To ensure that Health Care Services accurately analyzes the adequacy of provider networks when initially certifying a health plan and when new beneficiary populations are added, it should establish by September 2015 a process to verify the accuracy of the provider network data that it uses to determine if a health plan meets adequacy standards for provider networks.
DHCS has formalized and codified the provider network validation process in a formal procedure. This process was used for the behavioral health treatment transition into Medi-Cal managed care health plans (MCPs). This formal provider network validation process will be utilized each time that DHCS certifies or reviews a MCPs' provider network and will be modified, as appropriate. The procedure was updated to review all signature pages for submissions containing 25 or less. A random sampling of submissions occurs when the submission is 25 or more providers. Attached is the formal provider network validation procedure and sample evidence of record retention.
DHCS has completed building a new network certification process and tool. This new universal tool and process will initially be used in the transition of the responsibility of behavioral health treatment to managed care health plans no sooner than February 1, 2016. The process for verifying submitted provider data will be completed through obtaining executed plan contract signature pages. When the network submission contains fewer than 30 providers, all signature pages will be requested. When the network submission exceeds 30 providers, a statistically significant random sample will be generated and obtained from the health plan.
DHCS has instituted a process for certifying Medi-Cal managed care health plan (MCP) networks and ensuring that beneficiaries receive timely access to care. This process will include use of a standardized network certification tool which will be modified to meet the need of the specific transition or implementation. For example, on February 1, 2016, some Medi-Cal beneficiaries are scheduled to begin receiving behavioral health treatment services from MCPs instead of Regional Centers. DHCS is in the process of building a tool which will validate MCP networks prior to the health plans gaining this responsibility. It will measure the number of beneficiaries, types of services needed and frequency, among other indicators. The tool will address the following areas: primary care physician assignment, anticipated utilization rates, the automatic continuity of care process, and validating that health plans have infrastructure in place to provide the services.
†Response Type refers to the interval in which the auditee is providing the State Auditor with their status in implementing recommendations made in an audit report. Auditees must submit a response regarding their progress in implementing recommendations from our reports at three intervals from the release of the report: 60 days, six months, and one year or subsequent to one year.
*Agency responses received after June 2013 are posted verbatim.