Medi-Cal Operations Guide

1 Medi-Cal Operations Guide *Health Net of California, Inc., Health Net community Solutions, Inc., Health Net Life Insurance Company, and Managed Health Network, LLC are subsidiaries of Health Net, LLC and Centene Corporation. The MHN family of companies includes Managed Health Network and MHN services , LLC (MHN). Health Net and MHN are registered service marks of Health Net, LLC. All other identified trademarks/. service marks remain the property of their respective companies. All rights reserved. 21-881. BKT469202EO00 (12/21). Introduction Introduction The Health Net* Medi-Cal Operations Guide is a summary of Health Net's Medi-Cal county-specific provider manuals that are available in Health Net's Medi-Cal Provider Library on the Health Net provider website.

2 Providers are encouraged to use the electronic version of the applicable county-specific manual when possible for the most current information. Updated information in the electronic version of the manual supersedes information contained in this print Guide . The contents of this Guide are supplemental to the Provider Participation Agreement (PPA). When the contents of this Guide conflict with the PPA, the PPA takes precedence. Updates to the information in this Guide are made through provider updates or signed letters distributed by fax, the United States Postal Service or other carrier. Provider updates and signed letters are to be considered amendments to this Guide . How to Use the Guide This Guide contains the essential components of Health Net's Medi-Cal plan.

3 Refer to it for basic information about public health programs available to Medi-Cal patients, use of and access to Medi-Cal services , physician responsibilities for coordination of patient care, and provision of health care services . The primary focus of the Guide is in Chapters 4 through 7, which provide explanations of pertinent public health programs, medical service standards and sensitive services and self-referral program considerations. Chapter 1 contains contact information for plan and public health agencies. Chapter 2 describes enrollment criteria and procedures unique to the Medi-Cal managed care program. Chapter 3 describes access to care standards and referral and prior authorization requirements. Chapter 8 includes information on continuity of care, utilization management and health education programs available to Medi-Cal members.

4 Chapters 9 and 10 provide general information about claims, encounters, appeals, and grievances. For detailed county-specific information, consult the Health Net Medi-Cal provider Operations manuals for each county. Contractual Arrangements and Applicability to Los Angeles County As a general rule, providers participating through a subcontracting health plan, such as Molina Healthcare, follow the subcontracting plan's operational procedures; however, standard Medi-Cal policies for public health program interaction as described in this Guide apply to all participating providers, including providers contracting through Molina. Los Angeles County is a Two-Plan Model Program area. Under the Two-Plan Model Program, the Department of Health Care services (DHCS) contracts with one commercial plan, the Commercial Plan, and one Medi-Cal plan developed by the county, the Local Initiative.

5 In Los Angeles County, DHCS awarded Health Net the Commercial Plan contract. Health Net entered into contract with Molina in Los Angeles County as a subcontracting plan to provide Medi-Cal services through its respective provider network. Medi-Cal members in Los Angeles County are Health Net members, even if assigned to Molina. Disclaimer This Guide is not intended to provide legal advice on any matter and may not be relied on as a substitute for obtaining advice from a legal professional. Effective Date: January 1, 2022 i Introduction Impact of COVID-19 on services , regulations and requirements The following table lists impacts due to COVID-19. Providers must comply with all applicable contract requirements, state and federal regulations and guidance, including All Plan Letters (APLs) and Policy Letters.

6 COVID-19 impacts Description Phone number is temporarily suspended. Use the fax number Hospital Notification Unit 800-676-7969 to submit requests and contact the Health Net Provider services Center for status on urgent inpatient admission. community Based Adult services (CBAS) face-to-face assessment request Currently not available. Per revised APL 20-004,1 starting October 1, 2021, managed care plans will Initial health assessment (IHA) and Staying Healthy Assessment (SHA) resume IHA activities that were temporarily suspended during the period of December 1, 2019 September 30, 2021. Per DHCS APL 20-004, DHCS ceased provider timely access surveys to alleviate burdens on providers during the pandemic. Provider timely access surveys Per revised APL 20-004,1 DHCS will resume the timely access survey calls beginning in January 2022.

7 Stay informed about COVID-19. For ongoing changes and requirements for COVID-19, visit the following websites: Health Net's COVID-19 Provider Alerts web page: , under COVID-19 Updates, select Health Net Alerts ii Effective Date: January 1, 2022. Table of Contents Table of Contents Chapter 1 Who to Provider Member Resources .. Phone Numbers and Addresses .. Statewide Phone Kern County .. Los Angeles County .. Los Angeles County Health Net .. Los Angeles County Molina Healthcare .. Riverside Sacramento County .. San Bernardino San Diego County .. San Joaquin Stanislaus County .. Tulare County .. Chapter 2 Enrollment and Disenrollment .. Enrollment Criteria for Medi-Cal Managed Member Enrollment Process .. Member Disenrollment Process .. Eligibility Reports.

8 Verifying Eligibility .. Chapter 3 Access to Care .. Primary Care Access Standards .. Access to Confidential and Sensitive services .. Nurse Advice Line .. Emergency and Urgent Care .. community -Based Adult services .. Long-Term services and Supports (LTSS) Non-Urgent Appointment .. Mental Health services .. Transportation .. Access to services in Primary Language .. Referrals for Specialty Care .. Prior Authorization Requests .. Medication Prior Authorization Requests .. Effective Date: January 1, 2022 TOC-i Table of Contents Chapter 4 Medical Standards .. Preventive Care services .. Initial Health Assessment .. Child Health and Disability Prevention Program .. EPSDT Private Duty Nursing Adverse Childhood Experiences (ACEs) Screening .. Childhood Blood Lead Screening.

9 Immunizations .. Dental Screenings .. Routine Eye Examinations and Eyewear .. Pregnancy and Maternity Special Supplemental Nutrition Program for WIC .. Chapter 5 Sensitive and Self-Referral services .. Family Planning services .. HIV Testing and Counseling .. Pregnancy services and Pregnancy Termination .. Sexually Transmitted Infections .. Chapter 6 Public Health Carve-Out services .. Alcohol and Drug Treatment services .. California Children's services .. County Mental Health Plan .. Direct Observation Therapy for Early Start Program .. Local Education Agency services .. Long-Term Care .. Major Organ Transplants .. Refugee Health Regional Center TOC-ii Effective Date: January 1, 2022. Table of Contents Chapter 7 Public Health Waiver Programs.

10 AIDS Waiver Program .. Home and community -Based services Waiver Administered by the Department of Developmental services .. Multipurpose Senior services Program Waiver .. Chapter 8 Health Care Management .. Care Coordination .. Utilization Management .. Quality Improvement .. Credentialing and Recredentialing .. Chapter 9 Claim Billing and Encounter Claim Billing Information .. Coordination of Benefits .. Balance Billing and Other Billing Prohibitions .. Encounter Reporting .. Reimbursement Methods .. Third-Party Tort Liability .. Timely Claim Processing Requirements .. Chapter 10 Grievance and Appeals Procedures .. Member Grievance and Appeal Procedures .. Provider Grievance Procedure .. Provider Dispute and Appeal Procedures .. Glossary ..Glossary-i Index.