Required Specialty Types and Age Ranges for Community Care IPA
Date: 08/15/18
On February 16, 2018, the California Department of Health Care Services (DHCS) released All Plan Letter 18-005 regarding guidance on new annual network certification, network reporting requirements and associated network adequacy standards for managed care health plans by way of requirements issued in CMS-2390-F (Final Rule) sections 438.68, 438.206 and 438.207.
California Health and Wellness Plan (CHWP) must demonstrate and maintain a network adequate to serve adult and pediatric members within its service areas via the number, types and geographic location of providers.
In areas where the network may not be adequate, CHWP and Community Care IPA (CCIPA) must allow members to access services out-of-network (OON) for any deficient network components. CHWP and CCIPA cannot restrict members to only access practitioners in its own provider network if network adequacy deficiencies exist and must authorize services for OON providers.
CHWP will work with its network CCIPA to ensure an adequate number of primary care physicians (PCPs) and specialist providers are available and to collect the patient age ranges for all practitioners. This will assist members to quickly identify PCP and specialist providers for children, particularly providers who are not assigned a pediatric taxonomy and specialization (such as dermatologist versus pediatric dermatologist).
PROVIDER AGE RANGES
The patient age range categories are displayed below for CCIPA to use when validating the information for its network. This information will be displayed in the online and hard copy provider directories for members.
Age, lowest to highest | Description |
000-120 | Provider is accepting all members, children and adults |
005-120 | Provider is accepting children, ages 5 to adult |
000-018 | Provider is accepting children, birth to age 18 |
018-120 | Provider is accepting adults, ages 18 and older |
021-120 | Provider is accepting adults, ages 21 and older |
REQUIRED SPECALITIES
DHCS required specialty types for adequacy standard reporting includes adult and pediatric provider types, and is not limited to the DHCS critical specialties. CHWP monitors for network adequacy and will coordinate with CCIPA on any identified network deficiencies.
DHCS required adult and pediatric specialties | |||
Cardiologist/Interventional Cardiologist | General Surgeon | Neurologist | Physical Medicine and Rehabilitation |
Dermatologist | Hematologist | Obstetrician/Gynecologist | Primary Care Physician |
Endocrinologist | HIV/AIDS | Oncologist | Pulmonologist |
ENT/Otolaryngology | Infectious Diseases | Ophthalmologist |
|
Gastroenterologist | Nephrologist | Orthopedic Surgeon |
|
Other required specialties | |||
Allergist/Immunologist | Maternal/Fetal medicine | Podiatrist | Urologist |
Anesthesiologist | Neonatologists | Radiation Oncology | Vascular Surgeon |
Cardiovascular Surgeon | Neurological Surgeon | Radiologist/Nuclear Medicine |
|
Colon and Rectal Surgeon | Pain Medicine | Rheumatologist |
|
Geneticist | Plastic Surgeon | Thoracic Surgeon |
|
ADDITIONAL INFORMATION
Providers who have questions or need additional information may contact CHWP Provider Relations at 1-877-658-0305.