Quality Management Program and Resources
California Health & Wellness (CHWP) quality management program continuously monitors and evaluates the quality, appropriateness and outcome of care and services delivered to our members. It includes the development and implementation of standards for clinical care and service, measurement of compliance to standards, and the implementation of actions to improve performance.
Below is an overview of the components of the multifaceted Medi-Cal quality management program. It includes quality improvement (QI) processes and instructions on how to get more information from the CHWP provider website.
Open clinical dialogue
CHWP’s Provider Participation Agreement (PPA) includes a statement that participating providers can talk freely with members about their medical conditions, treatment options and medications, regardless of limits to coverage.
Quality performance improvement projects
CHWP conducts quality performance improvement projects (PIPs) targeting specific health care issues that impact a significant number of members. PIPs may also address the use of health services to enhance health outcomes. It includes testing small-scale change at the provider, member and health plan level to improve the quality of members’ health care and outcomes.
The current DHCS PIP cycle is September 2023—September 2026. The projects currently in process are:
- Non-Clinical PIP: Improve the percentage of referrals to Community Support programs (Sobering Centers, Day Habilitation programs) within seven days of visiting emergency department (ED) for members with a SUD/SMH diagnosis and seen in ED for the same diagnoses.
- Clinical PIP: Improving Well-Child Visits in the First 30 Months of Life—Well-Child Visits in the First 15 Months—Six or More Well-Child Visits (W30–6+) measure rate for their Black/African American populations.
PIPs require frequent reporting to DHCS and Health Services Advisory Group (HSAG) with specific expectations including completing a process map, failure mode and effect analysis, intervention analysis, and monthly progress monitoring. Depending on the progress of the initiatives, CHWP may expand the interventions across all counties.
CHWP measures quality of care and services provided to members through Healthcare Effectiveness Data and Information Set (HEDIS) performance measures for care and service, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for member satisfaction, member appeals and grievances, and access and availability surveys. In addition, CHWP conducts an annual provider satisfaction survey to identify opportunities to better serve its participating providers.
Starting in 2019, DHCS began leveraging the CMS Adult and Child Core sets to measure health plan performance. The new measure set called the Managed Care Accountability Set (MCAS) holds plans to significantly more measures and addresses care needs across preventive, chronic and behavioral health. DHCS revised the MCAS measures for measurement year 2022 and holds the Plan accountable to meet minimum performance levels at the 50th percentile on the following 18 HEDIS measures:
- Asthma Medication Ratio (AMR).
- Breast Cancer Screening (BCS).
- Cervical Cancer Screening (CCS).
- Child and Adolescent Well-Care Visits (WCV).
- Childhood Immunization Status – Combo 10 (CIS-10).
- Chlamydia Screening in Women (CHL).
- Comprehensive Diabetes Care: HbA1c Poor Control (> 9.0%) (HBD).
- Controlling High Blood Pressure (CBP).
- Developmental Screening in the First Three Years of Life (DEV).
- Follow-up After ED Visit for Mental Illness – 30 days (FUM).
- Follow-up After ED Visit for Substance Abuse – 30 days (FUA).
- Immunizations for Adolescents – Combo 2 (IMA-2).
- Lead Screening in Children (LSC).
- Prenatal & Postpartum Care: Timeliness of Prenatal Care (PPC-Pre).
- Prenatal & Postpartum Care: Postpartum Care – (PPC-Pst).
- Topical Fluoride for Children (TFL-CH),
- Well-Child Visits in the First 30 months of Life – Six or more well child visits in the first 15 months (W30-6+).
- Well-Child Visits in the First 30 Months of Life – Two or more visits during 15–30 months (W30-2+).
Appropriate timeliness of services, outreach to members, clinical documentation, correct coding, as well as timely and complete encounter submissions are important elements of meeting preventive care guidelines. CHWP offers provider office training materials, member outreach calls, member newsletters, and an online provider newsletter. All the information is designed to help providers and members accomplish these preventive measures.
MHN is CHWP’s behavioral health administrator. Practitioners and providers may refer members for behavioral health services or members can self-refer by calling MHN at the phone number on their CHWP ID cards. The QI Department utilizes several specific quality initiatives to help improve members’ physical and mental health outcomes. The health plan collaborates with MHN on quality improvement activities that may reach your office or practices.
Overall, members and providers may receive live calls from MHN’s quality team, providing members and providers with important educational information or reminders to take action when necessary. The focus of these initiatives may vary and include psychotropic medication management and timely follow-up care after an emergency department (ED) visit or hospital stay for mental illness and/or substance use, and coordinating referrals and care. Below is a summary of the potential collaborative quality improvement projects:
MHN telephonic outreach to –
- Families and children may be prescribed psychotropic medication.
- Physicians who are prescribing psychotropic medications.
- Members had an ED for mental illness and/or substance use, highlighting the importance of coordination of care.
- Timely follow-up for members who may have screened positive from a mental health screening (e.g., depression screening).
CalAIM is a multi-year initiative led by the Department of Healthcare Services (DHCS) to improve the quality of life for medical and social outcomes for Medi-Cal beneficiaries, especially for those with the most complex needs. Providers can refer to the CalAIM Resources for Providers page for tools and information to help easily navigate the different CalAIM programs, including those described below to support Medi-Cal members.
Enhanced Care Management (ECM)
ECM is a benefit that is being implemented statewide in phases. This program provides a whole-person approach to care that addresses the clinical and non-clinical circumstances of high-need Medi-Cal members. ECM is a collaborative and interdisciplinary approach which provides intensive and comprehensive care management services to population of focus.
The following seven core services are provided at the point of care:
- Outreach and engagement.
- Comprehensive assessment and care management plan.
- Enhanced care coordination.
- Health promotion.
- Comprehensive transitional care.
- Member and family support.
- Coordination of and referral to community and social support services.
The overall goal of the ECM benefit is to provide comprehensive care and achieve better health outcomes for the highest need beneficiaries in Medi-Cal. The health plan is required to contract with community-based ECM providers who have experience serving the ECM population of focus and expertise providing the core ECM services to eligible members under the Medi-Cal ECM benefit.
Community Supports (CS)
CS is an initiative to address social determinants of health and improve health equity statewide. CS services are medically appropriate and cost-effective alternatives to state plan services. DHCS has pre-approved 14 CS services to address the needs of members – including those with the most complex challenges affecting health, such as homelessness, unstable and unsafe housing, food insecurity, and/or other social needs.
The following CS services are optional and available to members.
- Asthma remediation.
- Community transition services/nursing facility transition services to a home.
- Day habilitation programs.
- Environmental accessibility adaptation (home modification).
- Housing deposit.
- Housing tenancy and sustaining services.
- Housing transition navigation.
- Medically tailored meals.
- Nursing facility transition/diversion to assisted living facilities.
- Personal care services and homemaker services.
- Recuperative care.
- Respite services.
- Short-term post-hospitalization housing.
- Sobering centers.
The key goal of the pre-approved CS services is to allow members to receive care in settings where they feel most comfortable and to keep them in their home or the community, as medically appropriate.
The Chronic Condition/Disease Management Program aims to identify and assist members in patient centered management of specific chronic medical conditions. This includes improving member knowledge, self-management skills and awareness of poor health habits that impact their chronic condition(s). Members gain improved quality of life and it promotes appropriate use of services.
A structured chronic condition/disease management program is available for Medi-Cal members who have one of the following chronic conditions: asthma, diabetes or heart failure. CHWP sends an introductory mailing to all targeted members and health plan physicians announcing the program and informing members they will receive a phone call. Once contact is made, the program is explained to members and a health assessment is initiated to identify clinical risk, education needs and to assign the member to the appropriate health coach. The health coach will complete an assessment and develop an individualized care plan based on the member’s or caregiver’s knowledge of their condition, lifestyle behaviors, and readiness to change.
To refer a member to the program, use the Care Management Referral Form on CHWP site under Provider Resources > Manuals, Forms and Resources > Forms. Members may self-refer to the program or opt out at any time.
The following interventions and resources are available at no cost to Medi-Cal members through self-referral or a referral from their primary care physician (PCP). For more information, members and providers can call the toll-free Health Education Information Line at 800-804-6074. Members will be directed to the appropriate service or resource based on their needs. Telephonic and web-based resources are available 24/7. Members and PCPs may request educational resources on health topics such as, but not limited to, nutrition, tobacco prevention and cessation, HIV/STD prevention, family planning, exercise, dental, perinatal care, diabetes, asthma, substance abuse and much more. Print educational resources are sent to members.
Start Smart for Your Baby
We want to help members take care of themselves and their babies from the time they find out they are pregnant through postpartum and newborn periods. Start Smart for Your Baby® (Start Smart) is a care management program for members who are pregnant.
The program can help members:
- Find a doctor.
- Set up appointments.
- Find community resources.
- Free healthy pregnancy education packet – Get packets with information about nutrition, exercise and health exams during pregnancy, and tips to care for your newborn.
- Access educational resources.
- Social worker support.
Members identified as having a high-risk pregnancy can receive extra help from case management nurses during the pregnancy. They can contact Member Services at 877-658-0305 to take part in the program.
Tobacco cessation program
The Kick It California tobacco cessation program (formerly known as the California Smokers’ Helpline) is available to CHWP members. The program offers free phone counseling, self-help materials and online help in six languages (English, Spanish, Cantonese, Mandarin, Korean, and Vietnamese). Specialized services are available to teens, pregnant women, and tobacco chewers to help members quit smoking and stay tobacco-free. Non-pregnant adult members are offered a 90-day regimen of all FDA approved tobacco cessation medications with at least one medication available without prior authorization.
CHWP members can enroll in the telephonic tobacco cessation program, without prior authorization for members of any age regardless if they opt to use tobacco cessation medications, by calling Kick It California at 800-300-8086, Monday–Friday, 7.a.m.–9 p.m., Saturday from 9 a.m.–5 p.m., or online. CHWP will cover tobacco cessation counseling for a least two separate quit attempts per year, without prior authorization, and with no mandatory break between quit attempts. Members may request a referral to group counseling by calling the Health Education Department at 800-804-6074.
Diabetes prevention program
Eligible members ages 18 and older with prediabetes can participate in a year-long, evidence-based, lifestyle change program. The program promotes and focuses on emphasizing weight loss through exercise, healthy eating and behavior modification. The program is designed to assist Medi-Cal members in preventing or delaying the onset of type 2 diabetes.
Behavioral health programs
myStrength, a personalized website and mobile application, is available to help members deal with depression, anxiety, stress, substance use, pain management, postpartum depression and more. CHWP provides members with Adverse Childhood Experiences (ACEs) Education and Resources. Members can request CHWP’s ACEs education and resources by calling the Health Education Department at 800-804-6074 or requesting them through their doctor.
CHWP Community Connect
Powered by findhelp, CHWP Community Connect offers the largest online search and referral platform. There are 10 topics to choose from, such as food, housing and transportation. Then select a subtopic which will contain a list of services based on the ZIP Code entered. The results can be viewed in over 100 languages. To use the tool, go to CHWP Community Connect, take the Social Needs Assessment, enter a ZIP Code, and click on Search.
To search for and make referrals to Community Supports (CS) providers and services, go to CHWP ECM CS, log into your account, complete and submit the CHWP CalAIM Assessment. Based on the results, a list of available CS services will appear to make a referral.
Clinical licensed nurses and social workers lead our case management (CM) teams and are familiar with evidence-based resources and best practice standards. They also have experience with the population, the barriers and obstacles they face, and how socioeconomic factors impact their ability to access services. The CHWP CM team coordinates care for members whose needs are functional and social in nature, as well as those with complex physical and or behavioral health conditions including high risk pregnancy. CHWP uses a holistic approach by integrating referral and access to community resources, transportation, follow-up care, medication review, specialty care, and education to
assist members in making better health care choices. Case managers partner with primary care physicians (PCPs) to support members with achieving their self-management health care goals.
This program supports CHWP members, families and caregivers by coordinating care and facilitating communication between health care providers. Once a member agrees to participate in the program, a care manager contacts the member’s PCP to coordinate care. This helps facilitate an appropriate personalized level of care for members, which may include:
- Telephonic and face-to-face (as needed) interactions.
- Comprehensive assessment of medical, psychosocial, cognitive, medication adherence, and durable medical equipment (DME) needs.
- Development of an individual care treatment plan in collaboration with the member and the health care team that reflects the member’s ongoing health care needs, abilities and preferences.
- Consolidation of treatment plans from multiple providers into a single plan of care to avoid fragmented or duplicate care.
- Coordination of treatment plans for acute or chronic illness, including emotional and social support issues.
- Coordination of resources to promote the member’s optimal health or improved functionality with referrals to other team members or programs as appropriate.
- Education and information about medical conditions and self-management skills, compliance with the medical plan of care, and other available services to reduce readmissions and inappropriate utilization of services.
- Communication to the provider and medical home.
- Support and education for pregnancies. High-risk pregnancies are offered extra help.
On an ongoing basis, CHWP evaluates the efficacy of this program by reviewing and comparing specific member outcomes and utilization before and after case management intervention.
Providers may refer a member by faxing the completed Care Management Referral Form to 855-556-7909 or mailing it to California Health & Wellness, 4191 E. Commerce Way, Sacramento, CA 95834-9679. The Care Management Referral Form is available on CHWP site under Provider Resources > Manuals, Forms and Resources > Forms. Members may self-refer to the program by calling 877-658-0305, option 1 and requesting case management.
CHWP’s evidence-based clinical practice guidelines are from nationally recognized sources and form the foundation for its disease management programs. All guidelines are reviewed and updated at least biannually and when new scientific evidence or national standards are published. Centene’s Corporate Clinical Policy Committee and the
California Health & Wellness Medical Advisory Council (MAC) adopt the clinical practice guidelines and tools, which are available at CHWP website under For Providers > QI Program > Practice Guidelines.
Guideline sources include, but are not limited to, the following:
- Disease management – Clinical guidelines and overview summaries are available to providers. They can quickly reference information about chronic conditions, which include asthma, diabetes and heart failure (HF). Sources are found within the guidelines.
- Behavioral health – Clinical guidelines are available for such disorders as attention deficit hyperactivity disorder (ADHD) and substance use disorder.
Preventive health guidelines
CHWP recommends that participating providers follow the preventive guidelines adopted from the United States Preventive Services Task Force (USPSTF), Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG), the American Cancer Society (ACS), and the American Academy of Family Physicians (AAFP) in the treatment of adult, senior, prenatal, and postpartum members. The guidelines of American Academy of Pediatrics (AAP) and the Advisory Committee for Immunization Practices (ACIP) are recommended for the preventive care and treatment of infants, children and adolescents. A member’s medical history and physical examination may indicate that further medical tests are needed. As always, the judgment of the treating physician is the final determinant of member care.
Current recommended guidelines of the specialty boards, academies and organizations used in the development of CHWP preventive health guidelines are available online at:
Providers who conduct periodic health assessments on Medi-Cal children ages 6 and under are responsible for screening children for elevated blood lead levels. Providers must follow the California Department of Public Health Guidelines for interpreting blood lead levels and performing follow-up activities for elevated levels.
CHWP provides electronic and web-based care gap reports to providers to help identify children who need a lead test. Reach out to your provider representative for information on how to obtain or review these reports. More information on DHCS’ childhood blood lead screening requirements, including provider reporting and documentation, and exceptions to conducting lead screening, can be found on the provider portal under the Quality Improvement Program section.
New Medi-Cal members must receive an initial health appointment (IHA), which includes an age-appropriate history, preventive care services and physical examination within 120 days after the date of enrollment. In addition to assessing the member’s health, this should be used to determine health practices, values, behaviors, knowledge, attitudes, cultural practices, beliefs, literacy levels, and health education needs.
Members under age 18 months require a health assessment within periodicity timelines established by the AAP for ages 2 and younger, whichever is less.
For members ages 21 and older, the IHA must follow DHCS guidelines and CHWP’s preventive care services guidelines. The preventive care guidelines in the USPSTF Guide to Clinical Preventive Services A and B Recommendations are considered the minimum acceptable standards for adult preventive care services. Guidelines for members under age 21 follow the AAP Recommendations for Preventive Pediatric Health Care periodicity schedule for wellness examination.
CHWP makes every effort to complete a health risk assessment (HRA) for new members. For new Seniors and Persons with Disabilities, CHWP works to complete the HRA within 45 or 90 days of enrollment, depending on risk level, and on an annual basis thereafter. HRAs can be completed more frequently than annually, due to a change in health status or by member request. HRA completion helps with early and ongoing identification of member needs, enabling CHWP and provider group care management teams to develop more comprehensive member-centric care plans. HRAs also help predict future consumption of medical care which is essential to the success of the care management program for both the provider groups and CHWP.
CHWP has established access and availability standards, which are reviewed and revised annually as needed. The standards strive to ensure compliance with all applicable state, federal, regulatory, and accreditation requirements. They also help ensure members have a comprehensive provider network and timely access to care.
CHWP monitors the network and evaluates whether members have sufficient access to practitioners and providers who meet members’ care needs. These include waiting time standards for regular and routine appointments, urgent care appointments and after-hours care, triage, and provisions for appropriate back-up for absences. The access standards are reviewed annually against applicable state and federal regulations and mandates, and are revised as needed. CHWP recommends providers review these periodically. After-hours scripts are also available that include examples on how to implement the script for live voice, auto attendant or answering machine messaging.
The complete set of access standards and revised after-hours scripts are available on CHWP website under For Providers > Provider Resources. Providers who do not have access to the Internet may contact the CHWP Provider Services Center to request printed copies of these standards and after-hours scripts.
Medical record documentation standards
CHWP has established standards for the administration of medical records to ensure medical records conform to good professional medical practice, support health management and permit effective member care. A good medical records management system not only provides support to clinical participating providers in the form of efficient data retrieval but also makes data available for statistical and quality of care analyses.
The medical record serves as a detailed analysis of the member’s history, a means of communication to assist the multidisciplinary health care team in providing quality medical care, a resource for statistical analysis, and a potential source of defense to support information in a lawsuit. It is the participating provider’s responsibility to ensure not only completeness and accuracy of content but also the confidentiality of the health record. CHWP requires that the provider adhere to the standards for maintaining member medical records and to safeguard the confidentiality of medical information.
Participating providers are responsible for responding to demands for information while protecting the confidentiality interests of CHWP members. All participating providers must have policies and procedures that address confidentiality and the consequences of improper disclosure of protected health information (PHI). Providers should refer to Provider Manual/Billing Manual to review specific levels of security of medical records that must be addressed by the participating provider’s policies and procedures governing the confidentiality of medical records and the release of members’ PHI.
CHWP monitors medical record documentation compliance and implements appropriate interventions to improve medical recordkeeping. Medical record guidelines are available through CHWP website or upon request by contacting CHWP Provider Services.
Medical record and facility site reviews
CHWP’s Facility Site Review Compliance Department conducts periodic medical record reviews (MRRs) and facility site reviews (FSRs) to measure PCP compliance with current DHCS medical record documentation and facility standards. These reviews are initially conducted prior to assignment of Medi-Cal members and then periodically every three years thereafter in accordance with DHCS requirements, or as needed for monitoring, evaluation or corrective action plan (CAP) issues. In an effort to decrease duplicative MRRs and FSRs and minimize the disruption of patient care at participating provider offices, CHWP and all other Medi-Cal managed care plans are required to collaborate in conducting FSRs and MRRs. On a county-by-county basis, the plans cooperatively determine which plan is responsible for performing a single audit of a PCP and administering a CAP when necessary. The responsible plan shares the audit results and CAP with the other participating health plans to avoid redundancy.
DHCS reviews the results of CHWP’s site reviews and may also audit a random sample of provider offices to ensure that they meet DHCS standards. Detailed information about audit criteria, compliance standards, scoring, and CAPs is available at CHWP website.
Physical accessibility review surveys
A component of the FSR is the Physical Accessibility Review Survey (PARS). PARS is conducted for PCPs, high-volume specialists, ancillary providers, community-based adult services (CBAS) providers, and hospitals. Based on the outcome of PARS, each PCP, high-volume specialist, ancillary, CBAS, or hospital provider site is designated as having basic or limited access along with the six specific accessibility indicator designations for parking, exterior building, interior building, restrooms, examination rooms, and medical equipment (accessible weight scales and adjustable examination tables).
- Basic access demonstrates facility site access for members with disabilities to parking, building access, elevator, physician’s office, examination rooms, and restrooms.
- Limited access demonstrates facility site access for members with disabilities as missing or incomplete in one or more features for parking, building access, elevator, physician’s office, examination rooms, and restrooms.
Results of PARS are made available in the provider directory, health plan website and to CHWP’s Member Services Department to assist members with selecting a PCP who can best serve their health care needs.
To determine medical appropriateness, CHWP uses recognized guidelines and criteria sets that are clearly documented, based on sound clinical evidence and include procedures for applying criteria based on the needs of individual CHWP members and characteristics of the local delivery systems. CHWP uses the following criteria:
- Title 22 of the California Code of Regulations (CCR).
- Medi-Cal Managed Care Division (MMCD) policy letters.
- DHCS Manual of Criteria for Medi-Cal Authorization.
- DHCS Medi-Cal Provider Manuals.
- The California Health & Wellness Medi-Cal contract with DHCS.
- Centene clinical policies and CHWP medical policies. If no plan-specific clinical policy exists, then nationally recognized decision support tools such as InterQual® Clinical Decision Support Criteria or MCG (formerly Milliman Care Guidelines®) criteria are used.
Additional information that the applicable Health Plan Medical Director will consider, when available, includes:
- Reports from peer reviewed medical literature, where a higher level of evidence and study quality is more strongly considered in determinations.
- Professional standards of safety and effectiveness recognized in the U.S. for diagnosis, care or treatment.
- Nationally recognized drug compendia resources, such as Facts & Comparisons®, DRUGDEX®, and The National Comprehensive Cancer Network® (NCCN) Guidelines.
- Medical association publications.
- Government-funded or independent entities that assess and report on clinical care decisions and technology, such as Agency for Healthcare Research and Quality (AHRQ), Hayes Technology Assessment, Up-To-Date, Cochrane Reviews, and the National Institute for Health and Care Excellence (NICE).
- Published expert opinions.
- Opinion of health professionals in the area of specialty involved.
When a decision results in a denial, the criteria used to arrive at the determination are identified in the denial letter. Each denial letter explains CHWP’s appeal process. A CHWP physician reviewer is available to discuss denial decisions. Copies of specific CHWP criteria are available on request by contacting CHWP Provider Services at 877-658-0305. Participating providers contracting with Community Care Independent Practice Association (CCIPA) must contact CCIPA’s utilization management (UM) department for the UM criteria.
Under California Health & Safety Code Section 1367(g), medical decisions regarding the nature and level of care to be provided to members, including the decision of who renders the service (for example, PCP instead of specialist, or in-network provider instead of out-of-network provider), must be made by qualified medical providers, unhindered by fiscal or administrative concerns.
Providers may contact CHWP’s UM staff through the Provider Services Center at 877-658-0305. CCIPA providers must contact UM staff through CCIPA.
UM decisions are based only on appropriateness of care, service and existence of coverage. CHWP does not specifically reward participating providers or other individuals for issuing denials of coverage for care or service. There are no financial incentives for UM decision-makers to encourage decisions that result in underutilization.
As of January 1, 2022, managed care plan outpatient pharmacy benefits were carved out and transitioned to the Medi-Cal fee-for-service (FFS) program known as Medi-Cal Rx. Magellan Medicaid Administration (MMA), Inc. administers the pharmacy benefit under Medi-Cal Rx.
Medi-Cal Rx covers prescription drugs as well as over-the-counter (OTC) medications and some medical supplies. The Medi-Cal Rx list of covered items and services under the pharmacy benefit is collectively referred to as the Contract Drug List and can be found on the Medi-Cal Rx website at https://medi-calrx.dhcs.ca.gov/home/cdl. This information can also be found on the CHWP website.
The CHWP Pharmacy & Therapeutics (P&T) Committee maintains the CHWP PDL. The P&T Committee, which consists of actively practicing pharmacists and practitioners, evaluates the safety profile, effectiveness and affordability of the medications. The medications listed are approved by the U.S. Food and Drug Administration (FDA) and are reviewed by the P&T committee. The CHWP PDL is continually reviewed and revised in response to recommendations from participating providers and as new clinical data and medication products become available.
Providers should submit prior authorization requests for items under the pharmacy benefit to 800-869-4325. Providers may also submit prior authorization requests through Cover My Meds.
Providers and members should visit the Medi-Cal Rx program with any questions or concerns regarding the Contract Drug List, Pharmacy Network, or other services covered under the Med-Cal Rx program.
CHWP is committed to treating members in a manner that respects their rights, recognizes their specific needs and maintains a mutually respectful relationship. In order to communicate this commitment, CHWP has adopted member rights and responsibilities, which apply to members’ relationships with CHWP, its practitioners and providers, and all other health care professionals providing care to its members. Member rights and responsibilities statements are distributed to new practitioners when they join the network and to existing practitioners, if requested.
Member rights and responsibilities are available at CHWP webiste under Member Resources > Member Rights and Responsibilities. Providers can request copies by contacting CHWP Provider Services at 877-658-0305.
A member or member representative who believes that a determination or application of coverage is incorrect has the right to file an appeal. CHWP responds to standard appeals within 30 calendar days. A 72-hour appeal resolution is available if waiting could seriously harm the member’s health.
Additionally, a Medi-Cal member must go through the plan’s internal appeals process before requesting an external state fair hearing and an independent medical review (IMR). Once the internal appeals process has been exhausted, the member may request a fair hearing from the California Department of Social Services (DSS) by calling the Public Inquiry and Response Unit at 800-743-8525 (TDD: 800-952-8349), online. or in writing via mail or secure fax to:
California Department of Social Services
State Hearings Division
PO Box 944243, MS 9-17-37
Sacramento, CA 94244-2430
In addition to the appeal process described above, members may contact the California Department of Managed Health Care (DMHC). However, DMHC requires that grievances must first be addressed with CHWP unless the DMHC decides an expedited review is needed due to uncommon and compelling conditions. DMHC is responsible for regulating health care service plans. DMHC receives complaints and inquiries about health plans via a toll-free number at 888-466-2219 (TDD: 877-688-9891). DMHC’s website has complaint forms and instructions online.
CHWP does not delegate member grievances or appeals. All grievances and appeals should be forwarded immediately to the CHWP Medi-Cal Member Services Department.
CHWP members’ protected health information (PHI), whether it is written, oral or electronic, is protected at all times and in all settings. CHWP practitioners and providers can only release PHI without authorization when:
- Needed for payment.
- Necessary for treatment or coordination of care.
- Used for health care operations (including, but not limited to, HEDIS reporting, appeals and grievances, utilization management, quality improvement, and disease or care management programs).
- Where permitted or required by law.
Any other disclosure of a CHWP member’s PHI must have a prior, written member authorization.
Particular care must be taken, as confidential PHI may be disclosed intentionally or unintentionally through many means, such as conversation, computer screen data, faxes, or forms. Participating providers must maintain the confidentiality of member information pertaining to the member’s access to these services. CHWP requires CCIPA to obtain Health Insurance Portability and Accountability Act (HIPAA) Business Associate agreements from people or organizations with which CCIPA contracts to provide clinical and administrative services to members.
Special authorization is required for uses and disclosures involving sensitive conditions, such as psychotherapy notes, AIDS or substance abuse. To release a member’s PHI regarding sensitive conditions, CHWP participating physicians and other providers must obtain prior, written authorization from the member (or authorized representative) that states information specific to the sensitive condition may be disclosed.
Interpreter services are available 24/7 at no cost to CHWP members and providers without unreasonable delay at all medical points of contact. The member has the right to file a complaint or grievance if linguistic needs are not met.
- Providers may not request or require an individual with limited English proficiency (LEP) to provide their own interpreter.
- Providers may not rely on staff other than qualified bilingual/multilingual staff to communicate directly with individuals with LEP.
- Providers may not rely on an adult or minor child accompanying an individual with LEP to interpret or facilitate communication.
- A minor child may be used as an interpreter in an emergency involving an imminent threat to the safety or welfare of the individual or the public where there is no qualified interpreter for the individual with LEP immediately available. Patients cannot give approval for the use of minor children as interpreters unless the above criteria is met.
- An accompanying adult may be used to interpret or facilitate communication when the individual with LEP specifically requests that the accompanying adult interpret, the accompanying adult agrees to provide such assistance, and reliance on that adult for such assistance is appropriate under the circumstances.
- Providers are encouraged to document in the member’s medical record the circumstances that resulted in the use of a minor or accompanying adult as an interpreter.
To obtain interpreter services, members and providers can contact the Customer Contact Center at the phone number located on the member’s ID card. Request in-person interpreters, including sign language interpreters, a minimum of 5 business days before the appointment during business hours.
Please allow for video remote or a phone interpreter if that is the only option available for the language, date and time of the appointment.