Manuals, Forms and Resources
Quick Reference
- Provider Quick Reference Guide – English (PDF)
- Medi-cal Enhanced Care Management (ECM) & Community Service Billing (CS) billing procedures for all Providers
Manuals
Provider Manual / Billing Manual – English (PDF)
Provider Directory – English (PDF)
- Provider Directory Imperial County – English (PDF)
- Provider Directory Northern Counties – English (PDF)
(Alpine, Amador, Butte, Calaveras, Colusa, El Dorado, Glenn, Inyo, Mariposa, Mono, Nevada, Placer, Plumas, Sierra, Sutter, Tehama, Tuolumne, Yuba)
Machine-readable Provider Directory (JSON)
Forms
- Care Management Referral Form – English (PDF)
- Continuity of Care Request Form – English (PDF)
- CBAS Treatment Request Form – English (PDF)
- Edinburgh Perinatal/Postnatal Depression Scale (EPDS) Questionnaire (PDF)
- Endoscopy Matrix – English (PDF)
- Health Education Materials Order Form – English (PDF)
- Hysterectomy Services Form – English (PDF)
- Long-Term Care Authorization form - English (PDF)
- Member PCP Change Form – English (PDF)
- Newborn Referral Form – English (PDF)
- Notification of Pregnancy Form – English (PDF)
- Palliative Care Referral Form – English (PDF)
- Physician Certification Statement (PCS) Form – Request for Transportation – English (PDF)
- Postpartum Care Notification Form – English (PDF)
- Potential Quality Issue (PQI) Referral Form – English (PDF)
- Prescription Drug Prior Authorization or Step Therapy Exception Request Form (No. 61-211) – English (PDF)
- Prior Authorization Form – Inpatient – English (PDF)
- Prior Authorization Form – Outpatient – English (PDF)
- Provider Data Reporting and Validation Form
- Provider Dispute Resolution Request Form – English (PDF)
- Sterilization Consent Form – English (PDF)
- Transfer/Termination Incident Report (PDF)
Access Standards
After Hours Sample Script - English (PDF)
Alcohol Misuse Screening and Counseling (AMSC) Trainings*
*Formerly Screening, Brief Intervention and Referral to Treatment (SBIRT) Trainings. External links below may not be updated to the new program name.
- DHCS SBIRT Information page
- DHCS SBIRT Training Links
- SAMHSA Funded, Addiction Technology Transfer Center Network: Foundations of SBIRT
- NICAA Clinician's Guide Online Training: Video Cases: Helping Patients Who Drink Too Much
- SAMHSA-HRSA Center for Integrated Health Solutions: Motivational Interviewing
AMSC Additional Resources
- NIAAA's Clinical Guide "Helping Patients Who Drink Too Much"
- SAMHSA-HRSA AUDIT and AUDIT-C Screening Instruments
- World Health Organization's Complete Guide to Clinical Implementation of AUDIT Screening Instrument - English (PDF)
AMSC Technical Manuals
- SAMHSA, Technical Assistance Publication 33: Systems-Level Implementation of Screening, Brief Intervention and Referral to Treatment (SBIRT) - English (PDF)
- SAMHSA, Treatment Improvement Protocol 35: Enhancing Motivation for Change in Substance Abuse Treatment - English (PDF)
- SAMHSA, Enhancing Motivation for Change in Substance Abuse Treatment, Quick Guide for Clinicians - English (PDF)
Behavioral Health
County Mental Health Department Contact List
California Children's Services (CCS)
- CCS Program Description
- County CCS Office Contact Information
- CCS Eligible Medical Conditions - English (PDF)
- CCS Application - English (PDF)
- CCS Paneled Provider List
- CCS Numbered Letters (how requests are reviewed and authorized)
- New Referral CCS/GHPP Client Service Authorization Request (PDF)
- Established CCS/GHPP Client Service Authorization Request (PDF)
- CCS/GHPP Discharge Planning Service Authorization Request (PDF)
Child Health and Disability Prevention (CHDP) Program
- CHDP Program Code Conversion - Comprehensive Table - English (PDF)
- CHDP Program Code Conversion Flyer - English (PDF)
Clinical Guideline Resources
- American Academy of Pediatrics: Recommendations for Preventive Pediatric Health Care
- American Diabetes Association: Standards of Medical Care in Diabetes
- Center for Disease Control and Prevention (CDC): Adult and Child Immunization Schedules
- National Heart, Lung, and Blood Institute: Guidelines for the Diagnosis and Management of Asthma
- National Heart, Lung, and Blood Institute: Guidelines for Management of Sickle Cell (PDF)
- U.S. Preventive Services Task Force
- U.S. Preventive Services Task Force Recommendations for Adult Preventive Health
Contracted Cancer Centers
California Health & Wellness Plan Contracted Cancer Centers (PDF)
Cultural, Linguistic & Disability Access
- 2016 Group Needs Assessment - Imperial - English (PDF)
- 2016 Group Needs Assessment - Northern 18 - English (PDF)
- A Practical Guide to Implementing the National CLAS Standards - English (PDF)
- California Standards for Healthcare Interpreters - English (PDF)
- Cultural, Linguistic & Disability Access Standards - English (PDF)
- Department of Health & Human Services – A Physicians Practical Guide to Culturally Competent Care
- Employee Language Skills Self-Assessment Tool - English (PDF)
- English-Spanish Dictionary of Health Related Terms - English (PDF)
- Interpreter Quick Reference Card - English (PDF)
- National Standards of Practice for Interpreters in Health Care - English (PDF)
- U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Health Literacy Resources
- Industry Collaboration Effort (ICE) Toolkit - Better Communication, Better Care: Provider Tools to Care for Diverse Populations - English (PDF)
- Office of Minority Health, The National Standards for Culturally and Linguistically Appropriate Services in Health Care (The National CLAS Standards)
Dental Anesthesia Policy
Dental Anesthesia Policy - English (PDF)
(NOTE: This policy is still awaiting State approval).
Electronic Transactions Resources
Integrated Care
Marketing Guidelines for Providers
Marketing Guidelines for Providers Serving Medi-Cal Members - English (PDF)
Patient Centered Medical Home Model
Patient Centered Medical Home Model
Reportable Communicable Diseases
Specified diseases and conditions are mandated by State laws and regulations to be reported by healthcare providers and laboratories to the Local Health Department.
- Communicable Diseases to be reported by Healthcare Providers
- Communicable Diseases to be reported by Laboratories
- California Local Health Department (LHD) Contact Information for Health Care Providers & Labs to Report Communicable Diseases and Submit Confidential Morbidity Report (CMR) forms (Word)
Tobacco Cessation
- Tobacco Cessation Services
- Clinical Practice Guidelines for Treating Tobacco Use and Other Tobacco Cessation Resources
WIC Information
| Company Name | Contact Information |
|---|---|
| 24/7 Nurse Line | Phone: (866) 896-8443 E-mail:info@nursewise.com |
| Acupuncture | American Specialty Health Group, Inc. Claims Department P.O. Box 509001 San Diego, CA 92150-9001 |
| Envolve Pharmacy Solutions | 2425 West Shaw Avenue Fresno, CA 93711 Toll Free: (800) 413-7721 Phone: (559) 244-3700 Fax: (559) 244-3793 |
| Envolve Pharmacy Solutions (Specialty Medication) | 6923 Lee Vista Blvd Suite 300 Orlando, FL 32822 Phone: (855) 422-2742 Fax: (877) 617-0830 |
| Envolve Vision Care | Phone: (800) 531-2818 |
| LogistiCare (Non-Emergent Transportation Management) | Brooks Williams National Accounts Sales, Manager Phone: (800) 486-7647, ext. 2413 Fax: (404) 888-5999 Email: brooks.williams@logisticare.com |
| MHN | 2370 Kerner Blvd. San Rafael, CA 94901 1-800-327-2133 |
| NIA (Radiology Management) | 4801 E Washington St # 1 Phoenix, AZ 85034 Phone: (800) 788-4005 |