First 5 Orange County and CalOptima Health are expanding the HealthySteps evidence-based model to 10 additional programs in Orange County. Applications are being accepted for this expansion, called the Dyadic Services Program Academy. Participation in the Academy includes a funding opportunity of $150,000 paid over 12 months, inclusion into community education sessions, and customized technical assistance.

The goal of this program is to decrease health inequities by increasing timely well-child visits, developmental and behavioral screenings, linkage to Community Supports, and dyadic care.

Applicants should be licensed clinic sites in Orange County that see a significant number of pediatric patients, from birth through the age of 3, who are insured by CalOptima Health. Preference will be given to licensed clinics that have at least 350 children ages 0–3 active in the practice, with a high percentage of CalOptima Health Medi-Cal members empaneled/active in the practice, and/or practices that have at least 3,500 visits per year for children in this age group.

Interested clinics can read this Notice of Funding Opportunity and apply for the Dyadic Services Program Academy at this link by 5 p.m. on July 10, 2024.

CalOptima Health has partnered with Verisys, previously Aperture Health, a national credentials verification organization, to manage the credentialing of our network providers.

Please review any emails you receive from donotreplyemail@aperturecvo.com. Providers will receive requests for ongoing credentialing applications. We ask that you complete, sign and date these documents and return the packet directly to Verisys by uploading to https://outreach.aperturecvo.com, using the access code “aperture.”

For help with uploading or to contact Verisys, providers can call Customer Service at 855-743-6161, Monday–Friday, 8 a.m. to 8 p.m. EST, email outreachsupport@verysis.com, fax 866-293-0421 or mail to:

Verisys

P.O. Box 221049

Louisville, KY 40252

If you have any questions regarding this transition, please call Provider Relations at 714-246-8600.

All CalOptima Health Community Network (CHCN) providers are invited to CalOptima Health’s quarterly virtual learn meeting on July 8 at Noon.

The Zoom webinar will cover a variety of topics, including:

• Access standards update
• Provider directory validation
• Provider Portal reports
• Initial Health Appointment (IHA)
• CalAIM implementation
• Partnership with SullivanLuallin Group to improve patient experience
• Disease management
• Covered California
• Dyadic services

Providers can register in advance using this Zoom link. You will receive a confirmation email with instructions on how to join the webinar.

If you have any questions about this webinar, please contact your Provider Relations representative at 714-246-8600 or providerservicesinbox@caloptima.com.

Providers and office staff are invited to attend one of three virtual training happening in July and August covering Measurement Year (MY) 2024 Healthcare Effectiveness Data and Information Set (HEDIS) document requirements.

The 90-minute webinars will cover an overview of HEDIS, hybrid measure specifications, common chart deficiencies and the required documentation to meet National Committee for Quality Assurance (NCQA) care standards.

The following sessions will be held on Microsoft Teams from 12:30 to 2 p.m.:

• Tuesday, July 9
• Tuesday, July 16
• Tuesday, August 6

To register, please email Irma Munoz, HEDIS Project Manager, at imunoz@caloptima.org with the date of the session you want to attend in the subject line. Providers should only register for one session, as all three will cover the same material. 

CalOptima Health continues to offer free cases of life-saving naloxone and free delivery directly to provider offices as part of our Drive to Revive campaign.

Providers who sign a simple distribution agreement can receive an unlimited number of cases that contain single-use, prescription-strength nasal spray doses of Kloxxado, naloxone’s brand name. 

Naloxone can potentially save lives if administered to someone having a known or suspected opioid overdose or fentanyl poisoning. Naloxone is easy to use, requires no special training and is safe even for use on children. CalOptima Health has information and a training video at www.caloptima.org/naloxone.  

Providers can order naloxone through CalOptima Health by following the steps below: 

1. Email naloxone@caloptima.org with the name and email address of your organization’s authorized representative. We will then send that person a Naloxone Distribution Agreement via DocuSign. 
2. Once you have the agreement, identify the number of cases you want. 
3. Sign and return the agreement. 
4. Receive the naloxone. CalOptima Health will deliver the naloxone during the business hours identified on the DocuSign. 

For questions about the event or the naloxone distribution program, email naloxone@caloptima.org. 

Providers can receive answers to questions about the Department of Health Care Services’ (DHCS) Electronic Visit Verification (EVV) system through two virtual office hours happening in July.

The one-hour webinars will be held on:

• July 11 at 10 a.m.; register here.
• July 19 at 3 p.m.; register here.

During these virtual office hours, providers can ask the EVV team questions about registering, capturing EVV visit data, navigating the CalEVV portal and more.

Please email any advanced questions to EVV@dhcs.ca.gov to allow time to prepare responses and possible live demonstrations. For more information about the EVV program, visit DHCS’ EVV webpage or the Department of Developmental Services' EVV webpage.

Federal and state regulations require CalOptima Health to provide interpreter services to limited English proficient (LEP) members who have a limited ability to read, speak, write or understand English.

Depending on the situation, providers may request either telephonic or face-to-face interpreter services for their CalOptima Health LEP patients.

How to request interpreter services:

• Verify the member’s eligibility and identify if the member is enrolled in a health network, CHCN or CalOptima Health Direct (COD).

• Determine whether telephonic or face-to-face interpreter service is needed.

a.  Telephonic interpreter service is recommended for urgent situations or short and simple conversations. This service is available 24/7.

b.   Face-to-face interpreter service, including American Sign Language, is recommended when complicated or extensive explanation of treatment or symptoms is required. This service is available for scheduled medical appointments in an ambulatory setting and requires at least five working days’ advance notice.

• Please have the following information ready at the time of the request:

a.  Member’s name

b.  Member’s Client Index Number (CIN)

c.  Member’s gender

d.  Member’s age

e.  Date of appointment

f.   Time of appointment

g.  Language needed

h.  Approximate duration

i.   Type of visit

j.   Name of doctor/facility

k.  Address of appointment/location

l.   Phone number of appointment/location

• If the member is in CHCN or COD, call CalOptima Health’s Customer Service department at 714-246-8500. Prior authorization is not required.

• If the member is in a health network, please use this list to contact the member’s health network after verifying eligibility. The member’s health network will work with you and the member to coordinate all interpreter services.

For additional information, please see Section N7 of the Provider Manual on the CalOptima Health website.

To improve HEDIS scores, CalOptima Health encourages providers to reduce imaging studies when evaluating members for low back pain (LBP).

The HEDIS LBP measure evaluates members ages 18–75 with a principal diagnosis of LBP in an outpatient or emergency department visit who did not have an imaging study (X-ray, CT scan or MRI) within 28 days of the primary diagnosis. A higher measure rate indicates appropriate treatment, as evidence shows that unnecessary or routine imagining for LBP is not associated with improved outcomes, according to NCQA.

How to improve your HEDIS scores for LBP:

• Avoid ordering diagnostic studies within 30 days of a diagnosis of new onset back pain in the absence of red flags (e.g., cancer, recent trauma, intravenous drug abuse, neurologic impairment, HIV, spinal infection, major organ transplant, prolonged use of corticosteroids, hospice, osteoporosis, fragility fracture, lumbar surgery, spondylopathy or palliative care).
• Provide patient education on comfort measures, e.g., pain relief, stretching exercises and activity level.
• Use correct exclusion codes if applicable (e.g., cancer).
• Look for other reasons for visits for LBP (e.g., depression, anxiety, narcotic dependency, psychosocial stressors, etc.).

Due to a high number of false positives and other negative impacts, CalOptima Health-contracted providers should avoid conducting unnecessary prostate cancer screenings on men over age 70.

The United States Preventive Services Task Force (USPSTF) recommends against prostate-specific antigen (PSA)-based screening for men ages 70 years and older. While USPSTF found evidence that PSA screenings may slightly lower the chance of death from prostate cancer, it also found that many men are at risk of negative effects from these screenings. Such effects include false positive test results that lead to more testing, as well as the diagnosis of problems that would not have caused symptoms or death.

For the Non-Recommended PSA-based Screening in Older Men HEDIS measure, a lower rate indicates better performance. You can improve this HEDIS score by:

• Educating patients on the adverse effects and benefits of testing.
• Avoid testing for low-risk men if the patient has no prior family history of prostate cancer or has no prior history of elevated PSA test value (>4.0 nanogram/milliliter [ng/mL]).

Providers should use spirometry testing when evaluating members suspected of a new or worsening diagnosis of chronic obstructive pulmonary disease (COPD). Spirometry results can verify a COPD diagnosis and be valuable when deciding a course of treatment.

The HEDIS Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR) measure evaluates the percentage of members ages 40 and older with a new diagnosis of COPD or newly active COPD who received appropriate spirometry to confirm the diagnosis.

This measure consists of:

• Diagnosis — A 12-month lookback period that begins July 1 of the year prior to the measurement year and ends June 30 of the measurement year. This lookback period captures the first COPD diagnosis.
• Spirometry testing — At least one claim/encounter for spirometry testing to confirm the diagnosis in the two years prior to the diagnosis through six months after the diagnosis.
• CalOptima Health offers the following best practice tips:
• Emphasize the importance of spirometry testing to members newly diagnosed with COPD or newly active COPD.
• Incorporate the use of spirometry testing for all members with a new diagnosis of COPD to verify.
• Perform in-office spirometry if equipment is available. Ensure you and your staff are trained on the proper administration of spirometry testing. Maintain and calibrate the spirometry equipment according to manufacturer guidelines.
• If equipment is not available, arrange for the member to complete spirometry testing at a location/provider where spirometry equipment is available. Submit timely claims for spirometry testing performed in-office.
• Check problem lists and encounter forms. Confirm that the diagnosis coding is accurate (i.e., acute vs. chronic bronchitis) to prevent the member from inadvertently being pulled into the SPR measure.
• Educate members about the importance of adhering to their medication regimen (proper dose, frequency route and time).

To review a list of relevant medical codes, click here. Please note this is not an all-inclusive list.

The Orange County Health Care Agency’s (HCA) Childhood Lead Poisoning Prevention Program (CLPPP) is dedicated to raising awareness of the dangers of lead. To reduce childhood lead poisoning and promote early detection, CLPPP offers case management and environmental investigations for eligible patients and education about environmental lead exposures and health education materials for providers. To order materials, please fill out and submit this form.

For general questions or those related to case management or environmental investigations, please contact CLPPP at 714-567-6220. For questions related to abatement or complaints about unsafe lead practices, please contact an Environmental Professional at 714-433-6000. For more information, please see this flyer or visit the CLPPP website at ochealthinfo.com/lead.

DHCS has sent CalOptima Health updated Cost-Avoided Other Health Coverage (OHC) and HMO Coverage codes. There are no actual changes to the OHC codes themselves, but there has been some re-coding for certain members if assigned one of the 11 Medicare Advantage plan carrier codes. The change will also be reflected in the Automated Eligibility Verification System (AEVS).

Impacted carrier codes are as follows:

1. A555
2. A600
3. A601
4. B117
5. B122
6. C153
7. K301
8. O060
9. S146
10. S149
11. W073  

For additional information and resources regarding OHC Codes and billing, please refer to the Provider Manual, Other Health Coverage Guidelines for Billing or visit the OHC Resources page.

On June 13, DHCS distributed the Non-Physician Medical Practitioners (NMP) section of the Medi-Cal Provider Manual, which was updated after extensive internal DHCS discussion and consultation with external stakeholders.

The most recent updates to the NMP section include the following:

• Removing the list of specific billing codes and covered services for nurse practitioners (NPs) and certified nurse midwives (CNMs) to ensure they can bill for services consistent with Medi-Cal policy and their scope of practice as defined in state statute and by their applicable licensing/certification boards (e.g., California Board of Registered Nursing and, for nurse midwives, also the American College of Nurse-Midwives). CNMs and NPs should utilize the various sections of the Medi-Cal Provider Manual to identify Medi-Cal coverage and billing policies that align with their scopes of practice.

o  For NPs, see Pages 4–10

o  For CNMs, see Pages 11–15

• Adding a list of specific Medi-Cal-covered services and associated billing codes that licensed midwives (LMs) can bill pursuant to their scope of practice as defined by the Medical Board of California (MBC) and consistent with established protocols, procedures and treatments authorized pursuant to Business and Professions Code (BPC) sections 2505–2521. Please note that DHCS is still undertaking some code refinement work based on recent direction and guidance received from the MBC, which is the entity that defines the LM scope of practice.

o  For LMs, see Pages 16–28

Additionally, in May 2024, DHCS published a new midwifery website for general policy information and helpful resources.

Click on the link below to find an outline of changes made to CalOptima Health policies and procedures during May 2024. The full description of the policies below is available on CalOptima Health’s website at:

www.caloptima.org/en/ForProviders/Resources/ManualsPoliciesandGuides.aspx.

Policies and Procedures Monthly Update

Click below for training webinars and meetings happening in June 2024:

Health education webinars

• CalOptima Health Board of Directors: August 1 at 2 p.m.
• Joint Meeting of the Provider and Member Advisory Committees: August 15 at Noon

All meetings have an option for virtual attendance. Visit the CalOptima Health website for more information.