News

Reminder: PCP Medical Home Program Rollout

Date: 05/31/18

As a Medi-Cal managed care organization, our focus is to facilitate quality care, appropriate care coordination and continuity of care as an essential component to coordinating care for our members. As such, we are instituting a Primary Care Medical Home model for all members. This model requires that members receive their primary care services from a primary care physician (PCP) chosen by and assigned to the member.

To carry out this model, we are unable to continue the practice of allowing PCPs to provide primary care services to members who are not assigned to them. The Primary Care Medical Home requires California Health & Wellness Plan (CHWP) to conform to the standard practice in the industry, meaning PCPs must verify eligibility and PCP assignment prior to providing health care services to our members.

Beginning with dates of service July 1, 2018 and beyond, CHWP will discontinue paying claims to PCPs who render primary care services to unassigned members on the date of service. As a contracted provider with CHWP and Medi-Cal, you will not be able to bill members for any co-pays or services. Claims for primary care services required due to governmental regulations or provided in an urgent care, immediate care, or after-hours clinic will continue to be paid regardless of PCP assignment. However, these claims must be billed appropriately to enable CHWP to identify these claims.

To avoid your claim being denied, please be sure that you are verifying a member is currently assigned to your practice prior to providing any primary care services. You can verify eligibility by the following methods:

1. California Health & Wellness Secure Web Portal
   • www.cahealthwellness.com
   • Click On For Providers
   • Login
   • Go To Check Member Eligibility
2. AEVS Website at www.medi-cal.ca.gov/Eligibility
3. California Health & Wellness Provider Services at 1-877-658-0305

If a member is not assigned to you at the time non-urgent primary care service is requested, the member must switch to your practice for primary care services. Members can request same day changes in order to accommodate patients that need to be seen that day. Please have the member request the PCP change by following one of the three methods indicated below.

1. Complete the member PCP change form found on www.cahealthwellness.com and fax it back to: 1-877-302-3434.
2. Call our Member Services Department at 1-877-658-0305 (TTY: 711).
3. Submit change requests via the CHWP Web Portal www.cahealthwellness.com.