Provider Network

• Leave of Absence/PCP Covering
• Monitoring Provider to Member Ratio
• PCP/Provider Network Changes
• Provider Directory
• Provider Resources
• Unsatisfactory Relations Between Member and Provider

Credentialing and Recredentialing

• Credentialing of Providers
• Delegated Credentialing and Recredentialing
• Recredentialing

Access Standards

• Access to Interpretive Services
• Facility Access for Physically Disabled Members
• Missed Appointments and Patient Recall
• Prenatal Care
• Primary Care Availability Standards
• Sensitive Healthcare Services
• Transportation Services

Enrollment and Assignment

• HPSJ Service Area
• Maintaining Patient/Provider Relationship When Assigning Members to Primary Care Providers
• PCP Assignment

Grievance Resolution

• Distribution of Member Rights and Responsibilities
• Member Grievance Procedures
• Provider Appeals/Expedited Appeal of UM Decisions to Deny, Defer or Modify for Medical Necessity

Utilization Management

• Authorization / Referral Policy
• Care Management Program
• Emergency Department Services
• Medical Review Guidelines
• Pharmacy & Therapeutics Committee
• Second Medical Options

Claims Processing (Under Construction)

Encounter Data Reporting (Under Construction)

Quality Management

• Delegated Quality Improvement/Utilization Management Activities
• Facility Site Review
• Mid-Level Practioners
• QI/UM Committee (QIUMC)
• Quality Improvement Plan (QI Plan)

Pharmacy Benefits

• Formulary Additions and Deletions
• Formulary and Pre-authorization Process

Medical Care Standards

• Adult Preventive Health
• Advice Nurse Program
• CHDP/Child Health and Disability Prevention Program
• Immunization Schedule
• Initial Health Assessments
• Medi-Cal Waiver Program Criteria
• Prenatal Care
• Reporting Infectious Disease to Public Health
• Sensitive Healthcare Services
• Women, Infants, and Children (WIC) Supplemental Food Program

Compliance

• Fraud and Abuse Reporting

Eligibility and Verification (Under Construction)

Infection Control

• Reporting of Infectious Disease to Public Health

Coordination of Care

• Alcohol and Substance Abuse Treatment Services
• California Children's Services (CCS)
• CSHCN Identification and Coordination
• Dental Care and Dental Anesthesia
• Developmental Disabilities Services Program
• Major Organ Transplant Cases - Identification and Referral Process
• Mental Health Services

Member Transfers and Disenrollment

• Involuntary Disenrollment (Member Status Change)
• Primary Care Provider Assignment - Member Requested
• Provider Charging Members
• Voluntary Member Disenrollment from Health Plan

Rights and Responsibilities

• Members' Rights and Responsibilities

Cultural and Linguistics Services

• Access to Interpreter Services
• Cultural and Linguistic Procedures
• Cultural Awareness and Sensitivity Training
• Enrollee Assessment
• Notification of Language Assistance Program
• Profiency of Interpreters
• Provider Language Assessment
• Readibility of Member Materials
• Translated Written Member Materials
• Translation Process of Written Member Materials