CalOptima Health Compliance Program

CalOptima Health is dedicated to maintaining the highest ethical standards while ensuring full compliance with laws, regulations and health care program requirements. Our Compliance Program applies to all our programs: Medi-Cal, OneCare and the Program of All-Inclusive Care for the Elderly (PACE). It aligns with guidelines from the Office of Inspector General, the Centers for Medicare & Medicaid Services (CMS) and the Department of Health Care Services (DHCS). The program is continuously updated to address emerging operational, regulatory and legal risks.

We require our employees, Board members and First Tier, Downstream and Related Entities (FDRs) to follow the principles outlined in our Compliance Program and Code of Conduct.

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TAKE ACTION

Report Compliance, Fraud or Abuse Issues

If you see any activity that you think is fraudulent or wasteful, we strongly encourage you to call our Compliance and Ethics Hotline at 1-855-507-1805 (TTY 711) or report it using our Compliance and Fraud, Waste and Abuse Reporting Form. The confidential form has instructions on how to fill it out and where to send it. You do not have to give your name to report fraudulent activity.

Complete the Compliance and Fraud, Waste and Abuse Reporting Form

First Tier, Downstream and Related Entities General Information

CalOptima Health’s Compliance Program reflects our commitment to conducting our operations in compliance with ethical standards, contractual obligations, and all applicable statutes, regulations and rules pertaining to our programs, including Medi-Cal, OneCare and Program of All-Inclusive Care for the Elderly (PACE).

CalOptima Health’s compliance commitment covers our own internal operations as well as our oversight and monitoring responsibilities for First Tier, Downstream and Related Entities (FDRs). “FDR” refers to CalOptima Health’s delegated subcontractors that perform administrative functions and/or provide health care services that CalOptima Health is required to perform and/or provide under our federal and state contracts with CMS and DHCS. FDRs include those directly contracted with CalOptima Health and those that are Downstream or Related Entities (i.e., subcontractors) with First Tier Entities, such as health networks, physician groups, participating providers, suppliers, pharmacy benefit managers and consultants.

CalOptima Health has incorporated all the elements of an effective Compliance Program as recommended by the Office of the Inspector General and required by CMS regulations. The program is continually evolving and may be modified and enhanced based on compliance monitoring and identification of new areas of operational, regulatory or legal risk. CalOptima Health requires that employees, Board members and FDRs conduct themselves in accordance with the program’s requirements.

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Compliance Resources

CalOptima Health Policies
Access CalOptima Health’s searchable database of policies.
CalOptima Health Code of Conduct (2026)
View CalOptima Health’s Code of Conduct.
FDR Compliance Attestation
View CalOptima Health’s FDR Compliance Attestation form.
Attestation Concerning the use of Offshore Subcontractors
View CalOptima Health’s Attestation Concerning the Use of Offshore Subcontractors Form.
CalOptima Health Compliance Plan (2026)
View CalOptima Health’s comprehensive Compliance Plan applicable to all CalOptima Health programs.
CalOptima Health Anti-Fraud, Waste & Abuse Plan (2026)
View CalOptima Health’s current Anti-Fraud, Waste and Abuse Plan.
CalOptima Health HIPAA Privacy and Security Program (2026)
View CalOptima Health’s overview of privacy and security regulations, policies and procedures.
HIPAA Training
View the Medicare Learning Network’s training on HIPAA Basics for Providers.
Disability Awareness Training
Disability awareness training identifies and explains the legal requirements related to access for people with disabilities. It is required for all health care providers and staff who care for CalOptima Health members. View CalOptima Health’s Disability Awareness Training.
Cultural Competency Training
Cultural competency training helps identify members with potential cultural or language needs and when alternative communication methods may be needed. It is required for all health care providers and staff who care for CalOptima Health members. View CalOptima Health’s Cultural Competency Training.
QAPI Fishbone Tool for Root Cause Analysis
View the QAPI Fishbone Tool for root cause analysis.
QAPI Five Whys Tool for Root Cause Analysis
View the QAPI Five Whys Tool for root cause analysis.
Terms and Conditions
View CalOptima Health’s standard terms and conditions. The terms and conditions printed, written and/or typed on the front and back of the purchase order are important to our Purchasing department.