispute resolution requirements. The Provider Manual is the Medi-Cal Provider Manual as specifically modified by the Alliance.

The Provider Manual may also be accessed on-line by visiting our website at http://www.ccah-alliance.org/providers.html.

Please refer to the Table of Contents for specific references to Plan policies and procedures. On-line at our website, you may now click on any item on the table of contents to go directly to the information you need. If further information or clarification is required, call the Provider Services Representative for your area.

The Manual will be revised annually as needed. Any modifications that you receive should be filed in the appropriate section as directed by the Provider Services Department.

Please contact your Provider Services Representative with any suggestions for additions or improvements to this manual.

1.2 What is Central Coast Alliance for Health? top

Central Coast Alliance for Health (the Alliance) is a County Organized Health System (COHS). The Alliance is one of five COHS health plans operating in California. The Alliance began operations in 1996 serving 29,000 Medi-Cal beneficiaries in Santa Cruz County. In 1998 the Alliance became a Healthy Families health plan for Santa Cruz County Healthy Families Members and in 1999 the Alliance expanded both the Medi-Cal and Healthy Families programs to Monterey County. As of August 2007 the Alliance was serving approximately 83,000 Medi-Cal beneficiaries and 2,900 Healthy Families members throughout Santa Cruz and Monterey Counties.

In July of 2004 the Alliance began operations for the Healthy Kids Program in Santa Cruz County. As of August 2007 the Alliance was serving approximately 1,800 Healthy Kids members in Santa Cruz County.

In July of 2005 the Alliance began operations for the Alliance Care In-Home Support Services (IHSS) Plan in Monterey County. As of August 2007, there were approximately 500 IHSS members in Monterey County.

The Alliance is governed by the Santa Cruz-Monterey Managed Medical Care Commission (also referred to as “the Commission”), comprised of 16 members representing physicians, clinics, hospitals, allied health providers, service agencies and the public. The Commission meets monthly to review local healthcare concerns, receive advisory input and to form policy for the Alliance. The Commission is advised by three advisory groups: Physicians Advisory Group, Allied Health Service Provider Advisory Group and the Member Advisory Group.

The Alliance’s mission is to ensure appropriate access to care for local Medi-Cal, Healthy Families, Healthy Kids, and Alliance Care IHSS recipients, to improve medical outcomes, minimize unnecessary suffering and cost, and to promote wellness. The Plan achieves this goal by increasing local provider satisfaction and by participation in service delivery. The Alliance’s policies are responsive to local input due to our local governance and operations.

Primary Care Providers in the Medi-Cal and Healthy Families programs have opportunities to share in financial savings as waste and avoidable medical costs are minimized with appropriate access to care, health promotion and case management. The Alliance creates positive changes for health plan members who select their PCP from the list of participating providers. The member’s chosen PCP ensures the member’s access to the health care system, provides primary care services and initiates appropriate referrals to specialty care. An ongoing relationship improves the member’s access, health outcomes and satisfaction.

The Alliance constantly recruits and contracts local providers with the goal of continually expanding the provider network.

Innovative provider payment arrangements include capitation payments for Medi-Cal PCPs and primary care case management for all programs.

1.3 State Medi-Cal Program, EDS, DMHC and the Alliance top

A. The Alliance and State Medi-Cal Program

The Alliance serves Medi-Cal beneficiaries under a contract with the State of California to operate a County Organized Health System health plan. The Alliance uses State policies and procedures as a point of departure. Unless the Commission creates an Alliance-specific policy, the Alliance relies on State Medi-Cal policies for its Medi-Cal program. The Alliance Provider Manual and updates, plus the Electronic Data Systems (EDS) manual and updates provide the policy information for the Alliance.

EDS serves as the Medi-Cal Fiscal Intermediary for the State Medi-Cal program. It processes and pays claims for all Medi-Cal members, except those covered under specific programs such as the Alliance. If you treat a member who is not an Alliance Medi-Cal member, you must bill EDS or the member’s Medi-Cal plan for those services. This would include members whose eligibility is through another county or who have an aid code not covered by the Alliance. (See Section 2 of the manual for a list of these codes.)

For EDS questions and inquiries you can call the following phone number:

§ Toll Free 1 (800) 541-5555

B. DMHC and Knox-Keene Licensure

The Alliance serves Healthy Families beneficiaries under a contract with the State Department of Managed Health Care and the Managed Risk Medical Insurance Board. The Alliance is licensed to perform as a health plan under the Knox-Keene Health Plan Act of 1975. The Alliance is bound by its agreement and licensure to operate the Healthy Kids, Healthy Families and Alliance Care IHSS programs in accordance with the regulations of the Knox-Keene Act. The Act is codified in Section 1300 of the California Health and Safety Code. The Alliance is mandated to comply with any newly passed legislation relative to the Knox-Keene Act and to ensure that contracted providers comply as well. Newly passed legislation will most likely result in future amendments to your provider services agreement.

1.4 Application, Credentialing and Contracting top

Overview

In order to become a provider in the Alliance network the provider must sign a provider services agreement. In addition, the Peer Review and Credentialing Committee of the Santa Cruz Monterey Managed Medical Care Commission must approve the credentialing of the provider. The following describes the steps taken for a physician/provider to complete the credentialing process:

1. Physician/Provider completes, signs and returns the Application, all attached Addendums and Application Supplements for the Alliance and attaches copies of all information requested below, as applicable. Submission of this information is required pursuant to section 7.3 (c) of the Services Agreement.

ü Copy of current Medical License or Business License

ü Copy of current Clinical Laboratory Improvement Amendments (CLIA) or Waiver

ü Copy of current DEA License

ü Copy of Documentation for National Provider Identifier (NPI*) and Taxonomy Code

ü Copy of Professional Liability Insurance (Malpractice) face sheet (Required limits are $1,000,000 per occurrence/$3,000,000 annual aggregate.)

ü Copy(ies) of Mid-Level Staff License(s)

ü Copy(ies) of Completed Mid-Level Agreement(s)

ü Signed Taxpayer Identification Form (W-9)

ü Signed Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion form

ü Signed Declaration of Confidentiality form

2. The Plan verifies the information provided (Medi-Cal number, license status, etc.)

3. The Peer Review and Credentialing Committee reviews application and supporting documentation and approves all new and re-credentialed providers.

4. Chairperson of the Commission countersigns the contract after Commission approval of credentialing.

5. A copy of the completed contract is returned to the physician/provider. A new provider orientation and training must be performed within 10 days of the credentialing approval.

6. Primary Care Physicians must also have a site review, conducted by a plan Utilization/Onsite Review Nurse, before the credentialing process is finalized.

7. Providers are re-credentialed every three years, based on expiration date of their license

* For information on how to obtain a NPI, please go to https://nppes.cms.hhs.gov/.

1.5 Contractual Requirements for Credentialing and Regulatory Compliance top

By signing your contract, you agreed that you and any providers working for you are and will continue to be properly licensed by the State of California to practice medicine and licensed to treat Medi-Cal beneficiaries. Additionally, you represented that you are qualified and in good standing in terms of all applicable legal, professional and regulatory standards. Physicians who are excluded from participation in Medi-Cal or Medicare programs by the U.S. Department of Health and Human Services may not provide services to Alliance members. You have represented that you are not excluded from participation. You have agreed that if you or any of your employees are ever excluded, you will not treat Alliance patients and you will notify us of such exclusion.

Additionally, each provider is required to maintain medical staff privileges at one of the Alliance’s contracted hospitals and all clinical privileges necessary to perform necessary services. If a provider does not have such privileges they are required to sign a formal agreement with a physician who does have such privileges, thereby making arrangements to provide those services to members. Primary care providers with more than 500 linked members are required to have medical staff privileges at the hospital in the community in which they are located, or to have a formal agreement with a provider who does have privileges at a hospital in their community.

You are required to immediately notify us by phone and in writing of the following actions taken towards you or any practitioner on your staff:

· Revocation, suspension, restriction, non-renewal of license, certification or clinical privileges.

· A peer review action, inquiry or formal corrective action proceeding or investigation.

· A malpractice action or governmental action, inquiry or formal allegation concerning qualifications or ability to perform services.

· Formal report to the state licensing board or similar organization or the National Practitioner Data Bank of adverse credentialing or peer review action.

· Any material change in any of the credentialing information.

· Sanctions under the Medicare or Medicaid programs.

· Any incident that may affect any license or certification, or that may materially affect performance of the obligations under the agreement.

If you fail to meet the credentialing standards or if your license, certification or privileges are revoked, suspended, expired or not renewed, the Alliance must ensure that you do not provide any services to our members. Any conduct that could adversely affect the health or welfare of a member will result in written notification that you are not to provide services to our members until the matter is resolved to our satisfaction.

1.6 Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion top

Your contract references this certification in Section 7.1 of the Agreement. In accordance with 45CFR (Code of Federal Regulations) Part 76, the Alliance receives federal funding through the Healthy Families Program and, therefore, must certify that it is not debarred or otherwise excluded from receiving these federal funds. Under this federal rule, the Alliance is considered to be a “lower tier participant” because we receive this federal funding. Our providers, as subcontractors, who receive federal funding by nature of their Agreement with the Alliance are also considered to be “lower tier participants” and must also attest to the fact, by signing this form, that they have not been debarred or otherwise excluded by the Federal government from receiving federal funding.

You received with your initial credentialing application and contract a form entitled the “Certification Regarding Debarment Suspension, Ineligibility and Voluntary Exclusion”. This form must be signed by you and returned with your completed credentialing application and signed agreement, certifying, as above, that you are eligible to participate in our program and receive funds provided by the federal government. Pursuant to this certification and your Agreement with the Alliance, should you or any provider with whom you hold a subcontract become suspended or ineligible to receive federal funds, you will notify the Alliance immediately.

A copy of the “Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion” may be found in Section 7 (Forms) of this Manual.

Provider Manual