PCP Medical Home Program Rollout - Clarification

Date: 09/18/18

California Health & Wellness Plan’s (CHWP’s) focus is to facilitate quality care, appropriate care coordination and continuity of care, which are the essential components to coordinating care for CHWP members.

As a reminder, CHWP is instituting the Primary Care Medical Home model. This model requires that members receive their primary care services from a primary care physician (PCP) chosen by and assigned to the member. This model does not apply to Indian Health Care (IHC) providers. IHC providers may continue to provide care to any CHWP member regardless of member assignment.

To carry out this model, with the exception of IHC providers, PCPs cannot provide primary care services to members who are not assigned to them. The Primary Care Medical Home requires CHWP to conform to the standard practice in the industry, requesting PCPs to verify eligibility and PCP assignment prior to providing health care services to CHWP members.

With the exception of IHC providers, starting with dates of service July 1, 2018, CHWP will discontinue paying claims to PCPs who render primary care services to unassigned members on the date-of-service. Contracted providers with CHWP and Medi-Cal are not able to bill members for any copayments or services. Claims for primary care services required due to governmental regulations or provided by an IHC provider in an urgent care, immediate care or after-hours clinic will continue to be processed regardless of PCP assignment. However, these claims must be billed appropriately to enable CHWP to identify these claims.

To avoid denied claims, providers are encouraged to verify that the member is currently assigned to their practice prior to providing any primary care services. Providers can verify eligibility by the following methods:

• Visit CHWP secure provider portal at www.cahealthwellness.com and  select For Providers > Login > Check Member Eligibility.
• Visit Medi-Cal’s automated eligibility verification system (AEVS) website at www.medi-cal.ca.gov/Eligibility.
• Contact CHWP Provider Services at 1-877-658-0305.

With the exception of IHC providers, if a member is not assigned to a CHWP contracting provider at the time non-urgent primary care service is requested, the member must switch to a CHWP contracting provider for primary care services.  

Members can request same day changes by following one of the three methods indicated below:

• Complete the member PCP change form found on www.cahealthwellness.com and fax it back to
  1-877-302-3434.
• Call the CHWP Member Services Department at 1-877-658-0305 (TTY: 711).
• Submit a change request via the CHWP website at www.cahealthwellness.com.

If you have questions regarding the information contained in this update, contact your Provider Relations representative or call 1-877-658-0305.