Provider Manual - HPSJ/MVHP

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Provider Manual

Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) is pleased to have you as part of our provider network. We recognize that the strength of our health care programs depends upon strong collaboration and communication with our providers, practitioners and their staff. The Provider Manual is intended to be a useful guide for participating providers/practitioners with Health Plan.

For the purposes of the Provider Manual, “provider” refers to health care practitioners and providers including any physician, nurse, other health care practitioner, hospital, ancillary provider, or other person or institution that furnishes Covered Services. Download a copy of the full Provider Manual below:

Medi-Cal Provider Manual

Medicare Advantage D-SNP Provider Manual

View or download individual sections

If you would like to download each section on its own, please click on the “PDF Download” button.

Medi-Cal

Section 1: Introduction

About Health Plan of San Joaquin and Mountain Valley Health Plan
Mission, Vision and Values
Governance and Committees
Intent of Provider Manual
How to Use Provider Manual

Section 2: Benefit Program

Health Plan Medi-Cal Managed Care (HMO)
Obtaining Coverage and Exclusions Information
Services Covered by Health Plan
Services Not Covered by Health Plan
Enhanced Care Management (ECM)
Community Supports
Major Organ Transplants
Medi-Cal Rx: Transition

Section 3: Provider Credentialing

Credentialing
Obtaining a Credentialing Application
Requirements for Network Participation
The Credentialing Process
Initial Credentialing
Recredentialing
Provider’s Rights during the Credentialing Process
Credentialing a New Group Provider
Delegated Credentialing
Facility and Ancillary Assessment and Verification

Section 4: Provider Contracting

Becoming a Participating Provider
Adding a New Provider to an Existing Contract
Terminating a Contract
Continuing Care Obligations of Terminating Providers
Facility/Ancillary Contracting

Section 5: Provider Services

Provider Rights and Responsibilities
Provider Directory Maintenance Responsibility
Provider Communication
Provider Education and Training
Doctor’s Referral Express (DRE)

Section 6: Eligibility, Enrollment, and Disenrollment

Medi-Cal Eligibility
Member Identification Cards
Verification of Eligibility
Primary Care Physician (PCP) Assignment and Change
Group/Clinic Assignment
Primary Care Physician (PCP) Auto-Assignment
Member Disenrollment

Section 7: Provider–Member Relationship

Member Rights and Responsibilities
Advance Directives
Role of Primary Care Providers (PCPs)
Role of Non-Physician Medical Practitioners (NPMPs)
Role of Specialists
Supporting Members in Self Care
Social Services Support for Members
Participation in Community Initiatives
Provider Panel Capacity
Open and Closed Panel Status
Timely Access to Care
Interpreter Services
HealthReach 24-Hour Nurse/Physician Advice
Transportation Services

Section 8: Utilization Management

Utilization Management Program Overview
Counseling Members on Treatment Options
Availability of Medical Review Criteria
Inpatient Care
Hospital Care
Utilization Management Staff Availability
Referrals to In-Network/Out-of-Network Providers
Continuity of Care
Obtaining a Second Opinion
Covered Services that Don’t Need Prior Authorization/Referral
Standing/Extended Referrals
Submitting Requests for Authorizations
Advantages of Submitting Authorizations Online vs. Fax
Turnaround Time for Prior Authorization
Emergency/Urgent Care Services
Inpatient Admissions
Inpatient Concurrent Review
Initial Health Appointments
Adult Preventive Guidelines
Annual Cognitive Health Assessment
Pediatric Preventive Guidelines
Blood Lead Screening of Young Children
Early Periodic Screening, Diagnostic Treatment (EPSDT) and California Health and Disability Program (CHDP)
Vaccines for Children (VFC)
Developmental Disabilities Services (DDS)
Regional Centers
California Children’s Services (CCS)
Children with Special Health Care Needs (CSHCN)
Family Planning Services
Sensitive Services for Adolescents and Adults
Facility/Ancillary Referrals and Authorizations

Section 9: Care Coordination

Provider Responsibilities for Care Coordination
Integrated Care Coordination
Complex Case Management (CCM)
Disease Management Programs
Transgender Services
Social Services
Centers of Excellence

Section 10: Claims Submission

Claims Management
Requirements for a Complete Claim
Complete Claim Submission Options
Claim Submission Timelines
Claims Determination Notification
Claim Reimbursement
Claim Overpayment
Personal Care Services (PCS) and Home Health Care Services (HHCS)
Ancillary Claims
Required Fields; CMS1500
Required Fields; UB04
Important Billing Tips
Claims Status and Questions
Member Billing

Section 11: Provider Payments

Forms
Capitation Payments
Fee-for-service Payment (FFS)
Street Medicine Payments
Electronic Funds Transfer (EFT)
Check Tracers
Payment Delays Related to Provider Directory
Encounter Data Submission
Coordination of Benefits (COB)
Payments to Out of Network Providers
Third Party Liability (TPL)
Facility Payments
High-Cost Pharmacy (Drugs)

Section 12: Dispute Resolution

Section 13: Quality Improvement and Health Equity (QIHE)

Quality Improvement and Health Equity (QIHE) Overview
Definition of Quality
Scope of the QIHE Program
Quality Improvement and Health Equity (QIHE) Process
Quality Improvement and Health Equity Committee (QIHEC) and Subcommittees
Quality Improvement and Health Equity Committee (QIHEC) – Governing Board of Quality and Health Equity Transformation Program (QIHETP)
Quality & Health Equity Operations Committee (QHEOC)
Peer Review and Credentialing Committee (PRCC)
Grievance and Appeals (G&A) Committee
Clinical Operations Committee (Clinical Ops)
Compliance Committee (CC)
Community Advisory Committee (CAC)
Pharmacy and Therapeutics Advisory (P&TA) Committee
Network Provider Committee Participation
Quality of Care Issues
Monitoring of Quality of Care Issues
Reporting Potential Quality of Care Issues (PQI)
Health Care Effectiveness Data and Information Set (HEDIS)
Tips for Improving HEDIS Scores
Clinical Practice Guidelines
Member Experience Survey
Provider Satisfaction Survey
Patient Safety

Section 14: Pharmacy Services

Pharmacy Claims Submission
Clinical Programs

Section 15: Behavioral Health

Behavioral Health Program
Behavioral Health Benefits
Health Plan Partnership with Claron and CHIPA
Behavioral Health Treatment (BHT) for Members Under 21
Serving Member’s Behavioral Health Needs
Behavioral Health Medications
Substance Use Disorder benefits for Members
Initial Health Assessment
Alcohol Misuse Screening and Behavioral Counseling Interventions

Section 16: Regulatory Compliance

Fraud, Waste, and Abuse (FWA)
False Claims Act
Health Insurance Portability and Accountability Act (HIPAA), Confidentiality Medical Information Act (CMIA) & California Consumer Privacy Act of 2018 (CCPA
Requirements Applicable to Sensitive Services
Training

Medicare Advantage D-SNP

Section 1: Introduction

About Health Plan of San Joaquin and Mountain Valley Health Plan
Dual Special Needs Plan (D-SNP)
Dual Special Needs Plan D-SNP
Mission, Vision, and Values
Provider Rights and Responsibilities
Governance and Committees
Intent of the Provider Manual
How to Use the Provider Manual
Key Department Contact List

Section 2: Benefit Programs

Obtaining Coverage and Exclusions Information
Services Covered by Health Plan Advantage D-SNP
Services Not Covered by Health Plan Advantage D-SNP
California Integrated Care Management (CICM)
Community Supports

Section 3: Provider Credentialing

Credentialing
Requirements for Credentialing/Recredentialing
The Credentialing Process
Recredentialing
Provider’s Rights During the Credentialing Process
Credentialing a New Group Provider
Facility and Ancillary Assessment and Verification
Facility Site Review

Section 4: Provider Contracting

Becoming a Participating Provider
Confirmation of Eligibility for Participation in Medicare
Terminating a Contract
Continuity of Care Obligations of Terminating Providers
Suspension, Termination or Non-renewal of Physician Contracts
Facility and Ancillary Contracting
Single Case Agreements

Section 5: Provider Services

Section 6: Eligibility, Enrollment, and Disenrollment

Health Plan Advantage D-SNP Eligibility
Member Identification Cards
Verification of Eligibility
Primary Care Physician (PCP) Assignment and Change
Group/Clinic Assignment
Primary Care Physician (PCP) Auto-Assignment
Member Disenrollment

Section 7: Provider–Member Relationship

Enrollee Rights and Responsibilities
Role of Primary Care Providers (PCPs)
Role of Non-Physician Medical Practitioners (NPMPS)
Role of Specialists
Network Adequacy
Time and Distance Access to Care
Wait Times for Care and Services
Assessing Urgency of Need of Care
Provider Panel Capacity
Open and Closed Panel Status
Provider Request for Enrollee Reassignment or Dismissal
Other Enrollee Supporting Services
Social Services Support for Enrollees
Participating in Community Initiatives
Interpreter Services
Carenet 24-Hour Nurse/Physician Line
Transportation Services
New Enrollee Outreach and Orientation
Eligibility Verification
Advance Directives

Section 8: Utilization Management

Utilization Management Program Overview
Counseling Members on Treatment Options
Availability of Medical Review Criteria
Inpatient Care
Hospital Care
Utilization Management Staff Availability
Referrals to In-Network/Out-of-Network Providers
Continuity of Care
Obtaining a Second Opinion
Covered Services that Don’t Need Prior Authorization
Ongoing Specialty Care Authorizations
Submitting Requests for Authorizations
Advantages of Submitting Authorizations Online
Turnaround Time for Prior Authorization
Emergency/Urgent Care Services
Inpatient Admissions
Inpatient Concurrent Review
Reopenings
Adult Preventive Guidelines
Developmental Disabilities Services (DDS) and Disabled Adult Children (DAC)
Regional Centers
Transgender Services
Authorizations

Section 9: Care Coordination Management

Provider Responsibilities for Care Coordination
Integrated Medical and Behavioral Care Coordination
Complex Case Management (CCM)
Standard Case Management (SCM)
Community-Well Case Management (CWCM)
Care Transition Services
California Integrated Case Management (CICM)
Chronic Conditions Improvement Plan (CCIP)
Requirements for Face-to-Face Encounter
Long-Term Services and Supports (LTSS)
Provider Training

Section 10: Claims and Billing

Claims Management
Requirements for a Complete Claim
Complete Claim Submission Options
Claim Submission Timelines
Claims Determination Notification
Claim Reimbursement
Risk Adjustment
Claim Overpayment
Ancillary Claims
Required Fields for CMS-1500 Form (Professional)
Required Fields for UB-04 Form (Institutional)
Important Billing Tips
Claims Status and Questions
Enrollee Billing

Section 11: Provider Payments

Section 12: Dispute Resolution

Grievances, Appeals, and Provider Disputes
Provider Dispute Resolution (PDR)
Type of Disputes
Requirements for Complete PDR
PDR Submission Timelines
PDR Determination Notification
Other Information

Section 13: Quality Improvement and Health Equity (QIHE)

Medicare Advantage Star Ratings Program Overview
Definition of Quality
Scope of the QIHETP
Responsibilities of Network Providers in Quality Improvement
Quality Improvement and Health Equity (QIHE) Process
Quality Improvement and Health Equity Committee (QIHEC) and Subcommittees
Network Provider Committee Participation
Quality of Care Issues
Health Care Effectiveness Data and Information Set (HEDIS)
Clinical Practice Guidelines
Enrollee Experience Survey
Health Outcomes Survey (HOS)
Provider Satisfaction Survey
Member Safety

Section 14: Pharmacy Services

Section 15: Regulatory Compliance

Compliance Policy
Fraud, Waste, and Abuse (FWA)
Other Regulations that Govern FWA
Health Insurance Portability and Accountability Act (HIPAA)
Breaches or Unauthorized Disclosure of PHI
Medicare Marketing Guidelines

Posted on October 10th, 2025 and last modified on December 31st, 2025.

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