2014 MEDI-CAL DIRECT (MCLA), PASC-SEIU, AND HEALTHY KIDS PROVIDER MANUAL 1 Contents 1.0 L.A. CARE ................................................................................................................................................. 8 GENERAL INTRODUCTION ........................................................................................................................ 8 HEALTHY KIDS PROGRAM ......................................................................................................................... 9 L.A. CARE DEPARTMENTAL CONTACT LIST ............................................................................................. 10 GLOSSARY OF TERMS ............................................................................................................................. 13 WEBSITE INFORMATION AVAILABLE TO PROVIDERS ............................................................................. 15 NOTICE TO PROVIDERS ........................................................................................................................... 16 2.0 MEMBERSHIP AND MEMBERSHIP SERVICES ........................................................................................ 17 RESPONSIBILITY OF PARTICIPATING PROVIDERS ................................................................................... 17 PROGRAM ELIGIBILITY ............................................................................................................................ 17 CONDITIONS OF ENROLLMENT .............................................................................................................. 17 MEMBER ENROLLMENT, ASSIGNMENT AND DISENROLLMENT ............................................................. 17 MEMBER IDENTIFICATION CARD ............................................................................................................ 20 ELIGIBILITY VERIFICATION ...................................................................................................................... 20 EVIDENCE OF COVERAGE........................................................................................................................ 20 CO-PAYMENTS ........................................................................................................................................ 20 MEMBER’S RIGHTS AND RESPONSIBILITIES ........................................................................................... 21 NOTICE TO MEMBERS REGARDING CHANGE IN COVERED SERVICES .................................................... 22 MEMBER GRIEVANCES ........................................................................................................................... 23 3.0 ACCESS TO CARE ................................................................................................................................... 25 RESPONSIBILITY OF PARTICIPATING PROVIDERS ................................................................................... 25 L.A. CARE/PARTICIPATING PHYSICIAN GROUP ACCESS REQUIREMENTS ............................................... 25 PRIMARY CARE ACCESS REQUIREMENTS ............................................................................................... 25 SPECIALTY CARE ACCESS REQUIREMENTS .............................................................................................. 27 ANCILLARY PROVIDER REQUIREMENTS.................................................................................................. 27 BEHAVIORAL HEALTH ACCESS REQUIREMENTS ..................................................................................... 27 PRIMARY CARE AVAILABILITY STANDARDS (RATIO/DISTANCE) ............................................................. 28 SPECIALTY CARE AVAILABILITY STANDARDS (RATIO/DISTANCE) ........................................................... 28 PHARMACY AVAILABILITY REQUIREMENTS (DISTANCE) ........................................................................ 30 PCP MINIMUM SITE HOUR REQUIREMENTS .......................................................................................... 30 4.0 SCOPE OF BENEFITS .............................................................................................................................. 31 HEALTH BENEFITS ................................................................................................................................... 31 5.0 UTILIZATION MANAGEMENT ................................................................................................................ 33 2 GOAL AND OBJECTIVES ........................................................................................................................... 33 SCOPE OF SERVICE .................................................................................................................................. 34 DELEGATION OF UTILIZATION MANAGEMENT ...................................................................................... 36 UM DELEGATION MONITORING AND OVERSIGHT ................................................................................. 37 UM REPORTS .......................................................................................................................................... 37 UM DELEGATION OVERSIGHT AUDITS ................................................................................................... 38 SUPPLEMENTAL AUDITS ......................................................................................................................... 38 CONTINUOUS MONITORING ACTIVITIES ................................................................................................ 39 BENEFITS ................................................................................................................................................. 40 NEW MEDICAL TECHNOLOGY ................................................................................................................ .40 RESPONSIBILITY OF PARTICIPATING PROVIDERS ................................................................................... 40 AFTER HOURS AUTHORIZATION ............................................................................................................. 41 UM REFERRAL MANAGEMENT REVIEW PROCESSES .............................................................................. 42 SERVICES REQUIRING PRIOR AUTHORIZATION ...................................................................................... 43 COORDINATION OF MEDICALLY NECESSARY SERVICES.......................................................................... 44 SECOND OPINION PROCESS ................................................................................................................... 61 STANDING REFERRAL PROCESS .............................................................................................................. 62 TUBERCULOSIS TREATMENT SERVICES PROVIDED BY PRIMARY CARE PROVIDER................................. 63 CERVICAL CANCER SCREENING ............................................................................................................... 63 CASE MANAGEMENT .............................................................................................................................. 64 HOSPICE CARE SERVICES ........................................................................................................................ 71 L.A. CARE APPEALS PROCESS .................................................................................................................. 72 INDEPENDENT MEDICAL REVIEW (IMR) ................................................................................................. 74 INITIAL AND PERIODIC HEALTH ASSESSMENTS ...................................................................................... 75 CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN)....................................................................... 80 MISSED OR BROKEN APPOINTMENTS .................................................................................................... 80 DISEASE MANAGEMENT ......................................................................................................................... 81 VISION SERVICES ....................................... …………………………………………………………………………………...86 MATRIX FOR LINKED AND CARVE OUT SERVICES BY PRODUCT LINE ..................................................... 87 CARE COORDINATION WITH MEDI-CAL LINKED AND CARVED-OUT SERVICES ...................................... 89 DESCRIPTION and RESPONSIBILITIES for the LINKED and CARVED OUT PROGRAMS ............................ 90 CALIFORNIA CHILDREN SERVICES (CCS) .................................................................................................. 90 MATERNAL AND CHILD HEALTH – COMPREHEHSIVE PRENATAL PROGRAM (CPSP).............................. 93 SCHOOL LINKED CHILD HEALTH AND DISABILITIES PREVENTION (CHDP) .............................................. 96 3 TUBERCULOSIS/DIRECT OBSERVATION THERAPY .................................................................................. 96 WOMEN, INFANTS AND CHILDREN (WIC) NUTRITIONAL SUPPLEMENT PROGRAM .............................. 98 DEVELOPMENTAL DISABILITIES SERVICES (DDS) .................................................................................... 99 EARLY INTERVENTION/EARLY START-MEDI-CAL .................................................................................. 102 SPECIALTY MENTAL HEALTH ................................................................................................................