AdministrativeMedicaidNovember 13, 2024

Updated provider manual now available

The new provider manual is now live on our provider website. This recently updated manual contains everything you need to know about our programs and how we work with you to provide quality care to our members. Several important updates were made this year, and we encourage you to review them below.

4: General benefits:

  • Benefit Programs and Populations (4.1):
    • The California Major Risk Medical Insurance Program (MRMIP) is scheduled to end on December 31, 2024.
  • Sensitive Services (4.7):
    • Moved disease surveillance language to Provider’s Role in Compliance, Ethics, Privacy, and Hotline Reporting.

8: Provider procedures and responsibilities:

  • Subcontractor Network Certifications (8.2):
    • New language added for the Alternative Access Standard process.
  • Access to Care, Appointment Standards, and After-Hour Services (8.3):
    • Starting January 1, 2025, requests for an urgent examination include weekends and holidays when requested within 48 hours for no authorization and 96 hours if authorization is required.
  • Preventive Healthcare (8.6):
    • Additional language was added on immunization to comply with APL 24-008.

14: Claims and encounters:

  • Electronic Visit Verification (14.4):
    • No language changes, but electronic visit verification was moved to its own subsection.
  • Alternative Payment Methodology (14.12):
    • The Department of Health Care Services (DHCS) has developed the state's new Alternative Payment Model (APM) for participating federally qualified health centers (FQHCs) in a manner to incentivize delivery system and practice transformation through the flexibilities available under a fully capitated reimbursement model on a per member per month (PMPM) basis.

15: State-directed payments:

  • Proposition 56 (15.1):
    • The value-based payment and physician services program has ended. We have a formal procedure for the acceptance, acknowledgment, and resolution of care provider grievances related to the processing or nonpayment of a directed payment. For questions regarding Proposition 56 payments, providers can contact Anthem at prop56@anthem.com.

16: Targeted rate increase (new):

  • New section and language added.

17: Grievances, appeals, disputes:

  • Independent Review Organization (17.5)
    • New subsection and language added.

18: Compliance and regulatory requirements:

  • Provider’s Role in Compliance, Ethics, Privacy, and Hotline Reporting (18.1):
    • Two new subdivisions were added on the topics of disease surveillance and the California Health and Human Services data exchange framework.
  • Delegation Oversight (18.6):
    • No new language was added, but the subsection was reworded.
  • Provider Financial Oversight (18.7):
    • Language changes made to provision for incurred but not reported (IBNR) claims.

While we strive to keep our provider manual current, be sure to check our provider website > Resources > Provider Manuals, Policies & Guidelines for the most up-to-date plan policy information.

If you have questions about the provider manual or provider bulletins, contact our Medi-Cal Customer Care Center at 800-407-4627 (TTY 711) outside L.A. County or 888-285-7801 (TTY 711) inside L.A. County.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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