Provider FAQ’s

We offer both capitation and fee-for-service contracts. Our capitation contracts include additional incentives and reimbursements not typically offered in traditional capitation arrangements. We will work with you to identify a mutually rewarding reimbursement method.

We offer incentives for physicians who are effective in helping patients meet certain preventive health and care measures. In addition, we offer incentives for:

• Board Certification
• Offices with expanded appointment access
• CCS-paneled physicians
Physicians who have a complex patient panel as compared to peers

We use the standard California Credentialing Application. The credentialing process typically takes 60 days. You will be able to see Health Plan members as soon as you are approved through the credentialing process.

We have contracts with most of the hospitals throughout our service areas in both San Joaquin and Stanislaus counties. For a listing of our contracted hospitals, please use our “Find A Provider” tool.

We have a growing and diverse provider network. A list of specialists by line of business can be found by using our “Find A Provider” tool or through our secure portal.

We have a comprehensive network including locally owned pharmacies as well as national chains such as Costco, CVS, K-Mart, Rite-Aid, Safeway, Save-Mart, Walgreens, and Wal-Mart.

We have a preferred drug list that encompasses most therapeutic categories. Some medications require prior authorization. You are able to conduct a search online via our “Searchable Formulary”. Health Plan’s Pharmacy and Therapeutics (P&T) Committee, which consists of area providers and pharmacists, meet quarterly and providers are notified of changes promptly after each P&T meeting.

We provide a 24-Hour Advice Nurse to all of our members. Members can call and speak to a registered nurse or access the audio health library for recorded messages on over 500 related health topics. In addition, we offer incentives to providers with extended hours and we are contracted with several Urgent Care facilities throughout the service area. Members and providers can call out Customer Service Department weekdays until 7:00 pm.

Our Case Management program includes facilitated nurse practitioner home visits when needed. Case Management can be initiated by the provider or by Health Plan. Our Care Management team also includes Social Workers who may assist with social service needs as well. We also offer a Disease Management program that provides interventions by severity of disease (stratified by claims history). The program includes member education, provider reports, provider contact, pharmacist intervention and when necessary, referral into our Case Management program. Disease Management programs include Asthma and Diabetes.

Prior Authorizations can be requested either online via our secure provider portal, Doctors Referral Express (DRE) or by fax. The turnaround time for a Prior Authorization is dependent on the status you request. The three Prior Authorization statuses include:

• Routine – 5 business day turnaround
• Urgent – 72 hour turnaround

You can submit claims electronically or by paper. For electronic claim submissions, we partner with two clearinghouses: Office Ally and Emdeon. We encourage electronic submissions since submitting paper claims increases reimbursement turnaround time.

We have selected Emdeon as out electronic payment and remittance reporting provider. This is no cost to you to use Emdeon ePayment and enrollment is free! Medical Providers:

• To enroll by fax or by mail, you can download the enrollment form at emdeon.com/epayment/enrollment.
• Enroll online at emdeon.com/eft
• Enroll by mail, send complete form to:

Emdeon (Attention: Emdeon Electronic Payment Service Enrollment) P.O. Box 148850 Nashville, TN 37214 Dental Providers: Visit emdeondental.com to create a Dental Provider Services (DPS) account and enroll in Emdeon ePayment. If you have questions about the enrollment process for dental providers, you can also call 888.255.7293.

You will receive a new provider in-service within 10 days of your contract execution date. At that time, you and your staff will receive an overview on a number of key areas, including direction on billing options, and how and when to submit referrals and authorizations. Also, we have a Provider Policy and Procedure Manual located on our secure website for your convenience.

You can learn more about our office locations by visiting the “Contact Us” page.

You can contact our Medical Director directly. You may also join Health Plan’s Physician Committee to share ideas and communicate ways in which we can best serve you and your patients.