My office received the 2021 Provider Packet: ... Provider Packet 2021 ... Please refer to the SCFHP Provider Manuals for additional details regarding the ...
2021 Provider Packet Attestation
Provider Network Operations Phone: 1-408-874-1788 Fax: 1-408-376-3537
Upon receipt of the Provider Packet, please complete and sign this form. Email a copy to ProviderServices@scfhp.com or fax to 1-408-376-3537.
Date of visit: __________________________________ Network: ____________________________________
Provider office:______________________________________________ TIN: _________________________
Type of provider: Primary Care Provider Specialist Ancillary
Contents of the 2021 Provider Packet:
Identification cards Provider Link Population Health Management program Case Management referral form Health Homes Program provider overview Health Homes Program referral form Long-term services and supports (LTSS) referrals Reporting critical incidents to SCFHP Potential Quality of Care Issue (PQI) referral form Your role as a SCFHP PCP Initial Health Assessment Alcohol misuse screening and counseling Adopted clinical & preventive guidelines Timely access standards & surveys Timely access to care standards (grid)
My office received the 2021 Provider Packet:
Provider/office staff name:
Title:
Provider/office staff signature:
SCFHP Provider Network Operations signature:
Line of business: Medi-Cal Cal MediConnect
Claims Provider dispute form Grievances & appeals submission process Medi-Cal member grievance & appeal form Cal MediConnect member grievance & appeal form Required compliance trainings Interpreter services reference guide Cal MediConnect member rights & responsibilities Medi-Cal member rights & responsibilities Health Education Request Health Education for patient (form) Provider data & attestations Change notification form Medi-Cal quick reference guide Cal MediConnect quick reference guide Medical covered services prior authorization grid
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Provider Packet
Provider Network Operations: ProviderServices@scfhp.com 1-408-874-1788, Monday through Friday, 8:30 a.m. to 5:00 p.m. www.scfhp.com Updated 02/2021
Santa Clara Family Health Plan Provider Packet 2021
Santa Clara Family Health Plan (SCFHP) is regulated by several state and government agencies, including the Centers for Medicare and Medicaid Services (CMS), the Department of Managed Healthcare (DMHC), and the Department of Healthcare Services (DHCS).
In order to maintain compliance with our regulators, SCFHP provides training and resources to all contracted providers and their office staff.
Working in collaboration with our providers, Santa Clara Family Health Plan is committed to supplying the care our members need, as well as the respect they deserve. We appreciate your continued support on this effort.
For any questions, please contact SCFHP Provider Network Operations at ProviderServices@scfhp.com or call 1-408-874-1788, Monday through Friday, 8:30 a.m. to 5 p.m.
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Contents
Identification cards ............................................................................................................................................................... 3 Provider Link ........................................................................................................................................................................ 5 Population Health Management .......................................................................................................................................... 6 Case Management Referral Form ....................................................................................................................................... 7 Health Homes Program Provider Overview......................................................................................................................... 9 Health Homes Program Referral Form .............................................................................................................................. 13 Long-term services and supports (LTSS) referrals.............................................................................................................19 Reporting critical incidents to SCFHP ............................................................................................................................... 22 Potential Quality of Care Issue (PQI) Referral Form ......................................................................................................... 23 Your role as an SCFHP PCP ............................................................................................................................................. 24 Initial Health Assessment .................................................................................................................................................. 25 Alcohol misuse screening and counseling ........................................................................................................................ 28 Adopted clinical and preventive guidelines ....................................................................................................................... 29 Timely access standards and surveys ............................................................................................................................... 31 Timely access to care standards ....................................................................................................................................... 32 Claims ................................................................................................................................................................................ 35 Provider Dispute Form ....................................................................................................................................................... 37 Summary of grievances and appeals submission process ................................................................................................ 38 Medi-Cal Member Grievance and Appeal Form.................................................................................................................39 Cal MediConnect Member Grievance and Appeal Form................................................................................................... 42 Required compliance trainings .......................................................................................................................................... 49 Interpreter Services Reference Guide ............................................................................................................................... 50 Cal MediConnect member rights and responsibilities ........................................................................................................51 Medi-Cal member rights and responsibilities..................................................................................................................... 52 Health Education ............................................................................................................................................................... 55 Request Health Education for Patient ................................................................................................................................56 Provider data and attestations ........................................................................................................................................... 57 Change Notification Form .................................................................................................................................................. 58 Medi-Cal Quick Reference Guide ...................................................................................................................................... 59 Cal MediConnect Quick Reference Guide......................................................................................................................... 62 Medical Covered Services Prior Authorization Grid .......................................................................................................... 64
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Identification cards
Santa Clara Family Health Plan (SCFHP) issues ID cards to members enrolled in one of two plans: 1. SCFHP Medi-Cal Plan 2. SCFHP Cal MediConnect Plan (Medicare-Medicaid Plan)
Before providing medical services to your patients, always verify the patient is an eligible SCFHP member. You can use the information on the patient's SCFHP ID card to verify their eligibility. See the next page for a sample of an SCFHP ID card.
When a patient presents an SCFHP ID card to you, update your records with the information you see on the card. Important billing information and instructions on who you can call are printed on the card.
How to check eligibility 24/7 · Log into Provider Link and use the Eligibility tab: https://providerportal.scfhp.com · Call the Interactive Voice Response (IVR): 1-408-874-1473
Questions? Contact SCFHP Provider Network Operations at ProviderServices@scfhp.com or call 1-408-874-1788, Monday through Friday, 8:30 a.m. to 5 p.m.
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Sample SCFHP identification cards Medi-Cal
Note: Members may have older versions of the ID Card. Authorizations and claims may be delegated. Please visit www.scfhp.com/auths or www.scfhp.com/claims for the latest authorization and claims information. Cal MediConnect
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Provider Link
Provider Link is the provider portal and Santa Clara Family Health Plan's online platform for accessing eligibility information, claims and authorizations status, and other helpful resources.
Create an account 1. Visit providerportal.scfhp.com to register. You can also access Provider Link from www.scfhp.com. 2. You will need to provide information like your tax identification number (TIN), a paid claim number from the last 180 days, and an active email address. 3. Create your own unique username, password, and security questions to complete registration.
How to check a patient's eligibility in an SCFHP plan After logging in, click on the Eligibility tab. You can quickly look up any patient's eligibility by:
1. Using the Select TIN drop-down menu and selecting All Providers; and 2. Entering the patient's SCFHP ID number OR the patient's last name and date of birth.
Click on the patient's name to find more information about the patient, like: · Contact information · Network · PCP name, phone number, and effective date · Eligibility status · Aid code · A history of the patient's SCFHP coverage dates
The information on Provider Link is updated daily. However, if a patient has changed primary care providers, the change will only be effective and seen on the portal on the first of the following month.
How to find a list of your SCFHP patients Under the same Eligibility tab, you can see a list of your SCFHP patients by using the Select TIN drop down menu and selecting your TIN. A list will appear at the bottom of your screen with patients that are associated with your TIN.
How to check claims and authorizations status Provider Link only displays claims and authorizations processed by SCFHP.
For the SCFHP Cal MediConnect Plan (Medicare-Medicaid Plan), you will see claims and authorizations on the portal. Additionally, MedImpact continually processes the pharmacy authorizations for the SCFHP Cal MediConnect Plan. To contact MedImpact, call: 1-800-788-2949.
For SCFHP Medi-Cal members affliated with delegated medical groups, you will need to contact the group to check claims and authorizations status.
Questions? Contact SCFHP Provider Network Operations at ProviderServices@scfhp.com or call 1-408-874-1788, Monday through Friday, 8:30 a.m. to 5 p.m.
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Population Health Management
SCFHP's Population Health Management (PHM) program is designed to improve access to medical, mental health, social services, preventive health services, and Home & Community Based Services (HCBS). Additionally, the PHM program works to improve coordination of care and improve seamless care transitions across multiple healthcare settings through a single point of contact.
To refer patients to the PHM program, please complete and submit a Case Management Referral Form. For your convenience, a description of the program and the referral form is attached. It can also be found on our website at www.scfhp.com under For providers and in Forms and documents.
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Case Management Referral Form
Case Management Email: CaseManagementHelpDesk@scfhp.com
Phone: 1-877-590-8999 Fax: 1-408-874-1432
Please return the completed form via SECURE email or fax and attach all applicable documentation. Allow up to three (3) business days for processing by Santa Clara Family Health Plan (SCFHP).
Patient information
Full name:
SCFHP ID:
DOB:
Spoken language: Primary diagnosis: Referral source:
Written language:
Physician Hospital discharge planner Community-based provider Vendor or delegate
Home phone:
Mobile phone:
SCFHP staff Skilled nursing facility Patient/caregiver Other:
Reason for referral (check all that apply): Linkage to community-based services
(homelessness, nutrition, or other social risk factors)
Advanced age with multiple chronic conditions
3 or more ER visits in the past 12 months
Evaluation for hospice/palliative care
Inadequate support for home safety (fall risk, assistance at home)
Hospitalized in the past 180 days
Evaluation for behavioral health
Access to SCFHP benefits (transportation, durable medical equipment, pharmacy)
Change in health status (transition of care)
Other: ________________________________
Applicable supporting documentation included (check all that apply):
Face sheet History Progress notes Medication list Care plan Treatment (Tx) plan Assessment Other: __________________________
Additional referral information
Information about person/clinic submitting this form
Name/agency:
Date:
Pho ne:
Email:
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Case Management Referral Form
Case Management Email: CaseManagementHelpDesk@scfhp.com
Phone: 1-877-590-8999 Fax: 1-408-874-1432
Referring SCFHP patients for case management SCFHP Case Management accepts referrals for any SCFHP-enrolled patient and their caregiver in need of support, resources, and assistance related to the coordination of care and services for complex medical or behavioral health conditions and non-medical risk factors. Patients can be referred to or can self-refer to case management without having to meet any program criteria. Case management services are at no cost to patients enrolled in SCFHP, and do not require patient consent. Patients may choose to decline case management services at any time without losing health plan coverage.
Upon referral, SCFHP's Case Management team will attempt to: · Connect with the patient to assess their needs; · Determine the most appropriate level of case management intervention; · Set goals for an individual care plan that integrates access to medical, behavioral health, long-term services benefits and support, and community resources.
SCFHP Case Managers are part of the interdisciplinary care team, which includes Registered Nurses (RN) and licensed social workers with expertise in behavioral health and long-term services and supports. They seek to seamlessly coordinate patient care with various providers across care settings to avoid duplication of services and to maximize support for the patient. Individual care plans are shared with the patient, their caregiver, and assigned primary care provider (PCP) as well as other stakeholders as permitted by the patient. Providers are encouraged to share any edits or modifications to an individual care plan to SCFHP's Case Management team to further support the patient's needs. If a patient declines case management services, the person who submitted the referral will be notified.
Examples of situations where patients should be referred for case management: Frequent ER visits or hospital admissions (3 or more in the past 12 months) Experiencing a transition in care Non-compliance with PCP visits, medications, or prescribed treatment for chronic conditions Complex medical and/or mental health conditions including progressive or degenerative diseases Diagnosis or conditions requiring a lengthy recovery period Significant impairments in one or more activities of daily living Other non-medical risk factors such as unstable housing, inadequate income, isolation, or lack of family or social supports
Form submission instructions: 1. Complete all sections of the form. 2. Provide your direct contact information. 3. Send completed form and supporting documentation via SECURE email to SCFHP Case Management at CaseManagementHelpDesk@scfhp.com. 4. Allow three (3) business days for a case management referral to be processed.
Thank you, SCFHP Case Management
Confidentiality Notice: This electronic fax transmission (including any documents, files or previous email messages attached to it) may contain confidential information that is intended for a specific individual and purpose and that is privileged or otherwise protected by law. If you are not the intended recipient, or a person responsible for delivering it to the intended recipient, please delete this fax and notify SCFHP UM of the error. Any disclosure, copying or distribution of this message, or taking of any action based on it, is strictly prohibited.
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HEALTH HOMES PROGRAM (HHP)
PROVIDER OVERVIEW
The Medi-Cal Health Homes Program (HHP) helps manage and coordinate care for Medi-Cal members with certain chronic health and/or mental health conditions who have high health care needs or experience chronic homelessness. Eligible members will be assigned to a community based care management entity (CB-CME) who will provide Health Homes Program services. Once enrolled in HHP, the member will be provided a care team that includes a care coordinator, clinical consultant, and a housing navigator. The care team will work with the member to manage and coordinate the member's care and connect them to community and social services. HHP services are provided at no cost to the member and will not change or take away any of the member's current Medi-Cal benefits. HHP WILL SERVE AS THE CENTRAL POINT FOR COORDINATING PATIENT-FOCUSED CARE AND AIMS TO:
Improve member outcomes by coordinating physical health services, mental health services, substance use disorder services, community-based Long-Term Services and Supports (LTSS), oral health, and social support needs
Create infrastructure to support multi-system coordination and care delivery Reduce avoidable health care costs, including hospital admissions/readmissions, ED visits,
and nursing facility stays
Address homelessness/unstable housing of eligible members
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HEALTH HOMES CORE SERVICES
Care Managment
Develop and update a Health Action Plan
(HAP) to guide services and care
Care Coordination
Coordinate care across ALL of their providers
Health Promotion
Educate members about and support them in adopting healthy behaviors
Transitional Care
Facilitate care transitions between the hospital, nursing homes,
other treatment facilities, and home
Member and Family Supports
Support the self-management and decision making efforts of members and their family and/
or support team
Referral to Community and Social Supports
Connect members to community and social services, including housing, as needed
Housing Navigation and Tenancy Support
Connect members experiencing chronic homelessness with housing and tenancy support
HEALTH HOMES CB-CMES
Community-Based Care Management Entities (CB-CMEs) will be the frontline providers of the Health Homes Program's (HHP) required services. These agencies will conduct outreach and engagement to SCFHP members who are HHP eligible, as well as deliver HHP services.
THE CB-CME CARE TEAM · Care coordinator · HHP director · Clinical consultant · Housing navigation
THE CB-CME CARE TEAM WILL OVERSEE THE DELIVERY OF HHP SERVICES AND: · Work with members and care teams to develop and update the Health Action Plan (HAP) · Ensure that members have access to their care team and care coordination services, including case conferences to ensure coordination among providers · Manage referrals, coordination, and follow-up to needed services and supports · Support members and their families during discharge from the hospital and treatment facilities · Provide services in person and accompanying members to appointments when needed
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ELIGIBILITY AND ENROLLMENT
To qualify for HHP, the member must be enrolled in Medi-Cal and must meet at least one condition from each of the two columns below:
Diagnosis
Acuity/Complexity Criteria
Have at least two of these conditions: o Chronic obstructive pulmonary disease (COPD) o Diabetes o Traumatic brain injury o Chronic or congestive heart failure o Coronary artery disease o Chronic liver disease o Chronic kidney disease o Dementia o Substance use disorders
Have hypertension (high blood pressure) and one of these conditions:
o COPD o Diabetes o Coronary artery disease o Chronic or congestive heart failure Have one of these conditions: o Major depression disorders o Bipolar disorder o Psychotic disorders (including
schizophrenia) Have asthma
Have three or more of the conditions listed under Diagnosis Have experienced an inpatient hospital admission in the last 12 months
Visited the emergency department three or more times in the last 12 months
Be chronically homeless
HOW DO ELIGIBLE MEDI-CAL MEMBERS JOIN HHP?
· Most eligible members will be contacted about HHP. The Department of Health Care Services and SCFHP will identify members who are eligible for HHP and place members on the Targeted Engagement List (TEL). Eligible members will receive a letter informing them of their eligibility.
· A provider submits a referral form for a member. If a member is not on the TEL but may be eligible, the provider can submit a referral form via the SCFHP Provider Portal, email healthhomescm@scfhp.com, or fax 1-408-874-1469. This may be necessary if the individual is newly enrolled in Medi-Cal.
· A member asks to join. Individuals can contact SCFHP Customer Service at 1-800-260-2055 and ask if they qualify for HHP.
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How to talk with an SCFHP member about HHP?
Consider using the following messages when talking with SCFHP members about HHP:
Members keep their doctors and receive extra support at no cost as part of their Medi-Cal benefits Members are given a care team including a care coordinator that works together with the member to help them get the health care and social services they need Joining HHP will not take away or change any of the member's Medi-Cal benefits Joining HHP is voluntary, and members can stop HHP services at any time
HHP services help your SCFHP members get the care they need to stay healthy. HHP works with you as their doctor to connect them to services they need.
For More Information
Online www.scfhp.com/health-homes
Email
healthhomes@scfhp.com
Call
1-408-874-1452
Visit
Santa Clara Family Health Plan 6201 San Ignacio Ave San Jose, CA 95119
Sign up to receive SCFHP's bi-monthly newsletter, Provider e-news. http://bit.ly/SCFHPeNews_Signup
If your organization is interested in becoming a CB-CME, please contact SCFHP at healthhomes@scfhp.com.
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Health Homes Program (HHP) Referral Form
Email: HealthHomesCM@scfhp.com Fax: 1-408-874-1469
Return completed referral form and all applicable documentation via SECURE email to HealthHomesCM@scfhp.com or fax to 1-408-874-1469. Allow up to 5 business days for referral to be reviewed once received.
Patient/Member Information
First Name:
Last Name:
DOB:
SCFHP ID:
Spoken Language:
Phone:
Current Address:
Name/Agency Referral Information
Referred by Name/Agency:
Address:
Phone:
Email:
Community Based Care Management Entity (CB-CME) Recommendation (Optional):
To qualify for HHP, the member must be enrolled in Medi-Cal and meet both the criteria
requirements below:
1. Can check at least one of the boxes below:
2. Can check at least one of the boxes below:
Have at least two of these conditions:
Have three or more of the following
Chronic obstructive pulmonary disease
conditions:
(COPD)
Chronic obstructive pulmonary disease
Diabetes
Diabetes
Traumatic brain injury (TBI)
Traumatic brain injury
Chronic or congestive heart failure (CHF)
Chronic or congestive health failure
Coronary artery disease (CAD)
Coronary artery disease
Chronic liver disease
Chronic liver disease
Chronic kidney disease
Chronic renal (kidney) disease
Dementia
Dementia
Substance use disorders
Substance use disorder
Have hypertension (high blood pressure)
Asthma
and one of these conditions:
One inpatient stay within the last 12 months
Chronic obstructive pulmonary disease Diabetes Coronary artery disease Chronic or congestive heart failure
Visited the emergency department 3 or more
times in the last year Chronic homelessness
Have one of these conditions:
Major depression disorders
Bipolar disorder
Psychotic disorders (including
schizophrenia)
Have asthma
Supporting Documents
The following supporting documents are recommended. Check all that apply and attach to this referral.
Face sheet Care plan Recent chart notes Other
Referrer Signature:
Date Referral Sent:
For SCFHP Use: Source: Email Fax Mail In-person Other
Date received:
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HHP Referral Form: Reference Page Eligible Conditions Diagnosis Codes
Email: HealthHomesCM@scfhp.com Fax: 1-408-874-1469
Asthma
J45.20, J45.21, J45.22, J45.30, J45.31, J45.32, J45.40, J45.41, J45.42, J45.50, J45.51, J45.52, J45.901, J45.902, J45.909, J45.991, J45.998
CAD
I20.0, I24.0, I24.1, I24.8, I24.9, I25.10, I25.110, I25.111, I25.118, I25.119, I25.5, I25.6, I25.700, I25.710, I25.720, I25.730, I25.750, I25.751, I25.758, I25.759, I25.760, I25.790, I25.811, I25.82, I25.83, I25.84, I25.89, I25.9, Z95.1, Z95.5, Z98.61
CHF I09.81, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.9, I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83 I50.84, I50.89
COPD
J41.0, J41.8, J42, J43.0, J43.1, J43.2, J43.8, J43.9, J44.0, J44.1, J44.9, J47.0, J47.1, J47.9
Dementia
F01.50, F01.51, F02.80, F0281, F03.90, F03.91, F04, F05, F06.8, F07.0, F07.81, F07.89, F09, F48.2, G30.9, G31.01, G31.09, G31.1, G31.83, R41.81
Diabetes E08.00, E08.01, E08.10, E08.11, E08.21, E08.22, E08.29, E08.311, E08.319, E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E08.351, E08.359, E08.36, E08.39, E08.40, E08.51, E08.52, E08.59, E08.610, E08.618, E08.620, E08.621, E08.622, E08.628, E08.630, E08.638, E08.641, E08.649, E08.65, E08.69, E08.8, E08.9, E09.00, E09.01, E09.10, E09.11, E09.21, E09.22, E09.29, E09.311, E09.319, E09.321, E09.329, E09.331, E09.339, E09.341, E09.349, E09.351, E09.359, E09.36, E09.39, E09.40, E09.41, E09.42, E09.43, E09.44, E09.49, E09.51, E09.52, E09.59, E09.610, E09.618, E09.620, E09.621, E09.622, E09.628, E09.630, E09.638, E09.641, E09.649, E09.65, E09.69, E09.8, E09.9, E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E11.36, E11.39, E11.40, E11.41, E11.42,E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359, E13.36, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, R81, Z46.81, R82.4 Z96.41, E08.3211, E08.3212, E08.3213, E08.3219, E08.3291, E08.3292, E08.3293, E08.3299, E08.3311, E08.3312, E08.3313, E08.3319, E08.391, E08.3392, E08.3393, E08.3399, E08.3411, E08.3412, E08.3413, E08.3419, E08.3491, E08.3492, E08.3493, E08.3499, E08.3511, E08.3512, E08.3513, E08.3519, E08.3521, E08.3522, E08.3523, E08.3529, E08.3531, E08.3532, E08.3533, E08.3539, E08.3541, E08.3542, E08.3543, E08.3549, E08.3551, E08.3552, E08.3553, E08.3559, E08.3591, E08.3592, E08.3593, E08.3599, E08.37X1, E08.37X2, E08.37X3, E08.37X9, E09.3211, E09.3212, E09.3213, E09.3219, E09.3291, E09.3292, E09.3293, E09.3299, E09.3311, E09.3312, E09.3313,
40346 HHP Referral Form: Reference Page, Eligible Conditions Diagnosis Codes
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HHP Referral Form: Reference Page Eligible Conditions Diagnosis Codes
Email: HealthHomesCM@scfhp.com Fax: 1-408-874-1469
E09.3319, E09.3391, E09.3392, E09.3393, E09.3399, E09.3411, E09.3412, E09.3413, E09.3419, E09.3491, E09.3492, E09.3493, E09.3499, E09.3511, E09.3512, E09.3513, E09.3519, E09.3521, E09.3522, E09.3523, E09.3529, E09.3531, E09.3532, E09.3533, E09.3539, E09.3541, E09.3542, E09.3543, E09.3549, E09.3551, E09.3552, E09.3553, E09.3559, E09.3591, E09.3592, E09.3593, E09.3599, E09.37X1, E09.37X2, E09.37X3, E09.37X9, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E10.37X1, E10.37X2, E10.37X3, E10.37X9, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531, E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E11.37X2, E11.37X3, E11.37X9, E11.3X11, E11.10, E11.11, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, E13.3319, E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599, E13.37X1, E13.37X2, E13.37X3, E13.37X9
Hypertension
I10, I67.4, I11.9, I11.0, I12.9, I12.0, I13.0, I13.10, I13.11, I13.2, I15.0, I15.1, I15.2, I15.8, I15.9, N26.2, I16.0, I16.1, I16.9
Liver disease K72.00, K74.0, K74.60, K74.69, K74.3, K74.4, K74.5, K75.81, K76.0, K76.89, K74.1, K74.2, K76.9, K75.0, K75.1, K70.41, K71.11, K72.01, K72.90, K72.91, K76.6, K76.7, K72.10, K72.11, K76.1, K76.3, K76.5, K76.81, K77, R17, R18.8, Z48.23, Z94.4
TBI S01.90XA, S01.90XD, S04.011S, S04.012S, S04.019S, S04.02XS, S04.031S, S04.032S, S04.039S, S04.041S,S04.042S, S04.049S, S04.10XS, S04.11XS, S04.12XS, S04.20XS, S04.21XS, S04.22XS, S04.30XS, S04.31XS,S04.32XS, S04.40XS, S04.41XS, S04.42XS, S04.50XS, S04.51XS, S04.52XS, S04.60XS, S04.61XS, S04.62XS,S04.70XS, S04.71XS, S04.72XS, S04.811S, S04.812S, S04.819S, S04.891S, S04.892S, S04.899S, S06.0X0A,S06.0X0D, S06.0X0S, S06.0X1A, S06.0X1D, S06.0X1S, S06.0X2A, S06.0X2D, S06.0X2S, S06.0X3A, S06.0X3D, S06.0X3S, S06.0X4A, S06.0X4D, S06.0X4S, S06.0X5A, S06.0X5D, S06.0X5S, S06.0X6A, S06.0X6D, S06.0X6S, S06.0X7A, S06.0X7D, S06.0X7S, S06.0X8A, S06.0X8D, S06.0X8S, S06.0X9A, S06.0X9D, S06.0X9S, S06.1X0A, S06.1X0D, S06.1X0S, S06.1X1A, S06.1X1D, S06.1X1S, S06.1X2A, S06.1X2D, S06.1X2S, S06.1X3A, S06.1X3D, S06.1X3S, S06.1X4A, S06.1X4D, S06.1X4S, S06.1X5A, S06.1X5D, S06.1X5S, S06.1X6A, S06.1X6D, S06.1X6S, S06.1X7A, S06.1X7D, S06.1X7S, S06.1X8A, S06.1X8D, S06.1X8S, S06.1X9A, S06.1X9D, S06.1X9S, S06.2X0A, S06.2X0D, S06.2X0S, S06.2X1A, S06.2X1D, S06.2X1S, S06.2X2A, S06.2X2D, S06.2X2S, S06.2X3A, S06.2X3D, S06.2X3S, S06.2X4A, S06.2X4D, S06.2X4S, S06.2X5A, S06.2X5D, S06.2X5S, S06.2X6A, S06.2X6D, S06.2X6S, S06.2X7A, S06.2X7D, S06.2X7S, S06.2X8A, S06.2X8D, S06.2X8S, S06.2X9A, S06.2X9D, S06.2X9S, S06.300A, S06.300D, S06.300S, S06.301A, S06.301D, S06.301S, S06.302A, S06.302D, S06.302S, S06.303A, S06.303D, S06.303S, S06.304A, S06.304D, S06.304S,
40346 HHP Referral Form: Reference Page, Eligible Conditions Diagnosis Codes
15
HHP Referral Form: Reference Page Eligible Conditions Diagnosis Codes
Email: HealthHomesCM@scfhp.com Fax: 1-408-874-1469
S06.305A, S06.305D, S06.305S, S06.306A, S06.306D, S06.306S, S06.307A, S06.307D, S06.307S, S06.308A, S06.308D, S06.308S, S06.309A, S06.309D, S06.309S, S06.310A, S06.310D, S06.310S, S06.311A, S06.311D, S06.311S, S06.312A, S06.312D, S06.312S, S06.313A, S06.313D, S06.313S, S06.314A, S06.314D, S06.314S, S06.315A, S06.315D, S06.315S, S06.316A, S06.316D, S06.316S, S06.317A, S06.317D, S06.317S, S06.318A, S06.318D, S06.318S, S06.319A, S06.319D, S06.319S, S06.320A, S06.320D, S06.320S, S06.321A, S06.321D, S06.321S, S06.322A, S06.322D, S06.322S, S06.323A, S06.323D, S06.323S, S06.324A, S06.324D, S06.324S, S06.325A, S06.325D, S06.325S, S06.326A, S06.326D, S06.326S, S06.327A, S06.327D, S06.327S, S06.328A, S06.328D, S06.328S, S06.329A, S06.329D, S06.329S, S06.330A, S06.330D, S06.330S, S06.331A, S06.331D, S06.331S, S06.332A, S06.332D, S06.332S, S06.333A, S06.333D, S06.333S, S06.334A, S06.334D, S06.334S, S06.335A, S06.335D, S06.335S, S06.336A, S06.336D, S06.336S, S06.337A, S06.337D, S06.337S, S06.338A, S06.338D, S06.338S, S06.339A, S06.339D, S06.339S, S06.340A, S06.340D, S06.340S, S06.341A, S06.341D, S06.341S, S06.342A, S06.342D, S06.342S, S06.343A, S06.343D, S06.343S, S06.344A, S06.344D, S06.344S, S06.345A, S06.345D, S06.345S, S06.346A, S06.346D, S06.346S, S06.347A, S06.347D, S06.347S, S06.348A, S06.348D, S06.348S, S06.349A,S06.349D, S06.349S, S06.350A, S06.350D, S06.350S, S06.351A, S06.351D, S06.351S,S06.352A, S06.352D, S06.352S, S06.353A, S06.353D, S06.353S, S06.354A, S06.354D, S06.354S, S06.355A, S06.355D, S06.355S, S06.356A, S06.356D, S06.356S, S06.357A, S06.357D, S06.357S, S06.358A, S06.358D, S06.358S, S06.359A, S06.359D, S06.359S, S06.360A, S06.360D, S06.360S, S06.361A, S06.361D, S06.361S, S06.362A, S06.362D, S06.362S, S06.363A, S06.363D, S06.363S, S06.364A, S06.364D, S06.364S, S06.365A,S06.365D, S06.365S, S06.366A, S06.366D, S06.366S, S06.367A, S06.367D, S06.367S, S06.368A, S06.368D, S06.368S, S06.369A, S06.369D, S06.369S, S06.370A, S06.370D, S06.370S, S06.371A, S06.371D, S06.371S, S06.372A, S06.372D, S06.372S, S06.373A, S06.373D, S06.373S, S06.374A, S06.374D, S06.374S, S06.375A, S06.375D, S06.375S, S06.376A, S06.376D, S06.376S, S06.377A, S06.377D, S06.377S, S06.378A, S06.378D, S06.378S, S06.379A, S06.379D, S06.379S, S06.380A, S06.380D, S06.380S, S06.381A, S06.381D, S06.381S, S06.382A, S06.382D, S06.382S, S06.383A, S06.383D, S06.383S, S06.384A, S06.384D, S06.384S, S06.385A, S06.385D, S06.385S, S06.386A, S06.386D, S06.386S, S06.387A, S06.387D, S06.387S, S06.388A, S06.388D, S06.388S, S06.389A, S06.389D, S06.389S, S06.4X0A, S06.4X0D, S06.4X0S, S06.4X1A, S06.4X1D, S06.4X1S, S06.4X2A, S06.4X2D, S06.4X2S, S06.4X3A, S06.4X3D, S06.4X3S, S06.4X4A, S06.4X4D, S06.4X4S, S06.4X5A, S06.4X5D, S06.4X5S, S06.4X6A, S06.4X6D, S06.4X6S, S06.4X7A, S06.4X7D, S06.4X7S, S06.4X8A, S06.4X8D, S06.4X8S, S06.4X9A, S06.4X9D, S06.4X9S, S06.5X0A, S06.5X0D, S06.5X0S, S06.5X1A, S06.5X1D, S06.5X1S, S06.5X2A, S06.5X2D, S06.5X2S, S06.5X3A, S06.5X3D, S06.5X3S, S06.5X4A, S06.5X4D, S06.5X4S, S06.5X5A, S06.5X5D, S06.5X5S, S06.5X6A, S06.5X6D, S06.5X6S, S06.5X7A, S06.5X7D, S06.5X7S, S06.5X8A, S06.5X8D, S06.5X8S, S06.5X9A, S06.5X9D, S06.5X9S, S06.6X0A, S06.6X0D, S06.6X0S, S06.6X1A, S06.6X1D, S06.6X1S, S06.6X2A, S06.6X2D, S06.6X2S, S06.6X3A, S06.6X3D, S06.6X3S, S06.6X4A, S06.6X4D, S06.6X4S, S06.6X5A, S06.6X5D, S06.6X5S, S06.6X6A, S06.6X6D, S06.6X6S, S06.6X7A, S06.6X7D, S06.6X7S, S06.6X8A, S06.6X8D, S06.6X8S, S06.6X9A, S06.6X9D, S06.6X9S, S06.810A, S06.810D, S06.810S, S06.811A, S06.811D, S06.811S, S06.812A, S06.812D, S06.812S, S06.813A, S06.813D, S06.813S, S06.814A, S06.814D, S06.814S, S06.815A, S06.815D, S06.815S, S06.816A, S06.816D, S06.816S, S06.817A, S06.817D, S06.817S, S06.818A, S06.818D, S06.818S, S06.819A,S06.819D, S06.819S, S06.820A, S06.820D, S06.820S, S06.821A, S06.821D, S06.821S, S06.822A, S06.822D, S06.822S, S06.823A, S06.823D, S06.823S, S06.824A, S06.824D, S06.824S, S06.825A, S06.825D, S06.825S, S06.826A, S06.826D, S06.826S, S06.827A, S06.827D, S06.827S, S06.828A, S06.828D, S06.828S, S06.829A, S06.829D, S06.829S, S06.890A, S06.890D, S06.890S, S06.891A, S06.891D, S06.891S, S06.892A, S06.892D, S06.892S, S06.893A, S06.893D, S06.893S, S06.894A, S06.894D, S06.894S, S06.895A, S06.895D, S06.895S, S06.896A, S06.896D, S06.896S, S06.897A,S06.897D, S06.897S,S06.898A, S06.898D, S06.898S,
40346 HHP Referral Form: Reference Page, Eligible Conditions Diagnosis Codes
16
HHP Referral Form: Reference Page Eligible Conditions Diagnosis Codes
Email: HealthHomesCM@scfhp.com Fax: 1-408-874-1469
S06.899A, S06.899D, S06.899S, S06.9X0A, S06.9X0D, S06.9X0S, S06.9X1A, S06.9X1D, S06.9X1S, S06.9X2A, S06.9X2D, S06.9X2S, S06.9X3A, S06.9X3D, S06.9X3S, S06.9X4A, S06.9X4D, S06.9X4S, S06.9X5A, S06.9X5D, S06.9X5S, S06.9X6A, S06.9X6D, S06.9X6S, S06.9X7A, S06.9X7D, S06.9X7S, S06.9X8A, S06.9X8D, S06.9X8S, S06.9X9A, S06.9X9D, S06.9X9S, S14.0XXS, S14.101S, S14.102S, S14.103S, S14.104S, S14.105S, S14.106S, S14.107S, S14.108S, S14.109S, S14.111S, S14.112S, S14.113S, S14.114S, S14.115S, S14.116S, S14.117S, S14.118S, S14.119S, S14.121S, S14.122S, S14.123S, S14.124S, S14.125S, S14.126S, S14.127S, S14.128S, S14.129S, S14.131S, S14.132S, S14.133S, S14.134S, S14.135S, S14.136S, S14.137S, S14.138S, S14.139S, S14.141S, S14.142S, S14.143S, S14.144S, S14.145S, S14.147S, S14.148S, S14.149S, S14.151S, S14.152S, S14.153S, S14.154S, S14.155S, S14.156S, S14.157S, S14.158S, S14.159S, S14.2XXS, S14.3XXS, S14.4XXS, S14.5XXS, S14.8XXS, S14.9XXS, S24.0XXS, S24.101S, S24.102S, S24.103S, S24.104S, S24.109S, S24.111S, S24.112S, S24.113S, S24.114S, S24.119S, S24.131S, S24.132S, S24.133S, S24.134S, S24.139S, S24.141S, S24.142S, S24.144S, S24.149S, S24.151S, S24.152S, S24.153S, S24.154S, S24.159S, S24.2XXS, S24.3XXS, S24.4XXS, S24.8XXS, S24.9XXS, S34.01XS, S34.02XS, S34.101S, S34.102S, S34.103S, S34.104S, S34.105S, S34.109S, S34.111S, S34.112S, S34.113S, S34.114S, S34.115S, S34.119S, S34.121S, S34.122S, S34.123S, S34.124S, S34.125S, S34.129S, S34.131S, S34.132S, S34.139S, S34.21XS, S34.22XS, S34.3XXS, S34.4XXS, S34.5XXS, S44.22XS, S44.30XS, S44.31XS, S44.32XS, S44.40XS, S44.41XS, S44.42XS, S44.50XS, S44.51XS, S44.52XS, S44.8X1S, S44.8X2S, S44.8X9S, S44.90XS, S44.91XS, S44.92XS, S54.00XS, S54.01XS, S54.02XS, S54.10XS, S54.11XS, S54.12XS, S54.20XS, S54.21XS, S54.22XS, S54.30XS, S54.31XS, S54.32XS, S54.8X1S, S54.8X2S, S54.8X9S, S54.90XS, S54.91XS, S54.92XS, S64.00XS, S64.01XS, S64.02XS, S64.21XS, S64.22XS, S64.30XS, S64.31XS, S64.32XS, S64.40XS, S64.490S, S64.491S, S64.492S, S64.493S, S64.494S, S64.495S, S64.496S, S64.497S, S64.498S, S64.8X1S, S64.8X2S, S64.8X9S, S64.90XS, S64.91XS, S64.92XS, S74.00XS, S74.01XS, S74.02XS, S74.10XS, S74.11XS, S74.12XS, S74.20XS, S74.21XS, S74.22XS, S74.8X1S, S74.8X2, S74.8X9S, S74.90XS, S74.91XS, S74.92XS, S84.00XS, S84.01XS, S84.02XS, S84.10XS, S84.11XS, S84.12XS, S84.20XS, S84.21XS, S84.22XS, S84.801S, S84.802S, S84.809S, S84.90XS, S84.91XS, S84.92XS, S94.00XS, S94.01XS, S94.02XS, S94.10XS, S94.11XS, S94.12XS, S94.20XS, S94.21XS, S94.22XS, S94.30XS, S94.31XS, S94.32XS, S94.8X1S, S94.8X2S, S94.8X9S, S94.90XS, S94.91XS, S94.92XS
Bipolar disorder
F31.0, F31.10, F31.11, F31.12, F31.13, F31.2, F31.30, F31.31, F31.32, F31.4, F31.5, F31.60, F31.61, F31.62, F31.63, F31.64, F31.70, F31.71, F31.72, F31.73, F31.74, F31.75, F31.76, F31.77, F31.78, F31.81, F31.89, F31.9
Major depressive disorder
F06.30, F06.31, F06.32, F06.33, F06.34, F30.10, F30.11, F30.12, F30.13, F30.2, F30.3, F30.4, F30.8, F30.9, F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.8, F32.9, F33.0, F33.1, F33.2, F33.3, F33.40, F33.41, F33.42, F33.8, F33.9, F34.1, F34.8, F34.9, F39, F32.81, F32.89, F34.81, F34.89
Psychotic disorder
F06.0, F06.2, F20.0, F20.1, F20.2, F20.3 , F20.5, F20.81, F20.89, F20.9, F21, F22, F23, F24, F25.0, F25.1, F25.8, F25.9, F28, F44.89
Alcohol related
F10.121, F10.14, F10.150, F10.151, F10.159, F10.180, F10.181, F10.182, F10.188, F10.19, F10.20, F10.220, F10.221, F10.229, F10.230, F10.231, F10.232, F10.239, F10.24, F10.250, F10.251, F10.259, F10.26, F10.27, F10.280, F10.281, F10.282, F10.288, F10.29, F10.921, F10.94, F10.950, F10.951, F10.959, F10.96, F10.97, F10.980, F10.981, F10.982, F10.988, F10.99, G62.1, I42.6, K29.20, K29.21, K70.0, K70.10, K70.11, K70.2, K70.30, K70.31, K70.40, K70.9
40346 HHP Referral Form: Reference Page, Eligible Conditions Diagnosis Codes
17
HHP Referral Form: Reference Page Eligible Conditions Diagnosis Codes
Email: HealthHomesCM@scfhp.com Fax: 1-408-874-1469
Substance related
F11.121, F11.122, F11.14, F11.150, F11.151, F11.159, F11.181, F11.182, F11.188, F11.19, F11.20, F11.220, F11.221, F11.222, F11.229, F11.23, F11.24, F11.250, F11.251, F11.259, F11.281, F11.282, F11.2 88, F11.29, F11.920, F11.921, F11.922, F11.929, F11.93, F11.94, F11.950, F11.951, F11.959, F11.981, F11.982, F11.988, F11.99, F12.120, F12.121, F12.122, F12.129, F12.150, F12.151, F12.159, F12.180, F12.188,F12.19, F12.220, F12.221, F12.222, F12.229, F12.250, F12.251, F12.259, F12.280, F12.288, F12.29, F12.920, F12.921, F12.922, F12.929, F12.950, F12.951, F12.959, F12.980, F12.988, F12.99, F13.121, F13.129, F13.14, F13.150, F13.151, F13.159, F13.180, F13.181, F13.182, F13.188, F13.19, F13.2 0, F13.220, F13.221, F13.229, F13.230, F13.231, F13.232, F13.239, F13.24, F13.250, F13.251, F13.259, F13.26, F13.27, F13.280, F13.281, F13.282, F13.288, F13.29, F13.920, F13.921, F13.929, F13.930, F13.931, F13.932, F13.939, F13.94, F13.950, F13.951, F13.959, F13.96, F13.97, F13.980, F13.981, F13.982, F13.988, F13.99, F14.121, F14.122, F14.129, F14.14, F14.150, F14.151, F14.159, F14.180, F14.181, F14.182, F14.188, F14.19, F14.20, F14.21, F14.220, F14.221, F14.222, F14.229, F14.23, F14.24, F14.250, F14.251, F14.259, F14.280, F14.281, F14.282, F14.288, F14.29, F14.920, F14.921, F14.922, F14.929, F14.94, F14.950, F14.951, F14.959, F14.980, F14.981, F14.982, F14.988, F14.99, F15.120, F15.121, F15.122, F15.129, F15.14, F15.150, F15.151, F15.159, F15.180, F15.181, F15.182, F15.188, F15.19, F15.20, F15.220, F15.221, F15.222, F15.229, F15.23, F15.24, F15.250, F15.251, F15.259, F15.280, F15.281, F15.282, F15.288, F15.29, F15.920, F15.921, F15.922, F15.929, F15.93, F15.94, F15.950, F15.951, F15.959, F15.980, F15.981, F15.982, F15.988, F15.99, F16.121, F16.122, F16.129, F16.14, F16.150, F16.151, F16.159, F16.180, F16.183, F16.188, F16.19, F16.20, F16.21, F16.220, F16.221, F16.229, F16.24, F16.250, F16.251, F16.259, F16.280, F16.283, F16.288, F16.29, F16.920, F16.921, F16.929, F16.94, F16.950, F16.951, F16.959, F16.980, F16.983, F16.988, F16.99, F18.120, F18.121, F18.129, F18.14, F18.150, F18.151, F18.159, F18.17, F18.180, F18.188, F18.19, F18.20, F18.220, F18.221, F18.229, F18.24, F18.250, F18.251, F18.259, F18.27, F18.280, F18.288, F18.29, F18.920, F18.921, F18.929, F18.94, F18.950, F18.951, F18.959, F18.97, F18.980, F18.988, F18.99, F19.121, F19.129, F19.14, F19.150, F19.151, F19.159, F19.16, F19.17, F19.180, F19.181, F19.182, F19.188, F19.19, F19.20, F19.21, F19.220, F19.221, F19.222, F19.229, F19.230, F19.231, F19.232, F19.239, F19.24, F19.250, F19.251, F19.259, F19.26, F19.27, F19.280, F19.281, F19.282, F19.288, F19.29, F19.920, F19.921, F19.929, F19.930, F19.931, F19.932, F19.939, F19.94, F19.950, F19.951, F19.959, F19.96, F19.97, F19.980, F19.981, F19.982, F19.988, F19.99, O35.5XX0, O35.5XX1, O35.5XX2, O35.5XX3, O35.5XX4, O35.5XX5, O35.5XX9, T40.0X1A, T40.0X1D, T40.0X2A, T40.0X2D, T40.0X3A, T40.0X3D, T40.0X4A, T40.0X4D, T40.1X1A, T40.1X1D, T40.1X2A, T40.1X2D, T40.1X3A, T40.1X3D, T40.1X4A, T40.1X4D, T40.2X1A, T40.2X1D, T40.2X2A,T40.2X2D, T40.2X3A, T40.2X3D, T40.2X4A, T40.2X4D, T40.3X1A, T40.3X1D, T40.3X2A, T40.3X2D, T40.3X3A, T40.3X3D, T40.3X4A, T40.3X4D, T40.4X1A, T40.4X1D, T40.4X2A, T40.4X2D, T40.4X3A, T40.4X3D, T40.4X4A, T40.4X4D, T40.601A, T40.601D, T40.602A, T40.602D, T40.603A, T40.603D, T40.604A, T40.604D, T40.691A, T40.691D, T40.692A, T40.692D, T40.693A, T40.693D, T40.694A, T40.694D, F12.23, F12.93
Kidney disease N18.1, N18.2, N18.3 , N18.4 , N18.5, N18.6, N18.9, Z48.22, Z49.01, Z49.02, Z49.31 , Z49.32, Z91.15, Z94.0
40346 HHP Referral Form: Reference Page, Eligible Conditions Diagnosis Codes
18
Long-term services and supports (LTSS) referrals
Long-term services and supports (LTSS) includes a range of home and community-based services that support people living independently in the community, as well as long term care provided in a skilled nursing facility. Characteristics of potential LTSS members include patients with multiple chronic conditions and functional limitations that make it hard to live independently and safely at home without assistance. Below is more information on the LTSS benefits.
What are the LTSS benefits?
Benefit
Description
Multipurpose Senior Services Program
(MSSP)
A team of care managers (an RN and a Social Worker)
provide:
· Individualized care planning · Social and health care management · Long term help arranging and coordinating
needed services · Monthly contact and quarterly home visits · Purchase of services if needs cannot be met by
low or no cost options
Eligibility
· Age 65+ with disabilities · Requires nursing facility
level of care · Unable to live at home
safely without MSSP
CommunityBased Adult Services
(CBAS)
Provides individualized care and services in an outpatient · Age 18+
facility up to 5 days/week.
· At risk for institutional
Services include:
· Skilled nursing care · Social services · Therapies (OT, PT, ST) · Personal care and assistance with activities of
care and have 1 or more chronic or postacute medical, cognitive or mental health condition(s) · Physician referral
daily living · Family/caregiver respite and training · Nutrition counseling and meals · Transportation to and from home
required
Nursing Facility
(NF)
A facility that provides care for people who cannot safely · LTC/SNF placement is
live at home but who do not need to be in the hospital.
made through a
Long-term care (LTC) is the provision of custodial care, a level of care that is the least intensive and is not at a
physician/licensed
skilled level. Medical, social, and personal care services
health care provider
that are needed regularly are provided in a licensed
referral
skilled nursing facility's (SNF) long-term care (LTC).
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Benefit
In-Home Supportive Services
(IHSS)
Description
Eligibility
IHSS is a State program available to eligible Medi-Cal
· Must be aged 65+ OR
beneficiaries and authorized by Santa Clara County
blind OR has a disability
Social Services Department. Once an application has
that will last 12 months
been submitted, an IHSS social worker will conduct an in-
or longer
home assessment to determine hours and services.
· Unable to live at home
IHSS recipients choose a care provider, usually a family
safely without help from
member, friend, or someone selected through a Care
a care provider
Registry. IHSS recipients hire their workers, set
· Application must be
schedules, and supervise the care they receive.
signed by the patient
Services provided by the care provider may include:
and a licensed professional
· Domestic services: cleaning, grocery shopping,
meal prep, errands, laundry · Personal care: grooming, bathing, toileting · Protective supervision · Paramedical
Supporting patient access and availability to LTSS benefits
Your patients can apply for MSSP, CBAS, and IHSS on their own, or they can seek assistance from SCFHP Case Management. Usually timely access to these programs and services improves when facilitated by the patient's case manager, ideally as part of an individualized care plan.
To contact SCFHP Case Management, call 1-877-590-8999 (TTY: 711), Monday through Friday, 8:30 a.m. to 5 p.m.
When providers understand the LTSS programs, eligibility criteria, and application process, they can educate patients and their family or caregivers about them, and follow the appropriate referral process.
Who should be referred for LTSS?
Patients who:
· Need social support · Need assistance with daily activities · Qualify for a nursing home but want to stay at home · Need caregiver support · Have issues with current LTSS services · Indicate they need more support · Have a history of repeated hospitalizations · Request non-medical support
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When should you contact the SCFHP LTSS team?
Providers may choose to work directly with the patient to facilitate LTSS applications, or they may reach out to the SCFHP LTSS team for assistance. The SCFHP LTSS team is available to help with LTSS inquiries, including confirming eligibility for these programs, monitoring waitlists, and tracking deadlines for the submission of documents required for application. If the patient will undergo care transition and the patient needs LTSS, it is recommended that the LTSS referral is initiated as soon as the discharge planning is identified. Application processes for these benefits can take one to three months or longer.
What are other reasons to coordinate with the SCFHP LTSS team?
If you think the patient needs more help deciding to apply for LTSS using: · CBAS referrals to encourage site visits · IHSS or MSSP to provide explanation on how it works and assistance with application · NF to coordinate on safe care transitions
If the patient's case manager needs help coordinating with LTSS providers or seeks help with finding other community resources or referrals for services and supports, such as access to food, non-medical transportation, personal care, and caregiver support.
Questions?
Email the SCFHP LTSS team at MLTSSHelpDesk@scfhp.com. For more training materials, visit www.scfhp.com and look under For Providers. For the direct link to the LTSS training PowerPoint, visit www.scfhp.com/media/2782/ltss_orientation.pdf.
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Reporting critical incidents to SCFHP
Critical incident refers to any actual or alleged event or situation that creates a significant risk of substantial or serious harm to the physical or mental health, safety, or well-being of a member.
Providers (i.e., physicians, skilled nursing facilities, CBAS, IHSS, hospitals, transportation, or others) are required to fax or email a copy of the Potential Quality of Care Issue Referral Form to SCFHP within 24
hours of the critical incident, as well as to whichever authority they report to.
You may also report critical incidents by calling SCFHP Customer Service:
Line of business
Medi-Cal Plan
Cal MediConnect Plan (MedicareMedicaid Plan)
Phone number
1-800-260-2055 (TTY: 711)
1-877-723-4795 (TTY: 711)
Hours of service 8:30 a.m. to 5 p.m., Monday through Friday 8 a.m. to 8 p.m., Monday through Friday
For your convenience, a Potential Quality of Care Issue Referral Form is attached.
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Potential Quality of Care Issue (PQI) Referral Form
Quality Improvement Fax: 1-408-874-1462
Email: pqi@scfhp.com
Please fill in all appropriate information and send the completed form to Santa Clara Family Health Plan's (SCFHP) Quality Improvement Department by fax or SECURE email.
Who is reporting the issue?
Name:
Department:
Phone :
Member Information
Member Name:
Date of Birth:
SCFHP ID:
Assigned PCP: Assigned PCP Address:
Required: Is the member a senior and person with disability (SPD)? Yes No
Provider/Facility involved with PQI
Provider/Facility Involved with PQI: Provider/Facility Address: Provider Phone:
Authorization # (if applicable): Call Tracking #: Provider Fax:
What is the issue? (attach any relevant documentation)
Date of potential quality of care issue: Issue (use additional pages as needed and attach to this form):
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23
Your role as an SCFHP PCP
The Primary Care Physician's (PCP) role is vital in the overall coordination of health care for each patient, as well as in providing routine and preventive health care services, including:
· Assessing each patient's health status by performing an Initial Health Assessment (IHA) within 120 calendar days of a patient enrolling with Santa Clara Family Health Plan (SCFHP)
· Providing and documenting preventive services in accordance with established criteria · Providing quality care, coordinating referrals to specialists and facilitating patients' access to
treatment · Referring patients to health education classes and educating them on the use of their health
education benefits · Providing basic case management services in collaboration with SCFHP Case Management · Assuring that members in your practice are not discriminated against in the delivery of services · Assuring that no unnecessary or redundant medical services are being provided · Identifying patients who have missed or cancelled appointments and re-scheduling those
appointments · Establishing a system for tracking and identifying any clinical problems unique to your patient
population
Please refer to the SCFHP Provider Manuals for additional details regarding the responsibilities of the PCP. Provider Manuals can be found on our website at www.scfhp.com, under For providers and on Provider resources.
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Initial Health Assessment
The Initial Health Assessment (IHA) is a comprehensive assessment that is completed during the patient's first visit with a new PCP, appropriate medical specialist, or non-physician medical provider, and must be documented in the patient's medical record. The IHA enables the PCP to assess and manage the patient's acute, chronic, and preventive health needs.
The California Department of Health Care Services (DHCS) requires PCPs to complete an IHA for all new plan members within 120 calendar days of enrollment in Santa Clara Family Health Plan. Providers are responsible for downloading a monthly list of newly assigned patients from Provider Link, scheduling IHA appointments, and rescheduling missed IHA appointments.
Login to Provider Link and access the Alerts tab to download a list of your new patients from Your member roster: providerportal.scfhp.com.
If you are attempting to schedule an IHA with a new patient, but are not having success, make sure to document a minimum of two attempts. Credit can be given for the IHA in your Facility Site Review Medical Record Review if it can be shown you made reasonable attempts to schedule an IHA with the patient.
When an advanced practitioner performs the IHA, the PCP must ensure that the IHA was completed in an accurate and comprehensive manner and that the documentation contains the patient's primary medical record.
Additional information regarding IHAs is available on the SCFHP website: https://www.scfhp.com/for-providers/initial-health-assessment
IHA components
1) Comprehensive history Sufficient to assess and diagnose acute and chronic conditions. The following is considered comprehensive history:
I. History of present illness and past medical history · Prior major illnesses and injuries · Prior operations · Prior hospitalizations · Current medications · Allergies · Age appropriate immunization status · Age appropriate feeding and dietary status
II. Social history · Marital status and living arrangements · Current employment · Occupational history · Use of alcohol, drugs, and tobacco · Level of education
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· Sexual history · Any other relevant social factors III. Review of organ systems
2) Preventative services Keep patients up-to-date with all currently recommended preventative services, including immunizations. For adult health care Providers should follow the current "A" and "B" recommendations of U.S. Preventive Services Task Force (USPSTF) Guide for providing preventive screening, testing, and counseling services for all patients regardless of health status. The guide can be found at: www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/
An interactive downloadable app with current USPSTF recommendations is also available for various platforms at: www.uspreventiveservicestaskforce.org/Page/Name/tools-and-resources-for-better-preventive-care
For patients under 21 Providers should follow the current American Academy of Pediatrics/Bright Futures' guidelines to provide age-specific assessments: brightfutures.aap.org/clinicalpractice/Pages/default.aspx
The Child Health and Disability Prevention Program's (CHDP) required assessments and services should also be included for the next lower age bracket if conducting IHAs at intervals closer than the CHDP intervals: https://www.dhcs.ca.gov/services/chdp/Documents/HealthPeriodicity.pdf
3) Comprehensive physical and mental status exam Sufficient to assess and diagnose acute and chronic conditions.
4) Diagnosis and plan of care Includes all follow-up activities, including return visit documentation, or "PRN" (as needed) if no specific interval is required.
5) Staying healthy assessment (SHA) SHA is a DHCS Individual Health Education Behavior Assessment that consists of seven age-specific pediatric questionnaires and two adult questionnaires. SHA must be administered as part of the IHA.
The SHA requirements for members transferring from a different health plan may be met if the medical record indicates that the SHA tool or behavioral risk assessment has been completed within the last 12 months. The completed DHCS SHA form must be included in the current medical record to receive credit for a Facility Site Review Medical Record Review. Forms are available at https://www.dhcs.ca.gov/formsandpubs/forms/Pages/StayingHealthy.aspx
Important links
IHA policy letter on DHCS website: https://tinyurl.com/IHA-PolicyLetter Provides information on the DHCS requirements for the IHA.
DHCS SHA information and forms: https://tinyurl.com/shainfodhcs The SHA is also available in nine different languages: http://tinyurl.com/shatooldhcs For more training, see DHCS's PowerPoint: https://tinyurl.com/dhcsshappt
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Clinical guidelines and updates on SCFHP's website: https://www.scfhp.com/for-providers/providerresources/initial-health-assessment/ Find the most up-to-date information about IHAs on the SCFHP website. Please use the appropriate clinical guidelines when conducting the IHA.
Provider Link: providerportal.scfhp.com Register to download lists of newly assigned patients per month in Alerts tab and in Your member roster.
Questions?
If you have any questions or concerns, please contact the SCFHP Provider Performance Program at ProviderPerformance@scfhp.com.
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Alcohol misuse screening and counseling
Alcohol misuse screening and counseling (AMSC), formerly called screening brief intervention and referral to treatment (SBIRT), is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with alcohol use disorders, as well as those who are at risk of developing these disorders. AMSC can be used by providers in a primary care setting to help identify patients who are at risk of hazardous alcohol use.
SCFHP covers expanded alcohol screenings for members 18 years of age and older who answer "yes" to the alcohol question in the Staying Healthy Assessment (SHA), or any time the PCP identifies a potential alcohol misuse problem. The question used to further evaluate is:
In the past year, have you had: · Men: Five or more alcohol drinks in one day? · Women: Four or more alcohol drinks in one day?
SCFHP also covers brief interventions for members who screen positively for risky or hazardous alcohol use, or for a potential alcohol use disorder.
The following HCPCS codes may be used to bill for these services:
Payer Code Description Medicare G0396 Alcohol and/or substance abuse structured screening and
brief intervention services; 15 to 30 minutes
G0397 Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes
Medi-Cal G0442 Alcohol and/or drug screening
G0443 Alcohol and/or drug screening, brief intervention, per 15 minutes
If you have questions about the referral process, please call Provider Network Operations at 1-408-874-1788 or email ProviderServices@scfhp.com.
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Adopted clinical and preventive guidelines
Santa Clara Family Health Plan (SCFHP) uses clinical and preventive guidelines to help providers make decisions about appropriate care for specific clinical circumstances. The guidelines are not intended to replace clinical judgment. The treating practitioner is ultimately responsible for the appropriate treatment of each patient. These guidelines are also used in related programs, including disease and population management.
Clinical practice guidelines are developed from scientific evidence or a consensus of health care professionals in the particular field. The guidelines are reviewed and updated at least every two years, and more frequently when updates are released by the issuing entity. SCFHP monitors compliance and patient outcomes related to these guidelines for quality improvement initiatives.
Preventive guidelines
Clinical practice guidelines · Antithrombotic Guidelines from the American College of Chest Physicians: http://journal.publications.chestnet.org/issue.aspx?journalid=99&issueid=23443
· Asthma Clinical Guidelines from the National Institute of Health: http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines
· Diabetes Clinical Guidelines from the American Diabetes Association: http://professional.diabetes.org/content/clinical-practice-recommendations
· Hyperlipidemia Guidelines from the American College of Cardiology/American Heart Association: https://www.ahajournals.org/doi/pdf/10.1161/01.cir.0000437738.63853.7a
· Hypertension Clinical Guidelines from the Joint National Committee Treatment of Hypertension: http://www.nmhs.net/documents/27JNC8HTNGuidelinesBookBooklet.pdf
Behavioral health guidelines · Adult Depression Clinical Guidelines from the Institute for Clinical Systems Improvement: http://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_beha vioral_health_guidelines/depression/
· Children and Adolescents with ADHD Guidelines from the American Academy of Pediatrics: http://pediatrics.aappublications.org/content/pediatrics/early/2011/10/14/peds.2011-2654.full.pdf
· Children and Adolescents with Depressive Disorder Clinical Guidelines from the American Academy of Child and Adolescent Psychiatry: http://www.jaacap.com/article/S0890-8567(09)62053-0/pdf
Preventive care guidelines · Adult (22-64 year) Preventative Guidelines from the American Association of Family Physicians: http://www.aafp.org/patient-care.html
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· CDC's Advisory Committee of Immunization Practices: https://www.cdc.gov/vaccines/index.html
· U.S. Preventive Health Services Task Force: http://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations
· Child and Adolescent (0 month to 21 years) Preventative Guidelines from the American Academy of Pediatrics: http://pediatriccare.solutions.aap.org/book.aspx?bookid=988
· American Academy of Pediatrics including CHDP assessments (PL 14-004): http://www.dhcs.ca.gov/services/chdp/Pages/Periodicity.aspx
· American Association of Family Physicians: http://www.aafp.org/patient-care.html
· CDC's Advisory Committee of Immunization Practices: https://www.cdc.gov/vaccines/index.html
· U.S. Preventive Health Services Task Force: http://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations
Prenatal preventive guidelines · ACOG Guidelines: http://www.acog.org/Patients
· ACOG Guidelines and Comprehensive Perinatal Services program (CPSP) guidelines (PL 14-004): http://www.acog.org/About-ACOG/ACOG-Departments/Deliveries-Before-39-Weeks/ACOG-ClinicalGuidelines
Seniors (65+ years) preventive guidelines · CDC's Advisory Committee of Immunization Practices: https://www.cdc.gov/vaccines/index.html
· U.S. Preventive Health Services Task Force: http://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations
· Treating tobacco use and dependence guidelines · PL 14-006 which refers to the US Preventive Services Task Force A and B Recommendations:
http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/
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Timely access standards and surveys
As a Santa Clara Family Health Plan (SCFHP) contracted provider, there are timely access to care standards set by SCFHP and the Department of Managed Health Care (DMHC) that you are required to follow.
Please see the grid for timely access requirements and standards. Use the grid as a resource to align your office protocols with these standards.
Providers who show continued non-compliance with access standards, through access surveys and other monitoring activities, are required to complete SCFHP's timely access to care training.
Visit our website for all trainings under For Providers and in Provider Training: https://www.scfhp.com/forproviders/provider-resources/provider-training/. PowerPoints are linked on the right.
If you have questions regarding timely access to care requirements, please call Carmen Switzer, Provider Network Access Manager, at 1-408-680-3517 or email CSwitzer@scfhp.com.
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Timely access to care standards
Provider Network Management Phone: 1-408-874-1788
Email: ProviderServices@scfhp.com
Appointment standards
Primary care providers Appointment type or service Urgent appointment
Non-urgent/routine appointment
Criteria
Immediate care is not needed for stabilization, but if not addressed in a timely way could escalate to an emergency situation.
Immediate care is not needed. For example, this appointment type could be related to new health issues or a follow-up for existing health problems.
Standard access timeframe Appointment offered within 48 hours of request.
Appointment offered within 10 business days of request.
Specialists Appointment type or service Urgent appointment
Non-urgent/routine appointment
Criteria
Immediate care is not needed for stabilization, but if not addressed in a timely way could escalate to an emergency situation.
Immediate care is not needed. For example, this appointment type could be related to new health issues or a follow up for existing health problems.
Standard access timeframe Appointment offered within 96 hours of request.
Appointment offered within 15 business days of request.
Obstetrics and gynecology Appointment type or service First prenatal visit
Criteria Immediate care is not needed.
Standard access timeframe
Appointment offered within 2 weeks of request.
Behavioral health providers Appointment type or service Non-life-threatening emergency appointment
Urgent appointment
Routine (non-urgent) appointment
Criteria
Immediate assessment or care is needed to stabilize a condition or situation, but there is no imminent risk of harm to self or others.
Immediate care is not needed for stabilization, but if not addressed in a timely way could escalate to an emergency situation.
An assessment of care is required with no urgency or potential risk of harm to self or others.
Standard access timeframe Appointment offered within 6 hours of request.
Appointment offered within 48 hours of request.
Appointment offered within 10 business days of request.
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Timely access to care standards
Provider Network Management Phone: 1-408-874-1788
Email: ProviderServices@scfhp.com
Behavioral health providers
Appointment type or service Follow-up routine appointment
Criteria
Follow-up care is required for non-urgent/routine care.
Standard access timeframe
Appointment offered within 30 business days of request.
Other provider types and facilities
Appointment type or service Criteria
Ancillary
Diagnosis or treatment of injury, illness, or other health conditions.
Pharmacy
Dispensing of a covered outpatient drug in an emergency situation.
Skilled nursing facility (SNF)
Patient's functional or medical complexity are such that outcome would be compromised with less than daily skilled services.
Intermediate care facility (ICF)
Services for developmental disabilities.
Community-based adult services (CBAS)
The setting supports access to and receipt of services in the community to meet participant's needs.
Standard access timeframe Appointment offered within 15 business days. Provide at least a 72-hour supply of a covered outpatient drug.
Provide service within 5 business days.
Provide service within 5 business days. Same as current 1115 waiver providers to consider the urgency of the services needed to meet requirements on timely access to care and services.
Extended appointment waiting time for non-urgent/routine appointments: The waiting time for a particular appointment may be extended if the referring/treating licensed health care provider or health professional providing triage or screening services has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the patient.
Rescheduling appointments: When it is necessary for a provider or patient to reschedule an appointment, the appointment shall be promptly rescheduled in a manner that is appropriate for the patient's health care needs and ensures continuity of care is consistent with professional and good practices.
Interpreter services: Providers are required to offer a qualified interpreter to an individual with limited English proficiency when oral interpretation is a reasonable step to provide meaningful access to that individual. Qualified translators should also be used when translating written content in paper or electronic format.
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Timely access to care standards
Provider Network Management Phone: 1-408-874-1788
Email: ProviderServices@scfhp.com
Other timely access requirements
Preventive care
Appointment type or service
Appointments including but not limited to:
Periodic follow-up Standing referrals for
chronic conditions Pregnancy Cardiac condition Mental health condition Lab and radiology
monitoring
Standard access requirements
May be scheduled in advance and must be consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of his/her practice.
Telephone access & in-office wait times
Appointment type or service Standard access requirements
Patient incoming calls
Patient calls must be picked up within 60 seconds.
Telephone triage and screening Patients must be offered a triage or screening 24 hours a day, 7 days a week.
Returning patient phone calls for non-medical related inquires
In-office wait time
Patient calls for medical-related issues must be returned within 30 minutes. Patient calls should be returned within one business day.
Patients must be seen by the provider within 30 minutes or less from the scheduled appointment time.
After-hours accessibility All providers are required to provide coverage 24 hours a day, 7 days a week.
Service
Automated systems, office, or exchange/answering services Life-threatening situation
Standard access requirement Must inform the patient that the provider will call back within 30 minutes.
Automated systems must provide emergency 911 instructions, such as: "Hang up and dial 911 or go to the nearest emergency room."
Urgent need to speak with a provider
Behavioral health providers should include the number to the Santa Clara County Behavioral Health:
"Hang up and dial 911 or go to the nearest emergency room or call Santa Clara County Behavioral Health at 1-800-704-0900."
Automated systems, office, or exchange/answering services must connect the patient with an on-call provider or should direct the patient on how to contact a provider after hours.
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Claims
The primary responsibility of our Claims Department is to adjudicate medical claims submitted by physicians, hospitals, and other health care providers. Santa Clara Family Health Plan (SCFHP) requires all contracted providers to bill their claims electronically. This includes corrected claims.
Billing time limit is 1 year from the date of service Electronic billing is required for all contracted providers
Payor ID: 24077 Clearinghouses
o Change Healthcare (formerly known as Emdeon) o Office Ally
Claims disputes
Medi-Cal If you disagree with a claim's outcome, you can submit a dispute within 365 calendar days from SCFHP's remittance advice. SCFHP will investigate your dispute and issue a written resolution within 45 working days from the date the dispute is received.
Cal MediConnect If you disagree with the claim's outcome, you may submit a dispute within 120 calendar days from SCFHP's remittance advice. SCFHP will investigate your dispute and issue a written resolution within 60 calendar days for contracted providers and 30 calendar days for non-contracted providers from the date the dispute is received.
Submit a dispute online: https://www.scfhp.com/for-providers/submit-a-claim-or-dispute/ Or mail a dispute to:
Attn: Claims Department Santa Clara Family Health Plan PO Box 18880 San Jose, CA 95158
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Claims and delegation
Medi-Cal For Medi-Cal members, SCFHP has a number of claims delegates within its provider network. Each agreement has unique characteristics that affect how and where you submit claims. The information below can assist you in submitting claims to the correct location, which will alleviate the need for SCFHP or our delegates to redirect a claim that was received at the incorrect location.
You may find the information to identify a delegated provider agreement on the back of the patient's SCFHP ID card, and additional details are available on the Quick Reference card in this packet.
Cal MediConnect SCFHP does not delegate claims payments for Cal MediConnect. Please submit claims directly to SCFHP.
Claim overpayments
SCFHP is responsible for meeting the Department of Healthcare Services (DHCS) and the Center for Medicare and Medicaid Services' (CMS) guidelines and regulations, which ensure qualitative, cost effective service delivery to our members and providers. It is also necessary to prove fiscal prudence and payment accuracy in reimbursements made to providers for services rendered per guidelines set forth in the California Code of Regulations, Title 22, Sections 50761, 53866.
When an overpayment is identified, either by SCFHP or the provider's business office, we will recover the payments that were made in error by requesting that the provider issue a lump sum check payable to SCFHP and mailed to:
Attn: Claims Revenue Recovery Santa Clara Family Health Plan PO Box 18880 San Jose, CA 95158
Alternatively, the overpayment can be recouped from monies due to the provider until the overp ayment is recovered. If the provider feels that a recovery of an overpayment initiated by SCFHP was in error, or if the provider disagrees with the recovery of an overpayment, the provider may file a dispute.
Claim inquires
Providers may inquire about the status of their claims by checking Provider Link (https://www.providerportal.scfhp.com), utilizing the IVR functionality through our phone system or by calling Provider Network Operations at 1-408-874-1788 Monday through Friday, from 8:30 a.m. to 5 p.m. You may also call after hours and leave a message. An SCFHP representative will return after-hours calls the next business day.
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Provider Dispute Form
Claims, Medical, and Administrative Disputes
Phone: 1-408-874-1788 Today's Date:
Submit provider disputes through Santa Clara Family Health Plan's online form or mail this completed form to: Santa Clara Family Health Plan, Attn: Provider Dispute Resolution Unit, P.O. Box 18880, San Jose CA 95158.
Fields with an asterisk (*) are required.
Be specific when completing the "Description of Dispute" and "Expected Outcome."
Provide additional information to support the description of the dispute. Do not include a copy of a claim that was previously processed.
Multiple "Like" claims are for the same provider and dispute but different members and dates of service. If filing multiple "Like" claims please complete this form and complete the Multiple "Like" Provider Dispute Form found on the SCFHP provider forms web page.
For routine follow-up status, instead of the Provider Dispute Resolution Form, please call SCFHP at 1-408-874-1788. Independent providers can check claims status online at www.scfhp.com.
Provider Information
*Provider NPI:
*Provider Tax ID #:
*Provider Name:
Address to which SCFHP should respond:
Provider Type: MD
Mental Health Professional
Hospital
Rehab
Home Health
Ambulance
ASC
SNF
Other:
DME
Claim Information
*Patient Name:
Date of Birth:
*Member ID #:
Original Claim #:
Patient Account #:
Billed Amount:
Date of Service:
Dispute Type:
Claim
Contract Dispute
Seeking resolution of a billing determination
Appeal of medical necessity/utilization management decision
Disputing request for reimbursement of overpayment
Other:
*Description of Dispute:
Expected Outcome:
Contact Information Contact Name (Please Print): Signature: Phone Number:
Fax Number:
Title: Date:
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Summary of grievances and appeals submission process
Contracted providers and facilities are required to make grievance forms and assistance readily available to SCFHP members. If you become aware of a member with a problem or complaint about SCFHP, its policies, or its providers, please direct the member to the SCFHP Customer Service. A copy of the form for Medi-Cal and Cal MediConnect is attached, and if more copies are needed, they can be found on our website:
Medi-Cal PDF form: https://www.scfhp.com/media/1559/member_grievance_form-en.pdf Medi-Cal online form: https://www.scfhp.com/forms/grievance-and-appeal-form-medi-cal/
Cal MediConnect PDF form: https://www.scfhp.com/media/1491/cmc_grievance_form_en.pdf Cal MediConnect online form: https://www.scfhp.com/forms/grievance-and-appeal-form/
For more information on submitting a complaint and how to access our online grievance/appeal form:
Medi-Cal: https://www.scfhp.com/for-members/grievance-and-appeal-process/ Cal MediConnect: https://www.scfhp.com/healthcare-plans/cal-mediconnect/complaints-grievances-
appeals/
As a provider, you may have concerns or experience issues around whether a patient's service is covered or the way a service is covered. If you have a problem or concern, or you disagree with an authorization denial issued by SCFHP or a delegated network, please contact SCFHP Customer Service so that we may assist:
Line of business
Medi-Cal Plan
Cal MediConnect Plan (Medicare-Medicaid Plan)
Phone number 1-800-260-2055 (TTY: 711)
Hours of service 8:30 a.m. to 5 p.m., Monday-Friday
1-877-723-4795 (TTY: 711) 8 a.m. to 8 p.m., Monday-Friday
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Member Grievance and Appeal Form
Phone: 1-800-260-2055
Fax: 1-408-874-1962 Office Hours: 8:30 a.m. to 5 p.m., Monday Friday
This form is optional. Santa Clara Family Health Plan can help you fill out this form or you may file a grievance verbally by calling us at 1-800-260-2055, 8:30 a.m. to 5 p.m., Monday Friday. TTY/TDD users should call 1-800-735-2929. Or, someone will contact you by phone as soon as we receive this form. We will assist you in any way we can and answer any questions that you have. We can help you in any language.
Member Name:
Member ID:
Date of Birth:
Address:
Home Phone:
Work/Cell Phone:
Name of person filing if different from above:
Relationship:
Telephone:
Date of Problem:
Describe the problem in detail:
What would you like someone to do about the problem?
Will you need language assistance?
Yes
No
Language preference:
Do you have a problem that needs medical attention in the next three days, or are you in severe pain?
Yes
No
Signature*:
Date:
*If signed by somebody other than the Member, an Authorized Representative Form (ARF) is required.
Grievance
SCFHP USE ONLY
Appeal
SCFHP RECEIPT DATE:
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Received by: Referred to: Information/Resolution:
FOR INTERNAL USE ONLY Date: Date:
Patient Notified: Yes
No
Notified by:
Special assistance provided (language, transportation):
Date:
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The Department of Managed Health Care requires Santa Clara Family Health Plan to inform you of the following: The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-800-260-2055 and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online. As a Medi-Cal beneficiary: You can request a State Fair Hearing. If you decide to request a hearing, you must do so within 90 days of the mailing of your notice. Please contact Santa Clara Family Health Plan for the forms that you need. They are also available from the Santa Clara County Department of Social Services. Information about the State Fair Hearing process is also available by writing:
California Department of Social Services State Hearings Division P.O. Box 944243, Mail Station 9-17-37 Sacramento, CA 94244-2430 Or by calling 1-800-952-5253 or TDD 1-800-952-8349.
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Cal MediConnect Member
Grievance and Appeal Form
Phone: 1-877-723-4795 (TTY: 711)
Fax: 1-408-874-1962
This form is optional. Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan ) (SCFHP Cal MediConnect) can help you fill out this form or you may file a grievance or appeal
verbally by calling Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. Someone will contact you by phone as soon as we receive this form. We will assist you in any
way we can and answer any questions that you have. We can help you in any language.
Member Name:
Member ID:
Date of Birth:
Address:
Home Phone:
Cell Phone:
Name of person filing if different from above:
Relationship:
Telephone:
Date of Problem:
Describe the problem in detail (use the back of this page if you need more room to write):
What would you like someone to do about the problem?
Will you need language assistance?
Yes
No
Language preference:
Do you have a problem that needs medical attention in the next 72 hours or are you in severe pain?
Yes
No
Signature*:
Date:
* If signed by someone other than the member, SCFHP must have a copy of the signed Appointment of Representative (AOR) form or equivalent written notice.
SCFHP USE ONLY
Grievance
Appeal SCFHP RECEIPT DATE/TIME:
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You can get help from the California Department of Managed Health Care The California Department of Managed Health Care is responsible for regulating health care service
plans. If you have a grievance against your health plan, you should first telephone your health plan at
1-877-723-4795 and use your health plan's grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you.
If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. For urgent issues, you may call the Department first without filing a grievance with your health plan.
You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services.
The Department also has a toll-free telephone number (1-888-466-2219) and a TTY line (1-877-688-9891) for the hearing and speech impaired. The Department's internet website www.dmhc.ca.gov has complaint forms, IMR application forms, and instructions online.
As a Medi-Cal beneficiary, you can request a State Hearing. If you decide to request a hearing, you must do so within 120 calendar days of the mailing of your notice. Please contact SCFHP for the forms that you need. They are also available from the Santa Clara County Department of Social Services. Information about the State Hearing process is also available:
· Phone: TTY:
1-800-952-5253 1-800-952-8349
· Write:
California Department of Social Services State Hearings Division PO Box 944243, MS 9-17-37 Sacramento, CA 94244-2430
Getting help from Medicare You can call Medicare directly for help with problems. Here are two ways to get help from Medicare:
· Phone: TTY:
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. 1-877-486-2048. The call is free.
· Website: www.medicare.gov
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You can get help from the Quality Improvement Organization (QIO) Our state has an organization called Livanta Beneficiary and Family Centered Care (BFCC)-Quality Improvement Organization (QIO). This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare.
Contact Livanta BFCC-QIO if you have a problem with the quality of care you have received, you think your hospital stay is ending too soon or you think your home health care, skill nursing facility care or comprehensive outpatient rehabilitation facility (CORF) services are ending too soon. Livanta BFCC-QIO is not connected with our plan.
· Phone: TTY:
1-877-588-1123, available 24 hours a day, 7 days a week. 1-855-877-6668, this number is for people who have hearing or speaking problems. You must have special telephone equipment to call it.
· Fax:
Appeals: 1-855-694-2929 All other reviews: 1-844-420-6672
· Write:
Livanta BFCC-QIO 10520 Guilford Road, Suite 202 Annapolis Junction, MD 20701
· Website: www.livanta.com
Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.
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Discrimination is Against the Law
Santa Clara Family Health Plan (SCFHP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. SCFHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
SCFHP:
· Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats)
· Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages
If you need these services, contact Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.
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If you believe that SCFHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Attn: Grievance and Appeals Department Santa Clara Family Health Plan 6201 San Ignacio Ave San Jose, CA 95119 Phone: 1-877-723-4795 TTY: 711 Fax: 1-408-874-1962 Email: CalMediConnectGrievances@scfhp.com
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a Customer Service representative is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, DC 20201 Phone: 1-800-368-1019 TDD: 1-800-537-7697
Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.
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Language Assistance Services
English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. The call is free.
Español (Spanish): ATENCIÓN: Si habla español, hay servicios de ayuda de idiomas gratis disponibles para usted. Llame a Servicio al Cliente al 1-877-723-4795 (TTY: 711) de lunes a viernes, de 8 a.m. a 8 p.m. La llamada es gratis.
Ting Vit (Vietnamese): CHÚ Ý: Nu quý v nói ting Vit, có dch v h tr ngôn ng, min phí dành cho quý v. Hãy gi n Dch V Khách Hàng theo s 1-877-723-4795 (TTY: 711), t Th Hai n Th Sáu, 8 gi sáng n 8 gi ti. Cuc gi là min phí.
(Chinese) 8 8 1-877-723-4795TTY 711
Tagalog (Tagalog): PAUNAWA: Kung nagsasalita ka ng Tagalog, may magagamit kang mga serbisyong tulong sa wika na walang bayad. Tumawag sa Serbisyo para sa Mamimili sa 1-877-723-4795 (TTY: 711), Lunes hanggang Biyernes, 8 a.m. hanggang 8 p.m. Ang pagtawag ay libre.
(Korean): : , . 8 8 1-877-723-4795 (TTY: 711) . .
(Armenian). . , : 1-877-723-4795 (TTY. 711), . 8:00 - 20:00: :
(Russian): : -, . 1-877-723-4795 (: 711), , 8:00 20:00. .
:(Farsi) . : . . (711:TTY) 1-877-723-4795 8 8
Japanese 1-877-723-4795TTY711 8 8
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Ntawv Hmoob (Hmong): LUS CEEV: Yog hais tias koj hais lus Hmoob, peb muaj kev pab txhais lus pub dawb rau koj. Hu rau Lub Chaw Pab Cuam Neeg Qhua rau ntawm tus xov tooj 1-877-723-4795 (TTY: 711), hnub Monday txog Friday, 8 teev sawv ntxov txog 8 teev tsaus ntuj. Qhov hu no yog hu dawb xwb.
(Punjabi): : , 1-877-723-4795 (TTY: 711) ' , 8 8
:(Arabic) 1-877-723-4795 . :
. . 8 8 (TTY: 711) )
(Hindi): : , , 1-877-723-4795 (TTY: 711) , , 8:00 8:00
(Thai): : 1-877-723-4795 (TTY: 711) 08.00 . 20.00 .
(Khmer):
1-877-723-4795 (TTY: 711)
8 8
(Lao): : , . 1-877-723-4795 (TTY: 711), 8 8 . .
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Required compliance trainings
The Center for Medicare and Medicaid Services (CMS) and the Department of Healthcare Services (DHCS) require that SCFHP providers and office staff are trained annually on the compliance topics below. The training modules are provided on the SCFHP website, and CMS offers training online as well.
Required trainings:
Avoiding Medicare Fraud & Abuse-A Roadmap for Physicians: https://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/Avoiding_Medicare_FandA_Physicians_FactSheet_905645.pdf
HIPAA Basics for Providers: https://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNProducts/Downloads/HIPAAPrivacyandSecurity.pdf
Medical Privacy of Protected Health Information: https://www.cms.gov/Outreach-andEducation/Medicare-Learning-Network-MLN/MLNProducts/downloads/SE0726FactSheet.pdf
Culture Competency & Disability Training: https://www.scfhp.com/media/2786/culturalcompetencytoolkit.pdf
Interdisciplinary Care Team (ICT)Core Competencies: https://www.scfhp.com/media/2787/ict20training_core_competencies.pdf
Medicare Learning Network (MLN) Official Information Health Care Professionals can Trust o Link to continuing education programs, webinars, podcasts, articles and more: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNGenInfo/index.html
When providers and their staff complete the required trainings, they must sign and complete an attestation form. The form should include the name of the training and the names of the staff who completed it to attest that the training was completed. Please retain a copy of the signed attestation form as proof of completion.
Visit our website at www.scfhp.com to access the trainings.
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Interpreter Services Reference Guide
Quality Improvement Email: Quality@scfhp.com ________________________________________________________________________________________
SCFHP provides foreign language and American Sign Language interpreters to members for any covered service -- at no cost to members or providers.
Telephone interpreting services (24 hours a day, 7 days a week)
LanguageLine Interpreting Services
Phone:
1-888-898-1364
How to use LanguageLine: 1. Call LanguageLine at 1-888-898-1364. 2. Press 1 for Spanish or press 2 for other languages. If you are requesting another language, clearly say the name of the language the member speaks. Press 0 if you don't know the name of the language you need. 3. An agent will come on the line. Take note of the agent's ID number and provide the agent with: a. Provider's office name b. Your first and last name c. Member's first and last name d. Member's date of birth e. Member's ID number
California Relay Services - Available in English and Spanish for members with hearing difficulties.
TTY:
Dial 711
In-person interpreting services (72 hours advance notice preferred)
Customer Service Medi-Cal:
1-800-260-2055 Monday Friday 8:30 a.m. 5:00 p.m.
Cal MediConnect:
1-877-723-4795 Monday Friday 8:00 a.m. 5:00 p.m.
How to request in-person interpreting services: 1. Call SCFHP Customer Service at 1-800-260-2055 (Medi-Cal) or 1-877-723-4795 (Cal MediConnect). Request interpreting services from the Customer Service Representative. 2. Provide the following information to schedule an appointment with an interpreter: a. Member's name and date of birth b. Provider's name and address c. Language needed (If unknown, allow the member to identify the language using the Language Identification Guide. To request a copy of the guide, please email Quality@scfhp.com.) d. Appointment date, time, and location e. Type of appointment (doctor's checkup, surgery, consultation, etc.) f. Onsite contact information for appointment (representative name, department location, phone number) g. Gender preference of interpreter
If you have any issues with telephone or in-person interpreters (no-show interpreters, etc.), please email Quality@scfhp.com. Include what service was used and the interpreter's ID number in the email.
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Your Rights and Responsibilities as a Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) Member
When you are a member of Santa Clara Family Health Plan (SCFHP) Cal MediConnect, you have certain rights and responsibilities. Rights are what you can expect to receive, including needed treatment and information. Responsibilities are what we expect you to do as a member of the plan.
Your rights and responsibilities as a member of SCFHP Cal MediConnect can be found in Chapter 8 of your Member Handbook.
You also have these rights and responsibilities:
· A right to a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
· A right to make recommendations regarding the organization's member rights and responsibilities policy.
· A responsibility to understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.
If you have questions, call Customer Service at 1-877-723-4795, Monday through Friday, 8 a.m. to 8 p.m. TTY users should call 1-800-735-2929 or 711.
Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.
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Member Rights and Responsibilities
As a member of SCFHP, you have certain rights and responsibilities. Rights are what you can expect to receive, including needed treatment and information. Responsibilities are what we expect you to do as an SCFHP member. The next two lists explain these rights and responsibilities.
Member Rights
SCFHP members have these rights: To receive needed and appropriate medical care, including preventive health services and health education. To be treated with respect, giving due consideration to your right to privacy and the need to maintain confidentiality of your medical information. To be provided with information about the plan and its services, including Covered Services. To be able to choose a primary care provider within SCFHP's networks. To participate in decision making regarding your own health care, including the right to refuse treatment. To voice grievances, either verbally or in writing, about the organization or the care received. To receive care coordination. To request an appeal of decisions to deny, defer or limit services or benefits. To receive oral interpretation services for their language. To receive free legal help at your local legal aid office or other groups. To formulate advance directives. To request a State Hearing, including information on the circumstances under which an expedited hearing is possible. To disenroll upon request. Members that can request expedited disenrollment include, but are not limited to, those receiving services under the Foster Care or Adoption Assistance Programs and those with special health care needs. To access Minor Consent Services. To receive written member-informing materials in alternative formats (such as braille, large-size print and audio format) upon request and in a timely fashion appropriate for the format being requested and in accordance with Welfare & Institutions Code Section 14182 (b)(12). To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation. To receive information on available treatment options and alternatives, presented in a manner appropriate to your condition and ability to understand.
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To have access to and receive a copy of your medical records, and request that they be amended or corrected, as specified in 45 Code of Federal Regulations §164.524 and 164.526.
Freedom to exercise these rights without adversely affecting how you are treated by SCFHP, your providers or the State.
To have access to family planning services, Freestanding Birth Centers, Federally Qualified Health Centers, Indian Health Service Facilities, midwifery services, Rural Health Centers, sexually transmitted disease services and Emergency Services outside SCFHP's networks pursuant to the federal law.
To take part in establishing SCFHP's public policy, by attending and/or joining the SCFHP Consumer Advisory Committee and attending any SCFHP Governing Board meeting.
Member Responsibilities
SCFHP members have these responsibilities: To carefully read all SCFHP materials as soon as you enroll so you understand how to use SCFHP's services. To carry your SCFHP ID card with you at all times and show it to all providers and pharmacies when getting services. To ask questions when you do not understand something about your coverage or medical care. To follow the rules of SCFHP membership as explained in this Member Handbook. To be responsible for your and your children's health. To talk to your health care provider so you can develop a strong relationship based on trust and cooperation. To call your health care provider when you need routine or urgent health care. To report unexpected changes in your health to your PCP. To ask questions about your medical condition. Make sure you understand the answers, and what you are supposed to do. To follow the treatment plan you and your health care provider create together, and know what might happen if you do not follow the treatment plan. To make and be on time for medical appointments. Let your health care provider know at least 24 hours before your scheduled appointment if you need to cancel. To tell SCFHP about any changes in: address; phone number; family status, such as marriage, divorce, etc.; and changes in any other health care coverage you might have. Tell SCFHP about these changes as soon as you know them or within 10 days of these changes.
53
To call or write SCFHP as soon as possible if you feel you were improperly billed or if the bill is wrong.
To treat all SCFHP personnel and health care providers with respect and courtesy. To submit requests for claims reimbursement for covered services within the required
time period. To be honest in your dealings with SCFHP and its plan providers. Do not commit fraud or
theft or do anything that threatens the property of SCFHP or the property or safety of any of its representatives, plan providers, plan providers' employees, or agents. To report wrongdoing. You are responsible for reporting health care fraud or wrongdoing to SCFHP. You can do this without giving your name by calling the SCFHP Compliance Hotline at 1-408-874-1450, go to www.scfhp.com, or you can call the California Department of Health Care Services (DHCS) Medi-Cal Fraud and Abuse Hotline toll-free at 1-800-822-6222.
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Health Education
At Santa Clara Family Health Plan (SCFHP), we are dedicated to helping our members stay healthy. We partner with a number of agencies within the community to provide health education classes and programs that best meet the needs of our membership.
All classes and programs are provided at no cost to SCFHP members. To enroll your patient for a specific class, you can do one of the following things:
Visit https://www.scfhp.com/for-members/health-education/ and call the organization who is listed. Login to Provider Link at https://www.providerportal.scfhp.com and complete and submit a Refer
Patient to Health Education form. Complete the Health Education Referral Form included in this packet and available on our website
under For providers and in Forms and documents, and o Email the completed form to HealthEd@scfhp.com, or o Fax the completed form to 1-408-874-1959
If your patient requires help in a language other than English, 24-hour interpreter services are available. Refer to the Reference guide for interpreter services in this packet.
For more information about classes and programs provided by SCFHP Health Education, please call SCFHP Customer Service and ask for Health Education at 1-800-260-2055 or email HealthEd@scfhp.com.
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Request Health Education for Patient
Phone: 1-800-260-2055 Fax: 1-408-874-1959
Email: healthed@scfhp.com
This form is for Primary Care Providers. If you are a SCFHP member, you can register for health education classes on the mySCFHP member portal at member.scfhp.com or call SCFHP Customer Service at 1-800-260-2055 (TTY: 1-800-735-2929 or 711) 8:30 a.m. to 5:00 p.m., Monday - Friday.
Member Information
Name:
Date:
Date of Birth:
SCFHP ID:
Address:
Home Phone:
Work/Cell Phone:
Physician Information
Referring Physician:
Address:
Phone:
Fax:
Classes and materials may be available in English, Spanish, Vietnamese, Chinese, and Tagalog.
All classes require pre-registration.
Chronic Disease Self-Management
Parent Education
Asthma
Diabetes
General Chronic Disease/Condition Management (High Blood Pressure, Heart Disease, Arthritis, etc.)
Basic Parenting Prenatal Education
Child Birth Preparation Prenatal Breastfeeding Infant Care Infant & Child CPR/First Aid
Counseling & Support Service Stress Management Anger Management
Exercise & Fitness
Programs for Children Asthma Camp (Summer. Ages 6-12) Diabetes Prevention Day Camp (Summer. Grades K-10) Summer Swimming Lessons (Ages 6 mo. 18 years)
Safety Programs
Fitness Center (All Year. Ages 13+)
Car Seat Safety
Nutrition & Weight Management Family Nutrition Education Weight Watchers
Smoking Cessation Smoking Cessation Workshop Smoker's Helpline Other (Please specify)
Submit an online version of this form on Provider Link at providerportal.scfhp.com, or email/fax this form to SCFHP Health Education.
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Provider data and attestations
Santa Clara Family Health Plan (SCFHP) is required by California Senate Bill 137 (SB137) to validate provider's data on a quarterly basis, as well as to ensure that our Provider Directory is as accurate as possible. This means you will receive faxes from us requesting that you verify the data that we have on file for you, called Provider Data Attestations. This includes validating information like names of physicians, licenses, office hours, languages, and more. This helps to ensure that the data in our Provider Directory and on our Find-a-Doctor search tool is as accurate as possible. Additionally, it assists other physicians to refer members to your office.
Verify that the data we have on file is correct or correct the data, and fax it back to us. Fax us the completed attestations to Provider Network Operations at 1-408-362-9871. You can also verify or correct your information and submit attestations in Provider Link at providerportal.scfhp.com.
If you have any questions, contact Provider Network Operations at 1-408-874-1788 or email providerservices@scfhp.com.
Example of a few data points on the Provider Data Attestation form:
If Blank or "Unknown" Please Complete
Facility Name Facility DBA (as applicable) Street Address City, State Zip Phone After Hours Phone Fax Email Website Contact NPI #
No Change
Changes Needed
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Change Notification Form
Provider Network Management
Phone: 1-408-874-1788 Fax: 1-408-362-9817
Email: ProviderServices@scfhp.com
To From
Provider Network Management
Fax Date
1-408-362-9817 or email to ProviderServices@scfhp.com
Please fill out the form below to notify Santa Clara Family Health Plan of any changes to your demographic information. You are required to notify SCFHP immediately of changes to this information. If you wish to make changes in your participation status or have questions, please call our Provider Network Management Department at 1-408-874-1788.
Provider Name (Required) License # (Required)
Address
Phone
Provider Email
Website
Specialty with Taxonomy Code (Required)
Expiration Date (Required)
NPI (Required)
Accepting New Patients
Yes
No
Fax
This email is intended for patient communication and should be published in the provider directory.
Office Hours
Board Certified
Yes
No
Board Certified
Yes
No
Hospital Privileges
IPA/Provider Group/Medical Group
Languages Spoken by Provider
Languages Spoken by Office Staff (Non-Clinical)
Languages Spoken by Clinical Staff
Languages Spoken by Skilled Medical Interpreters at this Location
Age Limits (Please Specify)
Gender Limits (Please Specify)
Current Tax ID #
New Tax ID #*
Effective Date
*If submitting a new tax ID number, please complete a W-9 form.
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Medi-Cal & Healthy Kids Quick Reference Guide
Santa Clara Family Health Plan Contact Information
Automated Eligibility: (24 hours/7 days week)
Phone:
1-800-720-3455
Language Interpretation Services:
Language Line:
1-888-898-1364
Customer Service: Mon-Fri 8:30 am 5 pm
Phone:
1-800-260-2055
Claims and Authorizations Information
Independent Physicians Medi-Cal & Healthy Kids Stanford Medical Center Medi-Cal & Healthy Kids Palo Alto Medical Foundation (PAMF) Medi-Cal ONLY
Authorizations: Phone: Email: Fax:
408-874-1821 umhelpdesk@scfhp.com 408-874-1957 408-376-3548
Claim Submission: Clearinghouses: Payor ID:
Provider Services:
Mailing Address:
Phone:
408-874-1788
Email:
providerservices@scfhp.com
Claims Inquiries: 408-874-1788
Change Healthcare & Office Ally 24077
Santa Clara Family Health Plan PO Box 18640 San Jose, CA 95158
DELEGATED ENTITIES
Valley Health Plan (VHP) Medi-Cal & Healthy Kids
Authorizations: Phone: Hospital Admissions:
Provider Services:
Phone:
Claims Inquiries: Phone: Email:
408-885-4647 VMC PURC 1-855-254-8264
408-885-2221 #7
408-885-4563 customerservice@uhin.org
Delegated Claim Submission:
Delegated for:
Out-of-Area and In-Area Professional
and Facility Claims
Payor ID: VHP01 VHP02
Clearinghouse: Utah Health Information Network Office Ally
Mailing Address:
Valley Health Plan PO Box 28407 San Jose, CA 95159
Language Interpretation Services:
Spanish
408-808-6151
Vietnamese
408-808-6152
Other
408-808-6150 (Including Tagalog & Chinese)
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Medi-Cal & Healthy Kids Quick Reference Guide
DELEGATED ENTITIES
Physicians Medical Group of San Jose (PMG) Medi-Cal & Healthy Kids
Authorizations: Phone: Website:
408-937-3645 www.pmgmd.com
Provider Services:
Phone:
408-937-3612
Delegated Claim Submission:
Delegated for:
Non-Emergency Professional
Claims In-Area (services within
Santa Clara, Santa Cruz, Alameda,
San Mateo and/or San Benito
Counties)
Claims Inquiries: Phone:
408-937-3620
Payor IDs: PMGSJ PMGSJ EXC01 EXC01 EXC01
Clearinghouses: ENS Proxymed Change HealthCare Office Ally WebMD
Mailing Address:
Excel MSO, Physicians Medical Group P.O. Box 1997 San Leandro, CA 94577-1997
Premier Care of Northern California Medi-Cal & Healthy Kids
Authorizations: Phone: Website:
1-877-216-4215 www.Capcms.com
Provider Services:
Phone:
1-877-216-4215
Claim Inquiries: Phone:
1-877-216-4215
Delegated Claim Submission:
Delegated for:
In-Area Professional Claims
services within Santa Clara, Santa
Cruz, Alameda, San Mateo and/or
San Benito Counties
Payor IDs: 95399 CAPMN CAPMN
Clearinghouses: Change HealthCare Office Ally MDX
Mailing Address:
Conifer Health Solutions PO Box 261040 Encino, CA 91426
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Medi-Cal & Healthy Kids Quick Reference Guide
DELEGATED ENTITIES
Kaiser Permanente Medi-Cal ONLY
Authorizations: Phone:
1-800-464-4000 #1
Delegated Claim Submission:
Delegated for:
All Professional and Facility claims
Provider Services:
Phone:
1-800-464-4000
Claim Inquiries: Phone:
1-800-390-3510
Payor IDs: 94135 94135 RH009 NKAISERCA
Clearinghouses: Change HealthCare Office Ally Relay Health SSI
Mailing Address:
Kaiser Foundation Health Plan Attn: Claims Administration Dept. PO Box 12923 Oakland, CA 94604-2923
Palo Alto Medical Foundation (PAMF) Healthy Kids ONLY
Authorizations: Phone: Fax:
1-855-263-4067 1-855-263-4068
Provider Services:
Phone:
1-877-854-6431
Delegated Claim Submission:
Delegated for:
In-area professional claims
Payor IDs: 94115 SC050
Clearinghouses: Change HealthCare Office Ally
Claim Inquiries: Phone:
1-877-252-1777
Mailing Address:
Palo Alto Medical Foundation PO Box 276950 Sacramento, CA 95827
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Cal MediConnect Quick Reference Guide
Eligibility
Providers are responsible for checking a member's eligibility each month. There are several ways to check eligibility:
1. Visit www.scfhp.com. 2. Call 24/7 automated eligibility line at 1-800-720-3455. 3. Call Santa Clara Family Health Plan (SCFHP) at 1-877-723-4795, 8:30 a.m. to 5:00 p.m., Monday
through Friday.
Claims Payment for Cal MediConnect Enrollees
For dual eligible beneficiaries enrolled in SCFHP's Cal MediConnect program, SCFHP will process the claim for both Medicare and Medi-Cal payment. SCFHP contracts with both Emdeon and Office Ally for clearinghouse services. Please use SCFHP Payer I.D. number 24077. The daily cutoff time for same day claims submission is 5:00 pm Pacific time. If you require clearinghouse submission assistance, please contact:
Emdeon Customer Services Office Ally
1-866-742-4355 1-866-575-4120 Option 1
Crossover Claims for Non-Cal MediConnect Enrollees
For dual eligible beneficiaries who choose not to enroll in a Cal MediConnect program, the beneficiary's Medicare program should be billed first. The "crossover claim" must go to the beneficiary's Medi-Cal plan, which will pay any amount owed under state Medi-Cal law.
Provider Network
Providers may view SCFHP's Cal MediConnect provider network by accessing the provider search located at www.scfhp.com/for-members/find-a-doctor.
Benefit Summary
Providers may access the member's benefit summary and member handbook (Evidence of Coverage) located at www.scfhp.com/healthcareplans/calmediconnect/member-materials.
Authorization Grid
SCFHP has an authorization grid for the Cal MediConnect program showing the covered services that require prior authorization. The PDF is available at www.scfhp.com/for-providers/forms in the Authorization category.
Provider Manual and Policies Providers may view the Provider Manual and Policies and Procedures at www.scfhp.com/for-providers/providerresources.
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Cal MediConnect Quick Reference Guide
Contact Information
Santa Clara Family Health Plan
Member Services
1-877-723-4795
TTY
1-800-735-2929
Provider Services
1-408-874-1788
Fax
1-408-376-3537
Utilization Management 1-408-874-1821
Fax
1-408-874-1957
Claims
1-408-874-1788
Pharmacy MedImpact
1-888-807-8666
Health Care Options
Enrollment TTY
7077
1-844-580-7272 1-800-430-
8:00 a.m. to 8:00 p.m., 7 days a week, including holidays 8:30 a.m. to 5:00 p.m., Monday through Friday 8:30 a.m. to 5:00 p.m., Monday through Friday 8:30 a.m. to 5:00 p.m., Monday through Friday
8:00 a.m. to 5:00 p.m., Monday through Friday
In-Home Support Services (IHSS)
Santa Clara County Social Services Agency 1-408-792-1600
Website www.sccgov.org
Behavioral Health
Santa Clara County Mental Health Department 1-800-704-0900
Website www.sccgov.org/sites/mhd
Community-Based Adult Services (CBAS) Contact SCFHP Member Services at the number above.
Multipurpose Senior Services Programs (MSSP)
Sourcewise (Formerly Council on Aging)
1-408-350-3200
Website www.mysourcewise.com/care-management
Email
community@mysourcewise.com
24-Hour Nurse Advice Line 1-877-509-0294
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Medical Covered Services Prior Authorization Grid
This Prior Authorization Grid contains services that require prior authorization only and is not intended to be a comprehensive list of covered services. Providers should refer to the appropriate Evidence of Coverage (EOC) for a complete list of covered services.
Santa Clara Family Health Plan (SCFHP) Utilization Management Department:
Telephone: 1-408-874-1821 Prior Authorization Request Submission Fax Lines: 1-408-874-1957
When faxing a request to SCFHP, please:
1. Use the SCFHP Prior Authorization Request Medical Services Form found at www.scfhp.com
2. Attach pertinent medical records, treatment plans, test results and evidence of conservative treatment to support medical necessity.
Other Contact Information:
SCFHP Automated Eligibility: SCFHP Customer Service:
Medi-Cal: Cal MediConnect:
1-800-720-3455
1-800-260-2055 1-877-723-4795
For Non-Emergency Medical Transportation (NEMT) & Non-Medical Transportation (NMT) contact SCFHP Customer Service
Benefits Authorized by Vendors:
Dental Services Denti-Cal:
Vision Services Vision Service Plan (VSP):
1-800-322-6384 1-844-613-4779
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64
Revised Date: 09/05/2020
Medical Covered Services Prior Authorization Grid
Category of Service Behavioral Health Treatment Durable Medical Equipment (DME) *Benefit and frequency limits apply. Refer to CMS, Noridian, and/or Medi-Cal Provider Manual
Experimental Procedure Home Health Inpatient Admissions
Long-Term Services and Supports (LTSS)
Services Requiring Prior Authorization
All Behavioral Health Treatment Services for members age 21 years and under with behavioral conditions that may or may not include autism spectrum
Cal MediConnect
Medi-Cal
Custom made items Any other DME or medical
supply exceeding $1000 Prosthetics & customized
orthotics exceeding $1000 Hearing aids and repairs Other specialty devices Requests over the benefit
limit
CPAP and BIPAP Enteral formula and supplies Hospital bed and mattress Power wheelchairs, scooters,
manual wheelchairs except standard adult and pediatric, and motorized wheelchairs and accessories Respiratory: Oxygen, BIPAP, CPAP, ventilators Prosthetics & customized orthotics except off-the-shelf covered items Hearing aids and repairs Other specialty devices Requests over the benefit limit
Experimental procedures Investigational procedures New technologies All home health services Home IV infusion services
All elective medical and surgical inpatient admissions to: · Acute hospital · Long Term Acute Care (LTAC)
All admissions for: · Acute inpatient psychiatric · Partial hospital psychiatric treatment · Substance use disorder including detoxification
Rehabilitation and therapy services: · Acute rehabilitation facilities · Skilled Nursing Facilities (SNF)
Community-Based Adult Services (CBAS) Long-Term Care (LTC)
40515 Medical Prior Authorization Grid Effective Date: 01/01/2021
65
Revised Date: 09/05/2020
Medical Covered Services Prior Authorization Grid
Category of Service Medications
Non-Contracted Providers Organ Transplant Outpatient Services and Procedures
Services Requiring Prior Authorization
Refer to the 2021 Medical Benefit Drug Prior Authorization Grid Physician administered drugs in the doctor's office or in an
outpatient setting All non-urgent/non-emergent services provided by non-contracted providers
All organ transplants
Abdominoplasty/Panniculectomy Bariatric surgery Breast reduction and augmentation surgery Cataract surgery Cochlear auditory implant Dental surgery, jaw surgery and orthognathic procedures Dermatology:
· Laser treatment · Skin injections · Implants All types of endoscopy except colonoscopy Gender reassignment surgery Genetic testing and counseling Hyperbaric oxygen therapy Intensive Outpatient Palliative Care (IOPC) Neuro and spinal cord stimulators Outpatient diagnostic imaging: · Magnetic Resonance Imaging (MRI) · Magnetic Resonance Angiography (MRA) · Nuclear cardiology procedures · Single-Photon Emission Computerized Tomography
(SPECT) · Positron-Emission Tomography (PET/PET-CT) Outpatient therapies · Occupational Therapy (OT) · Physical Therapy (PT) · Speech Therapy (ST) All plastic surgery and reconstructive procedures Podiatric surgeries Radiation therapy: · Proton beam therapy · Stereotactic Radiation Treatment (SBRT) Sleep studies Spinal procedures except epidural injections Surgery for Obstructive Sleep Apnea (OSA) Temporomandibular Disorder (TMJ) treatment
40515 Medical Prior Authorization Grid Effective Date: 01/01/2021
66
Revised Date: 09/05/2020
Medical Covered Services Prior Authorization Grid
Category of Service Transportation
Services Requiring Prior Authorization
Transplant-related services prior to surgery except cornea transplant
Unclassified procedures Varicose vein treatment Non-Emergency Medical Transportation (NEMT) except ground transportation from facility to facility and hospital to home.
40515 Medical Prior Authorization Grid Effective Date: 01/01/2021
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Revised Date: 09/05/2020
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