Community Care IPA (CCIPA)

One of our provider partners, Clinicas de Salud de Pueblo (Clinicas), has developed an Independent Practice Association (IPA) for patients they serve throughout Imperial County. If you are a Clinicas provider, your patients/our members will be assigned to the CCIPA as their primary care provider. We are working with Clinicas’ new Community Care IPA (CCIPA) to ensure that the 20,000 affected members continue to receive the care they need, when and where they need it.

California Health & Wellness (CH&W) members assigned to Clinicas were notified that they will be enrolled in the new CCIPA but will keep Clinicas as their primary care provider (PCP) beginning November 1, 2016. There will be no disruption in their care or the services that they receive.

  • Members can opt out at any time but will need to be assigned to a non-Clinicas/CCIPA provider. They will not be able to see a Clinicas provider without being assigned to the CCIPA. CCIPA members will only be able to receive care at their assigned CCIPA provider and must obtain prior authorization for specialty or certain other services required by CCIPA.
  • CCIPA members will be provided new ID cards, which will indicate that they are assigned to the CCIPA. For new members, they will have an option to select CCIPA as their PCP. If they do not select a PCP, they will be auto assigned to a provider consistent with the normal assignment process.
  • Members who are assigned to Clinicas will be enrolled in the CCIPA. If you are not part of the CCIPA, you will retain your CH&W members and they will not be moved into CCIPA unless they actively select to be moved. Members have the right to select a new provider at any time.
  • Certain services that may be outside of CCIPA’s provider network do not need prior authorization. These services include Emergency Care, Family Planning Services, HIV testing and counseling, pregnancy termination and STD services. Behavioral health services will continue to be provided through California Health & Wellness.
  • Members who are assigned to Clinicas as their PCP will need to get care through specialists contracted with CCIPA. To access specialty care and certain other providers, members who have Clinicas as their PCP will be required to get prior approval from CCIPA for referrals.
  • Members who have been receiving care from a health care provider may have a right to keep their provider for a designated period of time. Members can contact our customer service department or the Department of Managed Health Care, which protects HMO customers, by telephone at its toll-free number, 1-888-HMO-2219, or at a TDD number for the hearing impaired at 1-877-688-9891, or online at www.hmohelp.ca.gov.
  • CCIPA assigned members will still be eligibile for Continuity of Care services as listed in the Provider Manual. To request Continuity of Care for a member, please complete this form and submit it to California Health & Wellness.

This is a listing of the medical/ancillary services which California Health & Wellness will still manage for members assigned to the Community Care IPA.  These services are still subject to any authorization/referral guidelines in the California Health & Wellness Provider Manual. All other services are the responsibility for Community Care IPA for their assigned members.  

NOTE: California Children’s Services(CCS) Program medical services are for children with certain special health problems.  Providers and Health Professionals are responsible for identifying and referring possible CCS-eligible conditions to the County CCS Program in a timely manner

California Health & Wellness Covered Services for members assigned to Community Care IPA (CCIPA)

ABORTION – Facility Component**

DIALYSIS – Inpatient Facility Component

INFUSION THERAPY ADMINISTRATION, Outpatient Facility, excluding Drugs

ACUPUNCTURE

DRUGS/MEDICATIONS– Outpatient Non-Injectables

LITHOTRIPSY – Facility Component

AIDS - Facility Component

DRUGS/MEDICATIONS- Outpatient Self Injectables

MATERNITY/OBSTETRICAL SERVICES – Deliveries & Non-Deliveries - Inpatient - Facility Component

AMBULANCE (Air or Ground) In Area

DURABLE MEDICAL EQUIPMENT (DME) – - Outpatient Dispensing

MEDICAL TRANSPORTATION  - Non-Emergency

AMBULANCE (Air or Ground) Out of Area

EMERGENCY ADMISSIONS – In Area(Facility Component)

PROSTHETICS - Outpatient Dispensing

AMNIOCENTESIS TESTING – Facility Component

EMERGENCY ROOM VISITS - In Area (Professional Component)

RADIATION THERAPY – Facility Component

ANESTHESIA – OP Facility Component

EMERGENCY ROOM VISITS - Out of Area – Facility Component

RECONSTRUCTIVE SURGERY - Facility Component

APNEA MONITOR

EMERGENCY ROOM VISITS - Out of Area – Professional/Facility  Component

SKILLED NURSING FACILITY - Facility Component – includes Ancillary Services while Hospitalized

BLOOD AND BLOOD PRODUCTS from a Blood Bank or provided in Hospital

ENTERAL THERAPY

SURGERY – INPATIENT (Facility Component)

BLOOD AND BLOOD PRODUCTS  Hemophilia related Blood Factors

(e) EPSDT SUPPLEMENTAL SERVICES when medically necessary, Facility Component

SURGERY – OUTPATIENT Ambulatory Surgery Center or Hospital (OP Facility Component (includes supplies))

BLOOD TRANSFUSIONS

(e) EPSDT SUPPLEMENTAL SERVICES (e.g. private duty nursing) when medically necessary, Ancillary Services

SURGERY – Transgender,- Facility & Professional Component

BURN CARE – Facility Component

FAMILY PLANNING - In Plan &- Self-Referral to Out of Plan Provider (Facility Component**)

TMJ - Facility Component

CHEMICAL DEPENDENCY – Acute Inpatient Overdose Treatment – Facility Component

FETAL MONITORING – Facility Component

TRANSPLANTATION (when a Mainstream Benefit) – Facility Component

CHEMOTHERAPY ADMINISTRATION – Inpatient Facility Component

HEARING AIDS

TRANSPLANTATION (when a Mainstream Benefit) – Professional Component

CHEMOTHERAPY DRUGS

HEART CATHETERIZATION – Facility Component

TRANSPLANTATION (when a Mainstream Benefit) – Professional Component

COLOSTOMY SUPPLIES  - In conjunction with Home Health

HOME HEALTH – includes Nursing Visits, IV Therapy Services and Medications, other Therapies, Supplies and Equipment

TRANSPLANTATION (when a Mainstream Benefit) – Covered Injectable Immunosuppressive

COMMUNITY BASED ADULT SERVICES (CBAS)

HOSPICE CARE – Inpatient Facility Component

URGENT CARE SERVICES – Out of Area – Facility and Professional Combined Component

COSMETIC SURGERY – Medically Necessary – Facility Component

HOSPITALIZATION - In Area and Non-emergency Out of Area - Facility Component

VISION CARE – Eye Exams for Refractive Diagnoses

DENTAL SERVICES - Inpatient Facility Component

HYPERBARIC OXYGEN THERAPY, OP

(Facility Component)

VISION CARE – Implanted Lenses (Cataract Surgery)

 

IMPLANTS, SURGICAL

VISION CARE – Professional Component (excluding Refractions)

Specialists available to CCIPA members are listed below:
Alphabetically | By Specialty

For more information on Specialists, refer to our Provider Directory or our Find a Provider tool. 

For Medication Prior Authorizations, Please Note: CCIPA is responsible for all prior authorization of provider-administered medications EXCEPT for chemotherapy (including adjunctive therapy) and transplant immunosuppression. California Health & Wellness is responsible for prior authorization of all provider-administered medications for chemotherapy (including adjunctive therapy) and transplant immunosuppression.

Envolve Pharmacy Solutions is responsible for prior authorization of all self-administered medications.

Prior Authorization Routing Process for Requests Faxed to Incorrect Location:

When a prior authorization request is faxed to CH&W for a provider-administered medication that is not for chemotherapy  (including adjunctive therapy) or transplant immunosuppression:

  1. CH&W will generate and fax the PA request with a fax cover letter to the provider. The letter informs the provider that the request has been forwarded to CCIPA for review.
  2. CH&W will fax the PA request to CCIPA at (562) 766-2001.

When a prior authorization request is faxed to CCIPA for a provider-administered medication for chemotherapy  (including adjunctive therapy) or transplant immunosuppression:

  1. CCIPA will generate and fax a provider notification letter to the provider. The letter informs the provider that the request has been forwarded to CH&W for review.
  2. CCIPA will fax the PA request to CH&W at (877) 259-6961.

For more information, please contact our Pharmacy Department at 1-877-658-0305.
 

California Health & Wellness members can contact Member Services at 1-877-658-0305 (V/TTY: 711) if they have any questions and/or concerns.

For Medication Prior Authorizations, Please Note:

CCIPA is responsible for all prior authorization of provider-administered medications EXCEPT for chemotherapy (including adjunctive therapy) and transplant immunosuppression. California Health & Wellness is responsible for prior authorization of all provider-administered medications for chemotherapy (including adjunctive therapy) and transplant immunosuppression.

Envolve Pharmacy Solutions is responsible for prior authorization of all self-administered medications.

Prior Authorization Routing Process for Requests Faxed to Incorrect Location:

When a prior authorization request is faxed to CH&W for a provider-administered medication that is not for chemotherapy  (including adjunctive therapy) or transplant immunosuppression:

  1. CH&W will generate and fax the PA request with a fax cover letter to the provider. The letter informs the provider that the request has been forwarded to CCIPA for review.
  2. CH&W will fax the PA request to CCIPA at (562) 766-2001.

When a prior authorization request is faxed to CCIPA for a provider-administered medication for chemotherapy  (including adjunctive therapy) or transplant immunosuppression:

  1. CCIPA will generate and fax a provider notification letter to the provider. The letter informs the provider that the request has been forwarded to CH&W for review.
  2. CCIPA will fax the PA request to CH&W at (877) 259-6961.

For more information, please contact our Pharmacy Department at 1-877-658-0305.
 

California Health & Wellness members can contact Member Services at 1-877-658-0305 (V/TTY: 711) if they have any questions and/or concerns.