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Manuals, Policies and Guides

Notice

The Provider Manual and the PACE Resource Guide provide generalized information relative to the provision of health care goods and services to CalOptima Health members. For detailed information on requirements, please refer to the applicable CalOptima Health Policies and Procedures. In the event of a conflict between the contents of CalOptima Health’s Provider Manuals or PACE Resource Guide, and CalOptima Health's Policies and Procedures, the Policies and Procedures shall govern.

Provider Documents

The Long-Term Care Information section of this website has additional resources specifically for long term-care and hospice providers.

Provider Manual
The provider manual gives CalOptima Health providers the most current information about our Medi-Cal, OneCare (HMO D-SNP) and PACE programs. As a Medi-Cal managed care plan, the information in these resources is subject to change due to regulation or legislation. The manual references provider enrollment and registration responsibilities, claims submission information, member eligibility verification, and guidelines for submitting and processing medical authorizations.
PACE Resource Guide
The PACE Resource Guide provides information that is important for provider office staff to conduct everyday operations. The guidelines provided in this Provider Resource Guide are not all inclusive. For more detailed information and/or to obtain applicable forms and attachments, please see CalOptima Health’s Provider Manual.
PPS program resources and information
The Pediatric Preventive Services (PPS) program is an expansion of the Child Health and Disability Prevention (CHDP) program. The information in these resources is subject to change due to regulation or legislation.

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Policies and procedures

In addition to the provider manual, you may also access CalOptima Health's online policy and procedure database.

CalOptima Health’s Policies and Procedures
Access CalOptima Health’s searchable database of policies.
CalOptima Health Provider Portal LOA User Guide
IT Policy 1600 Provider Access to In-House Provider Portal

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Other resources and guides

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Community Health Assessments and Community Health Improvement Plans

CalOptima Health collaborates with the Orange County Health Care Agency (HCA) and Kaiser Permanente in the planning, development and implementation processes for the Orange County’s Community Health Assessment (CHA) and Community Health Improvement Plan (CHIP). This collaboration includes:

Participation in Steering Committee, monthly planning and implementation workgroup meetings
Providing a platform for HCA to seek public comments on CHIP priorities and goals from CalOptima Health's Member Advisory Committee (MAC), Provider Advisory Committee (PAC), Population Health Management Committee (PHMC), and Quality Improvement and Health Equity Committee (QIHEC).
Sharing various data (e.g. Healthcare Effectiveness Data and Information Set (HEDIS), utilization data, etc.) to support identification of CHA priority areas and CHIP goals.