2023 New Provider Handbook

Table of Contents

Member Rights Page 3
Clinical Practice Guidelines Page 5
Access to Care Page 7
Advanced Directives Page 11
Affirmative Statement Page 12
California Children’s Services (CCS) Page 13
Minor Consent and Rights Page 16
UM Decision Making Page 18
Denials Page 21
Women’s Health Services Page 28
Customer Service and Cultural & Linguistics Page 29
After Hours and Urgent Care Page 30
Authorizations and Referrals Page 31
Behavioral Health Page 34
Claims and Payment Page 35
Child Health and Disability Prevention (CHDP) Page 36
Marketing Guidelines Page 39
SMG Referral Request Form Page 40
Cultural Awareness Training Page 41
Fraud, Waste and Abuse/Compliance Training Page 45

Member Rights

 Be treated with respect and with due consideration for their dignity and privacy
 Expect that we will treat their records, including medical and personal information and
communications, confidentially
 Request and receive a copy of their medical records at no cost to the member, and request
that the records be amended or corrected
 Be free from any form of restraint or seclusion used as a means of coercion, discipline,
convenience or retaliation as specified in federal regulations
Take part in decisions regarding their health care
 Receive information on available treatment options and alternatives, presented in a manner
appropriate to the member’s condition and ability to understand
 Engage in candid discussions of appropriate or medically necessary treatment options for their
conditions regardless of cost or benefit coverage
 Receive the appropriate services that are not denied or reduced solely because of medical
 Refuse health care (to the extent of the law) and understand the consequences
 Decide ahead of time the care they want if they become sick, injured or seriously ill by making
a living will
 Be able to make decisions about their children’s health care if members are younger than age
18 and married, pregnant or have children
Grievances, Appeals, and Fair Hearings
 Pursue resolution of grievances and appeals about the health plan or care provided
 Freely exercise filing a grievance or an appeal without adversely affecting the way they are
 Continue to receive benefits pending the outcome of an appeal or a fair hearing under certain
Medical care
 Choose their PCPs from our network of providers
 Choose any Anthem network specialist after getting a referral from their PCPs, if appropriate
 Be referred to health care providers for ongoing treatment of chronic disabilities
 Have access to their PCPs or backups 24 hours a day, 365 days a year for urgent or
emergency care
 Get care right away from any hospital when their symptoms meet the definition of an
emergency medical condition
 Get post stabilization services following an emergency medical condition in certain
 Be free from discrimination and receive covered services without regard to race, color, creed,
gender, religion, age, national origin ancestry, marital status, sexual preference, health status,
income status, program membership, or physical or behavioral disability, except where
medically indicated 

Members’ Rights and Responsibilities
Serra annually distributes the Members’ Right and Responsibilities Statement to all
Physicians annually. Members’ Rights and Responsibilities are posted on every floor within
Quality Improvement (QI) Activities
You can request a hard copy of Serra’s QI Activities, Program Descriptions and Annual
Evaluations, upon request.
QI Results
Member Satisfaction Survey Results
Provider Satisfaction Survey Result
QI Program Plans and Annual Evaluations
Access to Care Standards
Access to Care Standards
Serra must ensure that all Physicians and Providers comply with the Access to Care
Standards, which assures that our members have 24 hours/7 days a week access to our
Provider Network.
Serra will ensure that our providers and physicians comply with the appointment availability,
after hours and ancillary regulatory standards. Serra’s goal is to ensure that our offices are
educated on these standards and this ensures our members’ have access to the needed
services. If you have any questions, regarding the Access Standards, please contact the UM
Dept. at (818) 504-4569.
Wait Times from Date of Request for Appointment
Health plan members have the right to appointments within the following time frames:

Urgent Appointment
services that do not need prior approval 48 Hours
services that need prior approval 96 Hours
Non-Urgent Appointments
Primary Care Appointment 10 Business Days
Specialist Appointment 15 Business Days
Appointment with a mental health care
provider (who is not a physician)

10 Business Days

Appointment for other services to diagnose or
treat a health condition

15 Business Days

Clinical Practice Guidelines and Preventative Health Guidelines
Clinical Practice Guidelines provide evidence-based recommendations for the
assessment and treatment of various disorders. All guidelines used for Serra’s Disease
Management Program are nationally recognized and represent appropriate standards of
care for each condition.

Clinical Guidelines

Asthma National Heart, Lung, and Blood Institute (NHLBI) National Education

and Prevention Program (NAEPP)

COPD Global Initiative for Chronic Obstructive Lung Disease
CHF Heart Failure Society of America Comprehensive heart Failure Practice

Guidelines, 2019

Serra’s Utilization Management Department is committed to delivering quality
care that will result in improved and better health for our members. Continuity of
care is accomplished through appropriate coordination with primary care
physicians and/or contracted providers in the provision of ambulatory care and
impatient health services.
Clinical Criteria for UM Decisions
Serra’ s UM Department uses criteria or guidelines to make decisions based on medical
necessity. These guidelines are developed through technology assessment and
structured evidence reviews, evidence -based consensus statements, expert opinions of
healthcare providers, and evidence-based guidelines from nationally recognized
professional healthcare organizations and public agencies. The guidelines come from a
variety of sources which include:
 Center for Medicare and Medicaid Services (CMS)
 National Coverage Determinations
 Local Coverage Determinations
 CMS Benefit Interpretation Manuals
 Medi-Cal Coverage Guidelines
 Apollo Medical Review Criteria
 Evidence in the peer-reviewed published medical literature
 Health Plan Medical Policies
Availability of Criteria
Providers and members have the right to request a copy of a guideline that Serra has
used to make a treatment authorization request decision. Specific criteria or guideline
are also available to the public upon request with the following disclosure: “The material
provided to you are guidelines used by the Per plan to authorize, modify, or deny care

for the person with similar illnesses or conditions. Care and treatment may vary
depending on individual need and the benefits covered under you contract.” If you
would like to obtain a copy of a particular criteria, please contact the Serra UM
Department at 818-504-4569.
SMG shall provide detailed information regarding denials and the denial process. The Denial
letter contains important information specific to the member’s health plan and process. Below is
a list of some of the information more information can be found in the Denial Policy.

a. The action taken, the reason for the action taken and a citation of the specific UM
criteria, regulations or plan authorization procedures supporting the action.
b. Members may contact their provider to obtain explanation or detail of diagnosis
or treatment codes and their meanings.
c. Member’s right to, and method of obtaining, a fair hearing to contest the decision.
d. Notice that the member may use the health plan Complaint/Grievance process
prior to or concurrent with the initiation of the state fair hearing process.
e. Health Plans Complaint/Grievance information, including the address and
telephone number.
f. State Fair Hearing information – Patient’s right to, and method of obtaining, a fair
hearing to contest the decision and the time limit for requesting a fair hearing.
g. The member has the right to request continuation of benefits during an appeal or
State Fair Hearing.
h. Health Plans Grievance/Complaints address and telephone number.
i. Information re: Department of Managed Health Care (DMHC) information (with
TTY and web address) Complaint Process.
j. The member’s right to obtain an independent Review (IMR) through the
Department of Managed Health Care (DMHC).
k. The State’s toll-free telephone number for obtaining information on legal service
organizations for representation.
Affirmative Statement About Incentives
UM Decisions are based appropriateness of care, service, and existence of coverage.
Serra does not specifically reward practitioners or individuals for issuing denials of
coverage or care. Financial incentives for UM decision makers do not encourage
decisions that result in under-utilization. Provider and practitioners are not prohibited
from acting on behalf of the member. Physicians cannot be penalized in any manner for
requesting or authorizing appropriate medical care. Practitioners are ensured
independence and impartiality in making referral decisions that will not influence:
 Hiring

 Compensation
 Termination
 Promotion
 Any other similar matters
Availability of Physician Reviewer
Only licensed physicians can make a denial decision. The physician reviewer is
available to discuss denial decisions with the requesting practitioner and can be
reached by calling 818-504-4750.
Appropriate Professionals
Licensed physicians oversee all UM Decision making process. Appropriate licensed
health professional conducts the supervision of all review decisions and process. All
denied or modified requests are determined only by qualified physicians. Non-Licensed
staff members may collect data for pre-authorization and concurrent review under the
supervision of a licensed personnel.
Access to UM Department Staff
 Serra provides the following communication services for member and
 Staff is available at lease eight hours a day during normal business hours for
inbound collect or toll-free calls regarding UM issues
 Staff can receive in bound communication regarding UM issues after normal
business hours.
 Staff is identified by name, title and organization name when initiating or
returning call regarding UM issues
 TDD/TTY service (711) is available to members who have hearing or speech
 Language assistance is available to members to discuss UM issues.

Nurse Advice Line/ Afterhours Services Line
Health Plans have a 24 hour, 7 days a week Nurse Advice Line available by calling the
toll-free number listed on the back of members insurance card. Serra members can also
access our After-Hours Service Line to receive fast and free medical advice over the
phone by the on-call physician that is available 24 hours a day, 7 days a week, including
weekends and holidays. Members can call 818-768-3000.
UM Timeliness Standards

Timeliness standards for decision-making and notification of decisions for all lines of
 Medi-Cal
 Emergency post-stabilization services decision-within 30 minutes of verbal
 Urgent (expedited) requests-decision within 72 hours; initial provider
notification within 24 hours; written member and provider notification within
72 hours from initial receipt of the request, including weekends and holidays.
 Pre-Service routine (non-urgent) requests-decision within 5 working days;
initial notification to practitioner within 24 hours of the decision, written
notification to member and practitioner within 2 business days of making
the decision.
 Decision and written notification to the member and provider for deferred or
delayed requests shall not exceed 14 calendar days.
 Retrospective review decision-within 30 days.
 Hospice inpatient care-24-hour response.
 Expedited Review decision-within 72 hours.

 Medicare
 Standard-decision within 14 calendar days; member notification shall be
done as expeditiously as the member’s condition requires, but not later than
14 calendar days after receipt of request.
 Expedited- decision within 72 hours; notification within 72 hours after
receipt of request.
 Extension (if justified)-additional 14 calendar days.
 Termination of Services-no later than 2 calendar days of 2 visits before
the coverage ends.

 Commercial
 Urgent-decision not to exceed 72 hours after receipt of request; notification
within 72 hours of receipt of request.
 Decisions- member and practitioner notification for urgent request shall be
done within 24 hours of the receipt of request.
 Urgent Concurrent-decisions within 24 hours of receipt of request;
notification within 24 hours of receipt of request.

 Non-Urgent-decisions within 5 business days; initial notification to
practitioner within 24 hours of the decision, written notification to member
and practitioner within 2 business days of making the decision.
 Standing-decision within 3 business days of receipt of request;
notification time frame depends on the service category.

Initial Health Assessment (IHA)
All Medi-Cal members should receive timely access to an IHA within 120 days of
enrollment regardless of age. Additionally, if a member refuses an IHA, the refusal must
be documented in the medical record.
Provider Grievance
A provider of medical services may submit a grievance concerning an authorization or
denial of a service, denial, deferral, or modification of a prior authorization request or
claim by calling Serra Medical Group UM Department at (818) 504-4569 or the Claims
Department at (818) 504-4681.
Providers who are submitting claims for retroactive review (review after the services
have been provided) should submit the claims directly to SMG UM Department. If the
UM Department requested that you send medical records, please submit your response
to the UM department. 
If a provider would like to appeal or dispute a claim payment, the provider must submit it
in writing by mail to SMG Claims Department. All appeals and disputes are entered in
the SMG Database for investigation, and providers will receive a written response.

Advance Directives

An advanced directive is a legal document that states a person’s wishes about receiving
medical care if that person is no longer able to make medical decisions because of a serious
illness or injury. An advance directive may also give a person (such as a spouse, relative, or
friend) the authority to make medical decisions for another person when that person can no
longer make decisions. This form will be provided to the patient upon request.
Policy and Procedures
To provide members with their right to have an advanced directive and to designate someone to
make provisions for their health care decisions in the event they are unable to.
To educate the staff on Advanced Directives.

An advanced directive is a legal document that states a person’s wishes about receiving
medical care if that person is no longer able to make medical decisions because of a serious
illness or injury. An advance directive may also give a person (such as a spouse, relative, or
friend) the authority to make medical decisions for another person when that person can no
longer make decisions.
Serra Medical Group (SCMC) has written policies and procedures on Advanced Directives.
 SCMC’s policies and procedures on Advanced Directives
◦ Allow a member’s representative to manage care or make treatment decisions
when the member is incapacitated and unable to do so.
◦ SCMC complies with state law in regard to Advanced Directives.
◦ SCMC is not required to provide care that conflicts with the Advanced Directive.
◦ SCMC must allow a member or the member’s representative to be involved in
decisions about withholding resuscitative services or declining/withdrawing life-
sustaining treatment.
◦ An Advanced Directive can be annulled.
 SCMC has information describing the member’s rights to formulate advance directives
and is provided to all adult members (defined as 18 years of age or older).
 SCMC will not refuse to treat or otherwise discriminate against a member who has
completed an advance directive.
 New members are informed of advance directive policy at the initial visit.
 Advance directives are documented in the patient’s medical record.
 Patients have the right to be represented by parents, guardians, family members or
other conservators of members who are unable to fully participate in their treatment
Medicare Advantage

  1. SCMC ensures that any advanced directive (English or Spanish) executed by a member is
    brought to the immediate attention of the attending physician.
  2. SCMC ensures that the advanced directive is filed with proper documentation within the
    EMR. Staff may locate status/execution of advanced directives within the Patient Data Tables
    under the Advanced Directives Tab.
  3. Each physician at SCMC must honor advanced directives to the fullest extent permitted under
    California Law. Physicians are not required to provider care that conflicts with an advanced
  4. SCMC ensures that the member’s primary care physician (PCP), Attending physician or
    healthcare facility discusses with and provides medical advice to a member regarding advanced
  5. SCMC ensures that physicians do not condition the provision of care, or otherwise
    discriminate, based on whether an individual has executed an advanced directive.
  6. SCMC provides education for participating providers and the community on advanced
    directives annually.

 Educational materials must define what constitutes an advanced directive and
emphasize that an advanced directive is designed to enhance an incapacitated
individual’s control over medical treatment.
 Educational materials must describe applicable state laws concerning advanced
directives. Community education efforts must be documented.

  1. SCMC must inform individuals that complaints concerning noncompliance with the advanced
    directive requirements may be filed with The California Department of Health Care Services
    (DHCS) for Cal MediConnect members and the State Survey and Certification Agency for
    Medicare Advantage (MA) members.
    SMG will provide a copy of a policy upon request. You may call the UM Department at (818)
    504-4569. Monday-Friday 8:30 am – 5:30 pm.

Affirmative Statement

Confidentiality is vital to the quality of care and service provided to our members. We will
respect and maintain the confidentiality of all discussions, records and information generated
and accessed within the confines of my day-to-day job responsibilities. We also agree not to
discuss confidential information except to persons authorized to receive or review such
We affirm that:
 UM decision making is based only on appropriateness of care and service and existence
of coverage
 Serra Medical Group, Inc., does not specifically reward practitioners or other individuals
conducting utilization review for issuing denials/deferrals/modification of coverage or
 Financial incentives for UM decision – makers do not encourage decisions that result in
 SCMC does not use incentives to encourage barriers to care and service.
 Medical Management Program description, policies practitioner contracts must not
contain language indicating improper utilization incentive programs. Terms under which
a practitioner may be entitled to a bonus or incentive pay cannot influence a
practitioner’s decision to withhold, delay, or deny necessary service.
 Practitioners are ensured independence and impartiality in making referral decisions that
will not influence:

o Hiring
o Compensation
o Termination
o Promotion
o Any other similar matters

Serra Medical Group, Inc distributes this statement affirming that UM decision making is based
only on appropriateness of care, service, and existence of coverage. Serra does not specifically
reward practitioners or other individuals for issuing denials of coverage or service care; financial
incentives for UM decision makers do not encourage decisions that result in underutilization.
Serra Medical Group distributes this statement to all staff, including:
 Practitioners
 Providers
 Employees
 Enrollees
Signs are posted (English/Spanish) on every floor. Website and paper copy available upon
request. Serra will mail it affirmative statement about incentives to recipients who do not have
fax, email or internet access.
Practitioners and staff sign affirmative statements annually during QI meeting.
California Children’s Services (CCS)

Serra Medical Group will assure that all potential or actual CCS cases are referred to CCS and the
Health Plan immediately. Will coordinate the care i.e. the follow-up on all CCS referrals and the
facilitation of care between all involved parties, as needed.
Upon adequate diagnostic evidence that a Medi-Cal member under 21 years of age may have a
CCS eligible condition, Serra shall refer the member to the local CCS office for determination of

 To timely refer all eligible patient with eligible condition to CCS.(within 24 hours of
 To assure that a potential CCS case is a CCS designated Diagnosis that has not been referred
to CCS or is awaiting a CCS determination to include the following criteria:
◦ A description of the CCS deferral process. To include the follow-up with CCS until
group receives a final outcome of the CCS deferral (approval or denial) from CCS.
◦ All potential or actual CCS Cases are referred to CCS and the Health Plan immediately,
not to exceed 1 business day from date of identification.
◦ The title of the person responsible for making the referral to CCS and the following up
with CCS on the outcome (including process). (The HMO coordinator will process and
follow-up until denied/approved).

◦ The title of the person responsible for notifying the health Plan Case Management of
the CCS referral/case and the outcome. (The HME coordinator will inform the case
manager of the referral to CCS).
 Evidence of CCS Education & Updates
◦ Serra Medical Group will provide evidence of CCS education and updates,
◦ Will provide evidence of list (s) of contracted and/or list non-contracted CCS paneled
◦ And is accessible to the group’s practitioners/providers and the UM department.
 Serra Shall assure that Where a request is made for children’s preventive services by the
Member, the Member’s parent(s) or guardian or through a referral from the local CHDP
program, an appointment shall be made for the Member to be examined within two weeks of
the request and reflected in the referral log.
 There must be documentation in the medical record noting that the PCP is aware of member’s
CCS status, or that the PCP was the referring MD to CCS.
 Serra physicians must indicate in the medical record that the child is receiving routine
preventive health services.
 Serra shall assure that at each non-emergency Primary Care encounter with Members under
the age of twenty-one (21) years, the Member (if an emancipated minor) or the parent(s) or
guardian of the Member shall be advised of the children’s preventive services due and
available from PPG, if the Member has not received children’s preventive services in
accordance with CHDP preventive standards for children of the Members’ age. Documentation
shall be entered in the Member’s medical Record which shall indicate the receipt of children’s
preventive services in accordance with the CHDP standards or proof of voluntary refusal of
these services in the form of a signed statement by the Member (if an emancipated minor) or
the parent(s) or guardian of the Member. If the responsible party refuses to sign this
statement, the refusal shall be noted in the Member’s Medical record.
 In an emergency admission, Serra Medical Group or Serra’s network physicians shall be
notified the next working day and inform the CCS program about the member.
 SCMC’s CCS policy/Procedure describes Serra’s process to identify and refer potential Case
Management cases to the health plan and coordination between SCMC and the health plan
CCS coordinator regarding CCS eligible cases.
 The Confidential Screening/billing Report form, PM 160-PHP, shall be used to report all
children’s preventive services Encounters. Serra Medical Group submits completed forms to
the appropriate Health Plan and to the local children’s preventive services program (local
regional CHDP office) within thirty (30) calendar days of the end of each month for all
encounters during that month.
 CCS Log shall include all factors:
 Member Name
 Date of Birth
 ID Number
 County
 Diagnosis/requested service

 Date request received
 Date referred to CCS
 ICCS Status
 Referral Status
 Denial / Carve Out Notification for CCS Eligible Members
 Letter will be issued appropriately and include instructions on how to file an appeal
that is in compliance with all regulatory requirements.
 CCS Inpatient: When CCS approves admission, SCMC will issue a denial within 24
hours of the CCS decision.
 CCS Inpatient: Denied CCS admission, SCMC will adjudicate and approve per
medical necessity guidelines or review with Medical Director and issue a CCS
appeal when indicated.
 Designated Public Hospitals: Partial and full CCS eligible hospital stays will be
directly billed to Medi-Cal FFS. SCMC will not be billed for part of the admission.
The hospital will receive one payment for the entire stay based on the DRG for that
 Private Hospital Admission: Partial and full CCS eligible hospital stays will be
directly billed to Medi-Cal FFS. SCMC will not be billed for any part of the
admission. The hospital will receive on payment for the entire stay based on the
DRG for that stay.
 Services that are not covered by CCS, when necessary, there is documentation in
the medical record that a specialty provider referral has been issued.
 When services are covered by CCS, there is a summary and/or documentation in
the medical records by the PCP indicating the consult results have been reviewed
or discussed with the CCS paneled physician.
 Serra physicians/healthcare providers must document evidence of transition
planning from CCS to other programs for children who have reached age 19 and
will continue to need services by the time they reach age 21. SCMC will assist
patient to complete the “AGE OUT” form.
 Serra shall provide required notification to beneficiaries and representatives in
accordance with the time frames set forth in Title 22, CCR, Sections 51014.1 and

  1. Such notice shall be deposited with the United States Postal Service in time
    for pick up no later than the third working day after the decision is made, not to
    exceed 14 calendar days from receipt of the original request for Medi-cal members.
     Letter must be approved by the Health Plan and DHS. The letter must include the
    following information.
     The action taken, the reason for the action taken and a citation of the specific UM
    Criteria, regulations or evidence of coverage supporting the action.
     Health Plans Complaint/Grievance Information

 State Fair Hearing Information
 Department of Managed Health Care(DMHC) Information e.g complaint process,
TTY, Web Address, Independent Medical Review(IMR)
 The State’ s Toll Free Telephone Number & Address for obtaining information on
Legal Service Organizations for representation.
 Translation or Written materials/ Translation Assistance.

Minor Consent and Rights

Serra Medical Group follows an established policy and procedure regarding m minor
consents. Under California state law, minor consent services are those covered
services of a sensitive nature that minor do not need parental consent to access or
obtain. The health care provider is not permitted to inform a parent or legal guardian
without the minor’s consent. Minors under age 18 may consent to medical care related
to the those listed below.
The following procedure must be followed:
1) Abortions do not require prior authorization (without parental consent or court
2) The following services do not require prior authorization
a) Sexual assault, including rape diagnosis, treatment and collection of medical
evidence. The treating provider must attempt to contact the minor’s parent or
legal guardian and note in the minor’s treatment record the date and time of the
attempted contact and whether it was successful. This provision does not apply if
the treating provider reasonably believes that the minor’s parent or legal guardian
committed the sexual assault on the minor of if the minor is over age 12 and
treated for rape.
b) Drug or alcohol abuse for children twelve (12) years of age or older, except for
the replacement narcotic abuse treatment
c) Pregnancy, prevention, or treatment of pregnancy (except sterilization)
d) Family Planning, including the right to receive birth control
e) Sexually transmitted diseases (STD’s in children 12 years of age or older
f) Infectious, contagious, communicable, and sexually transmitted diseases
diagnosis and treatment for children ages 12 and older
g) General medical, psychiatric, or dental care if all of the following conditions are
h) The minor is age 15 or older
i) The minor is living separate and apart from his or her parents or guardian,
whether with or without the consent of a parent or guardian and regardless of the
duration of the separate residence.
j) The minor is managing his or her own financial affairs, regardless of the source
of the minor’s income, If the minor is an emancipated minor, he or she may
consent to medical, dental and psychiatric care.
k) Outpatient behavioral health treatment or counseling for children twelve (12)
years or older under specific conditions, who in the opinion of the attending
provider, the minor is mature enough to participate intelligently in the outpatient
or residential shelter services.
i) The minor would represent a danger of serious physical or mental harm to
himself or herself or others without the behavioral health treatment,
counseling, or residential shelter service.
ii) The children are the alleged victims of incest or child abuse
iii) Skeletal X-ray- A health care provider may take skeletal x-ray of a child
without the consent of the child’s parent or legal guardian, but only for the
purposes of diagnosing the case as one of possible child abuse or neglect
and determining the extent of the abuse or neglect.

3) Confidential HIV Testing and counseling for children ages 12 and older
4) Preventive Services
5) Prenatal- self refer & in network

Clinical Information and Utilization Management Decision Making

Serra Community Medical Clinic (SCMC) will ensure that the following information is collected to
support UM decision-making. The UM process shall ensure that information needed to make a
determination of medical necessity has been collected.
Serra shall request medical information from the provider in order to determine whether to
approve, modify or deny requests for authorization, Serra shall request only information
reasonably necessary to make the determination and consults with the treating provider
Only Board-Certified Physician will participate in UM Decision making
 SCMC will obtain clinical information from the ordering physician that is pertinent to the
requested services.

 Clinical information to be obtained include at least the following:
 History of presenting problems.
 Clinical exam findings
 Diagnostic testing results
 Treatment progress notes
 Psychosocial history
 Information on consultations with the treating practitioner
 Evaluations from other health care practitioners and providers
 Photographs
 Operative and pathological reports
 Rehab evaluation
 Printed copy of criteria related to the request.
 Information regarding benefits for services or procedures
 Information regarding the local delivery system
 Information from patient and responsible family member
 HMO department will check health plan coverage to see if the requested services are
 The medical record must reflect medical necessity for the requested services.
 A request for services will be sent to the HMO department for review.
 If all relevant information is collected and it shows medical necessity the referral is
 The member is called within 24 hours and the notice is sent within 2 working days.

 The Medical Assistant for the requesting physician is sent a task (PCM) within 2 working
days with the status of the request.
 The MA makes the appointment for the services requested
 The referral request status is available immediately for the requesting physician to view.
 Timeframes are as follow:
o Routine request within 5 days of receipt of information.
o Imminent or serious threat to member health 72 hours.
o Providers notified by telephone of decision within 24 hours (all cases) followed by
written notice within 2 (two) business days.

Extension allowed Only if member requests or the provider organization justifies a need for
additional information and how the delay is in the interest of the member (for example, the
receipt of additional medical evidence from non-contracted providers may change a decision to
Pharmacy Request Prior Authorization (Health Net)
SMG will utilize the most current required DMHC Prescription Drug and Prior Authorization form
for all prior authorization prescription request. The form is available on the Health Net provider
website at provider/ under Pharmacy information and in the Provider Library
under forms. For HMO Commercial send by secure fax to (800) 314-6223 and for Medi-Cal
send by secure fax to (800) 977-8226. Health Net will respond via fax to advise provider the
status of the request. Request for HMO commercial members will be processed within 72 hours
for non- urgent request and 24 hours for exigent requests. Request for Medi-Cal members will
be processed within 24 hours.

Time frames for timeliness of Pharmacy Prior Authorization Request:
Serra adheres to the ICE UM Timeliness standards for CA Commercial HMO, CMS and Medi-
cal for approvals, denials and modifications for medical necessity.

Commercial: CA Health & Safety Code section 1367.241(CA SB 282; 2015-2016)
 Urgent Concurrent-(exigent)decision and notification within 24 hours of the request.
 Urgent Preservice-(exigent) decision and notification within 24 hours of the request.
 Non-Urgent Pre-service- decision and notification within 72 hours of the receipt of the
 Post Service- decision and written notification within 30 days of receipt of request.
 Urgent Concurrent-decision and notification within 24 hours of the request.
 Urgent Pre-service-decision and notification within 24 hours of the request.
 Non-Urgent Pre-service- decision and notification within 5 or 14 days of the receipt of the
 Post Service- decision and written notification within 30 days of receipt of request.

 Urgent Concurrent-(exigent) decision and notification within 24 hours of the request.
 Urgent Pre-service-(exigent) decision and notification within 24 hours of the request.
 Non-Urgent Pre-service- decision and notification within 5 business days of the receipt of
the request, written notification within 2 business day so f decision.
 Post Service- decision and written notification within 30 days of receipt of request.


ERISA defines a denial as an adverse determination related to the following:
 Failure to provide or make payment (in whole or part) for benefits including any denial,
reduction, termination.
 Failure to provide or make payment that is based on a determination of a member’s
eligibility to participate in a plan.

 Includes a denial, reduction, termination of, or failure to provide or make payment (in
whole or part) for a benefit resulting from application of any utilization review.
 Failure to cover an item or service for which benefits are otherwise provided because it
is determined to be experimental or Investigational, or not necessary or appropriate.
Decision Making Process
No individual, other than a licensed physician or a licensed healthcare professional who is
competent to evaluate the specific clinical issues involved in the healthcare services requested
by the provider, may deny or modify requests for authorization of healthcare services for an
enrollee for reasons of medical necessity. The decision of the physician or other healthcare
professional shall be communicated to the provider and the enrollee. If the healthcare service
plan requests medical information from providers in order to determine whether to approve,
modify, or deny requests for authorization, the plan shall request only the information
reasonably necessary to make the determination.
 Only California licensed physicians are to evaluate specific clinical issues may deny or
modify requests for service based on medical necessity.
 Behavioral Health care practitioners are available to review cases pertaining to their
 Only a psychiatrist, doctoral-level clinical psychologist or certified addiction medicine
specialist may deny or modify request for behavioral health care services based on
medical necessity.
 Consultation will be with an appropriate behavioral health practitioner or use of
behavioral health UR criteria prior to denial.
 SCMC to assure that only the Medical Director and/or physician member of the UM
Committee may make a medical necessity denial determination.
 SCMC is responsible classifying and documenting denials appropriately for medical and
non-medical necessity denials.
 A licensed physician will do a review of any denial for medical necessity.
 A physician, dentist, vision, or pharmacist, as appropriate, reviews any non-
behavioral health denial of care based on medical necessity.
 A physician or a chiropractor may review denial files for chiropractic services.
 A physician or a physical therapist reviews physical therapy denials.
 A physician or a dentist may review denial for dental procedures.
 A physician or a pharmacist may review denial files for pharmaceutical
 Appropriate behavioral health practitioner or pharmacist, as appropriate,
reviews any behavioral health denial of care based on medical necessity.
 A doctoral level clinical psychologist or certified addiction-medicine specialists
may review behavioral health denials.
Initial Practitioner Notification of Denials

 Physician reviewer will be available by phone to physicians to discuss determinations.
 Written communication to the referring physician or other healthcare provider must
include the name and phone number of the health care professional responsible for the
denial, delay, or modification.
 For delay notifications, the notification will contain a description of the criteria or
guideline used including a citation of the specific regulations or plan authorization
procedures supporting the action and the clinical reason for the decisions regarding
medical necessity and when the enrollee can expect a decision.
 Practitioners shall be notified by telephone of all denials that pertain to the members
they are treating (e.g., a Surgeon must be notified that his/her member had a surgical
procedure denied, even if the service had to be requested by the primary care
Physician). Notification will be documented in PCM (Patient Chart Manager (HMO
authorization Log) with date and time that the practitioner was notified that a physician or
other reviewer is available to discuss the denial.
 The treating providers can readily access SCMC’s Medical Director by phone at 818-
504-4750, Monday through Friday 8:30am to 5:00 pm and afterhours for peer to peer
reviews regarding adverse decisions. Turnaround time for Medical Director to contact
treating provider is 48 hours. Each request for a peer to peer is documented and
monitored for completion.
Denials, Deferrals, Modifications, and Termination Letters

  1. Will be issued appropriately and include instructions on how to file an appeal that is in
    compliance with all regulatory requirements.
    a. SCMC shall provide required notification to beneficiaries and representatives in
    accordance with the timeframes set forth in Title 22, CCR, Sections 51014.1 and
  2. Such notice shall be deposited with the United States Postal Service in
    time for pick-up no later than the third working day after the decision is made, not
    to exceed 14 calendar days from receipt of the original request for Medi-Cal and
    30 days for Healthy Families/Healthy Kids
    Per Title 22, notice of denial is not required if the denial is a denial of a
    request for prior authorization for coverage for treatment that has already
    been provided to the patient

b. SCMC will follow CMS regulations for timeliness of notifications for Medicare
c. SCMC prohibits the use of verbal denials and other intangible methods of
documenting physician reviews of authorization request.
d. SCMC will ensure that the member and provider notifications of prior
authorizations decisions are in adherence with written notification standards.

  1. Deferrals: Medi-Cal requests maybe deferred for up to – 14 days (from SCMCs receipt
    of the request for prior authorization) to allow the provider time to submit additional
    information requested by SCMC and to allow time for SCMC to decide. If, after 28 days
    from SCMC receipt of the request for prior authorization, the provider has not complied
    with SCMC’s request for additional information, SCMC shall provide the patient notice of
    denial. If within – 14-day period, the provider does comply, SCMC shall take appropriate

action on the request for prior authorization as supplemented by the additional
information, including providing any notice to the patient. (Health Net).
a. It is up to the health plan to notify SCMC. if they are adopting the 14/14-day rule
for deferrals.

  1. Pended: If SCMC cannot make a determination for non-urgent prospective or continued
    stay reviews within the required time frames due to not receiving all of the requested
    necessary information, then SCMC will immediately notify the health care provider and
    the covered person in writing. Notification will be sent upon the expiration of the required
    five (5) business days’ time frame or as soon as SCMC becomes aware that they will not
    be able to meet the required five (5) business days’ time frame, whichever occurs first.
    The notification must specify the information requested, but not received, and the
    anticipated date on which a prospective or continued stay review determination may be
    rendered. Upon receipt of all necessary information, SCMC will render a prospective or
    continued stay review determination within the required five (5) business days’ time
    a. Notifications sent to members and Practitioners include:
    i. Information was requested but not received
    ii. Consultation by an expert reviewer is required
    iii. Additional examinations or test are required
    iv. Time Frame for submitting the information
    v. Expected date of decisions
    vi. Type of expert reviewer required, if applicable
  2. Modification: Services requested may be modified without sending a modification notice
    only in the following situations:
     Modification of request for durable medical equipment if the substituted equipment
    can perform all medically significant functions that would have been performed by
    the requested equipment.
     Modification of the duration of any approved therapy or length of stay in an acute
    facility if SCMC provides an opportunity for the provider to request additional therapy
    or inpatient days before the end of the approved duration of therapy or length of stay.
  3. Terminations: Action to terminate or reduce the level of treatment or service currently
    being received. SCMC shall notify members’ notice of action taken to terminate a
    treatment regimen already in place. In the case of concurrent review, care shall not be
    discontinued until the enrollee’s treating provider had been notified of the plan’s
    decision, and a care plan has been agreed upon by the treating provider that is
    appropriate for the medical needs of that patient.
    Serra will verify the member’s preferred language prior to issuing the NOA’s in the appropriate
    preferred language. Serra will verify if the member has requested an alternative format prior to
    issuing the NOA’s in the appropriate format.
    Translation of Written Materials and Alternative Format– SCMC has a process to translate
    member materials into county specific threshold languages or alternative format. Translation

assistance and alternative format is available for all denials, deferrals, modification and
termination letters. Enrollees preferred language/requested alternative format will be verified
prior to issuing an NOA in the appropriate preferred language/requested alternative format.
The threshold languages for LA County are:
 Arabic
 Armenian
 Cambodian
 Cantonese
 Chinese
 Farsi
 Korean
 Mandarin
 Russian
 Spanish
 Tagalog
 Vietnamese

a. Health Plan address & telephone number for obtaining information on legal
service organizations for representation.
b. Non-Discrimination Notice

Member notification is required within 2 working days of making the decision. If there is a
request for additional information, then the decision must be made within 5 days not to exceed
14 th calendar days. If the requested information is not received by the 14 th calendar day, an NOA
denial letter is issued, and the member is to be notified on that day.
 Urgent Denials: Member and provider are notified within 24 hours by phone and a denial
letter is mailed out within 24 hours.
SCMC will specify utilization review criteria (a description/explanation of the criteria or
guidelines used).
Alternative treatment plan (requires only for modification of request that were not approved as
initially requested. (Industry Collaborative Effort (ICE) recommends that ER denial letters should
indicate that care could have been provided at an urgent care setting or during office hours.
 Appeal rights and Independent Medical Review (IMR) information (An explanation of
appeal process including the opportunity to request IMR in cases where member
believes that health care services have been improperly denied or modified. Urgent and
concurrent denial notification shall include additional information regarding expedited
appeal rights.
 For urgent care situations, expedited external review may occur at the same time as the
internal appeal process. SCMC may discontinue the internal appeal for all member
request that were addressed by the external review if it is not required to continue the
internal appeal process under state law. (SCMC continues the internal appeal process
for the components of the request that are not addressed in the external review).

 Member may request an independent, external review for any referral that is denied,
modified or delayed because of lack of medical necessity.
 SCMC will provide any relevant medical information such as the member’s medical
condition, health care service being provided. The confidentiality of all medical records
information shall be maintained pursuant to applicable state and federal laws.

Additional Notification Requirements
 Member’s right to call the State Medi-Cal Managed Care Ombudsman Office for
answering questions or help in appealing the decision.
 Member’s right to, and method of obtaining, a fair hearing to contest the denial, deferral,
or modification action and the decision SCMC has made.
 Member’s right to represent himself/herself at the fair hearing or to be represented by
legal counsel, friend, or another spokesperson.
 Name and address of SCMC and State toll-free telephone number for obtaining
information on legal service organization for representation.
 Member’s right to appeal within at least 90 days to appeal the decision through the
health plan’s grievance/appeal process.
 Member’s right to appeal to the Department of Managed Health Care (DMHC) if not
satisfied with the appeal decision at the Plan Level.

Rescinding or Modifying an Authorization- AB 1455 requirement – Prohibit the UM
organization from rescinding or modifying an authorization once services have been
rendered by the provider.
AB 1324 Serra Community Clinic will identify and manage open authorizations and ensure
that the provider’s claims are paid appropriately for services provided in good faith when an
authorization has been given, but the member is later determined to have been ineligible at
the time of service.

Terminal Illness
Denial of coverage to an enrollee with a terminal illness for treatment, services or supplies
deemed experimental, as recommended by a participating plan provider. (Terminal illness refers
to an incurable or irreversible condition that has a high probability of causing death within one
year or less). The following information shall be provided to the enrollee within five business
 A statement with the specific medical and scientific reasons for denying coverage
 A description of alternative treatment, services, or supplies covered by the plan, if any.
 Copies of the plan’s grievance procedures or complaint form, or both. The complaint for
should provide an opportunity for the enrollee to request a conference as a part of the
plan’s grievance procedures. Upon receiving a complaint form requesting a conference,
the plan shall provide the enrollee,

2023 Serra Medical Group Page | 25
 Conference within 30 days, an opportunity to attend a conference, to review the
information provided to the enrollee. The conference shall be conducted by a plan
representative having authority to determine the disposition of the complaint. The plan
shall allow attendance, in person, at the conference, by an enrollee, a designee of the
enrollee, or both, or, if the enrollee is a minor or incompetent, the patent, guardian, or
conservator of the enrollee, as appropriate.
 Conference within 5 days-If the treating participating physician determines, after
consultation with the health plan medical Director or his or her designee, based on
standard medical practice, that the effectiveness of either the proposed treatment,
services, or supplies or any alternative treatment, services, or supplies covered by the
plan, would be materially reduced if not provided at the earliest possible date.
 Nothing in this section shall limit the responsibilities, rights, or authority.
Department of Managed Care (DMHC) information
Contact numbers shall be in a 12-font bold face type and include:
Toll-free telephone number: 1-888-HMO-2219
Hearing and speech impaired telephone number: 1-877-688-9891

California Relay Service telephone numbers: 1-800-735-2929 (TTY) or 1-888-877-5378


Internet website:

 Non-Discrimination Notice-Notice informing individuals and nondiscrimination and
accessibility requirements.
 Multi Language letter (LAP Notice of Translation)- ICE DMHC Notice of translation
Translation of Written Materials and Alternative Format– SCMC has a process to translate
member materials into county specific threshold languages or alternative format. Translation
assistance and alternative format is available for all denials, deferrals, modification and
termination letters. Enrollees preferred language/requested alternative format will be verified
prior to issuing an NOA in the appropriate preferred language/requested alternative format.

Instructions for filing grievance against health plan

ERISA Rights Statement – “If your group health plan is subject to the Employee Retirement
Income Security Act (ERISA), you may be entitled to additional rights. Please consult with
your plan administrator to determine if your plan is governed by ERISA
 Statement of right to bring civil action when all required reviews of the request including
the appeal process, has been completed and there is still disagreement with the
outcome of the resolution.
 Statement of right to request, free of charge, copies of all documents, records and other
information relevant to the request for benefits.

Direct Access to Women’s Health Services

Serra Medical Group assures that members have direct access to in network obstetrics and
gynecology (OB/GYN) and other women’s health services, including routine and preventive
Members do not need to obtain a referral prior to receiving OB/GYN care, preventive women’s
health services/specialists, and/or specialist care services within the network
SCMC arranges for specialty care outside of the provider network when SCMC’s network
providers are unavailable or inadequate to meet a member’s medical needs.

 Members that need OB/GYN preventive care, are pregnant or have a gynecological
concern, may self-refer to an OB/GYN physician, Family Practice Physician or Surgeon
who provides such services within the network.
 SCMC will assist members by providing a list of available physicians who can provide
 The provider must consult with the member’s primary care physician regarding the
members condition and treatment plan.
 No prior authorization is needed to obtain the above services within SCMC’s network.
 Members have a right to self-refer for a screening mammography.

Customer Service and Cultural & Linguistics

Styles of Speech
People vary greatly in the length of time between comments and responses. The speed of their
speech and their willingness to interrupt may vary.
o Tolerate gaps between questions and answers; impatience can be seen as a sign of
o Listen to the volume and speed of the member’s speech as well as the content. Modify
your own speech to more closely match that of the member to make them more
o Rapid exchanges and even interruptions are a part of some conversational styles
o Do not be offended if a member interrupts you
o Stay aware of your interruption patterns, especially if the member is older than you are
Eye Contact
The way people interpret various types of eye contact is tied to cultural background.
o Look people directly in the eyes to demonstrate communication engagement
o For other cultures, direct eye contact is considered rude or disrespectful. Never force a
member to make eye contact with you.
o If a member seems uncomfortable with direct eye contact, try sitting next to them instead
of across from them
Body Language
o Follow the member’s lead on physical distance and contact
o Stay sensitive to those who do not feel comfortable
o Gestures can have different meanings
o Be conservative in your own use of gestures and body language
o Do not interpret member’s feelings or level of pain solely from facial expressions
Gently Guide Member Conversation
English language predisposes us to a direct communication style however, other languages and
cultures differ.
o Non English-speaking members or individuals from diverse cultural backgrounds may be
less likely to ask questions
Facilitate member-centered communication
Avoid questions that can be answered with “yes” or “no”
o Steer the member back to the topic by asking a question that clearly demonstrates that
you are listening
o Some members can tell you more about their health through story telling than by
answering direct questions

Always aim to speak with member in the same language possible by using translation
services or staff that may speak the same language.

Emergency/After Hours/Urgent Care and Requests
After regular Serra Community Medical Clinic hours, weekends and holidays, HMO
members requiring ER attention will be as follows:
 Telephone Operator calls the on-call physician and notifies him/her of the need
for ER attention. The operator will keep a record of all calls from the ERs and fax
them to Serra Community every AM for processing and follow-up.
 Urgent Care
◦ 5:30 PM to 08:30 PM. Monday – Friday at Serra Community Medical Clinic:
9375 San Fernando Rd. Sun Valley, CA 91352
◦ May also send member to First Aid Urgent Care: 9064 Van Nuys Blvd,
Panorama City, CA 91402
 ER
◦ Operator will forward information to the on-call physician

▪ The Operator will tell the requesting ER that they will get a called
back from the on-call physician within 30 minutes

All these procedures MUST be completed within 30 minutes of the operator receiving
the initial call. If the time exceeds 30 minutes, the requesting ER assumes that
permission was given to treat. SCMC will be financially responsible. All information
obtained will be forwarded to SCMC every morning.

Authorizations and Referrals

Non-Emergency Services Requiring Prior Authorization:
Allergy Orthopedics
Audiology Otolaryngology
Cardiology Physical Therapy
Chiropractic Podiatry
Dermatology Radiology
Endocrinology Rheumatology
Gastroenterology Urology
Nephrology Diagnostic Procedures
Neurology DME
Neurosurgery Home Health
Oncology/Hematology General Surgery/Bariatric Surgery
Ophthalmology Medications: Injection, Biologics, and others.
o Non-emergency out of area care (outside of L.A. County)
o Out of network care, services not provided by a contracted network doctor
o Inpatient admissions, post-stabilization/nonemergency/elective
o Inpatient admission to skilled nursing facility or nursing home
o Outpatient hospital services/surgery
o Outpatient, non-hospital , such as surgeries or sleep studies
o Outpatient diagnostic services, minimally invasive or invasive such as CT
Scans, MRIs, colonoscopy, endoscopy, flexible sigmoidoscopy, and cardiac

Services That Do Not Require Prior Authorization
 Emergency Services, whether in or out of L.A. County but within the
continental USA (except for care provided outside of the United States which
is subject to retrospective review).
 Emergency Care provided in Canada or Mexico is covered
 Urgent care, whether in or out of network
 Mental health care and substance use treatment
 Routine Women’s health services – a woman can go
directly to any network provider for women’s health care such as breast or
pelvic exams

o This includes care provided by a Certified Nurse
 Midwife/OB-GYN and Certified Nurse Practitioners
 Basic prenatal care – a woman can go directly to any network provider for
basic pre-natal care
 Family planning services, including: counseling, pregnancy tests and
procedures for the termination of pregnancy (abortion)
 Treatment for Sexually Transmitted Diseases, includes: testing, counseling,
treatment and prevention
 Emergency medical transportation
 Urgent Referrals: within 72 hours from receipt of all necessary information to make
the determination.
o The provider notifies the utilization management department or calls the
medical director or on-call physician that the patient is being sent for
emergency services.
o The provider or designee must ensure that the required paperwork is

 Non-Emergency Referrals: within 5 working days from receipt of all necessary
information to make the determination.
o The provider or designee completes a referral for service form.
o The form and the medical record/pertinent information are forwarded to the
utilization management department.
o Eligibility and benefits are checked, and the referral and accompanying data
is forwarded to the UM Nurse for review.
o If criteria is not met, UM Nurse forwards to Medical Director for further review.
Timeliness of UM Decision Making:
 For urgent concurrent review (decisions), SCMC makes decisions and gives
electronic or written notification of the decision to practitioners and members
within 24 hours of the request. Notification must be oral, unless the practitioner or
member requests written notification.
 For urgent preservice decisions, SCMC makes decisions and gives electronic or
written notification of the decision to practitioners and members within 24 hours
of the request. Notification must be oral, unless the practitioner or member
requests written notification.
 For nonurgent preservice decisions, SCMC makes decisions and gives initial
notification to the practitioner within 24 hours of the decision. Member notification
is within 2 business days of the decision for approvals. Written/Electronic
notification of a denial to the practitioner and member is done within 2 business
days of making the decision
 For nonurgent post service decisions, SCMC makes decisions and gives
electronic or written notification of the decision to practitioners and members
within 30 calendar days of the request.

UM Decision Notification to Providers:
 Physicians within SCMC are given telephone notification. Written notification is
available within SCMC’s EMR for all in house physicians.
 Contracted physicians outside of SCMC are given notification of UM decisions by
mail and by telephone.
Consultation Communication between Primary Care and Specialist Physician:
 EMR is a centralized file for all SCMC patients. Specialist consultations are available in
EMR for all SCMC Physicians to review. The PCP will review the specialist progress
note(s) and acknowledge on the PCP progress note once reviewed. (i.e. “Specialist note
reviewed” Yes or N/A will be checked as appropriate by the PCP.)
You may submit request for service by fax to: (818) 683-1076 along with medical
records/pertinent information. You may call to verify that your fax was received (818) 504-4569.
 You may submit request for service by fax to: (818) 683-1076 along with medical
records/pertinent information. You may call to check the status of your request at (818)
Retrospective Review: Cover letter, Claims & Medical Records must be submitted for review.
Please mail retrospective and regular claims to:
Serra Medical Group
9375 San Fernando Rd.
Sun Valley, CA 91352
Non-contracted providers must have a signed Release of Information form by the member in order to share patient information.

All authorizations will be processed in compliance with ICE Guidelines and Time Frames.
Affirmative Statement available upon request and available via web
( SMG UM decisions are made using Apollo’s Medical Review
Criteria. Utilization Management Criteria is available to the public and practitioners upon
request. Physician reviewer is available by phone to physicians to discuss determinations by
calling 818-683-1076.

Behavioral Health

Members can access services by self-referral 24 hours a day, seven days a week, by a family
referral, or referral from the PCP or other appropriate provider.
Serra Medical Group covers all Medically Necessary Covered Services for the Member,
including the following services (Medi-Cal Only):

  1. Emergency room professional services as described in Title 22, CCR, Section 53855,
    except services provided by psychiatrists, psychologists, licensed clinical social workers,
    marriage, family and child counselors, or other Specialty Mental Health Providers.
    2.All laboratory and radiology services when these services are necessary for the
    diagnosis, monitoring, or treatment of a Member’s mental health condition.
    3.Medically Necessary covered services after SCMC has been notified by a specialty
    mental health provider that a Member has been admitted to a psychiatric inpatient
    hospital, including the initial health history and physical examination required upon
    admission and any consultations related to Medically Necessary covered Services.
    However, notwithstanding this requirement, SCMC shall not be responsible for nursing
    facility services including room and board charges for psychiatric inpatient hospital stays
    by Members unless the services are classified an IMD services and are provided to
    members are less that age 22 or greater than age 64. MCPs are not required to pay for
    duplicate test or procedures that are not medically necessary.
    Medi-Cal children and youth must have a covered diagnosis and meet the following criteria:
  2. Have a condition what would not be responsive to physical health care-based
    treatment; and
  3. The service are necessary to correct or ameliorate a mental illness and condition
    discovered by a screening conducted by the MCP, the Child Health and Disability
    Prevention Program, or any qualified provider operating within the scope of his or her
    practice, as defined by state law regardless of whether or not that provider is a Medi-Cal
    Behavioral Health for Medi-Cal is a carve-out and will be coordinated through Community
    Mental Health Services organizations (e.g., health plan, County Department of Mental Health,
    etc.) For Healthy Families, which is not a carve-out, procedures may be different but must be in
    accordance with the Healthy Families and regulatory requirements. For more information,
    please Serra Medical Group at 818-504-4569.

Claims and Payment
All claims (including Retro Claims) must be mailed to:
Serra Community Medical Clinic
9375 San Fernando Rd.,
Sun Valley, CA 91352
To determine who is responsible for paying, please call Serra Medical Group or the
Health Plan for explanation of benefits/eligibility.

Billing- All paper claims must be submitted on CMS 1500 form for professional services
and UB-04 form for facility services.
Claims Adjudication- Each claim is subject to a comprehensive series of
quality checks called “edits” and “audits.” Quality checks verify and validate all claim
information to determine if the claim should be paid, denied or
suspended for manual review. Edit and audit checks include verification of:

  • Data validity
  • Procedure and diagnosis compatibility
  • Provider eligibility on date of service
  • Recipient eligibility on date of service
  • Medicare or other insurance coverage
  • Claim duplication
  • Authorization requirements

Provider Disputes
When the claim is the responsibility of the Serra Medical Group, a provider dispute can
be filed in writing to Serra Medical Group. Contact the Serra Medical Group for more
information on how to file a claims dispute.

Child Health and Disability Prevention (CHDP)

The CHDP program is administered by the Integrated Systems of Care Division (ISCD) of the
Department of Health Care Services (DHCS). The program is operated by local county health
departments and offices in the cities of Berkeley, Long Beach and Pasadena. The CHDP
program is designed to ensure that eligible children and youth receive periodic health
assessments and have access to ongoing health care from a medical and dental home.
As of July 1, 2016, all Medi-Cal managed care plans (MCPs) are capitated for EPSDT
services. The expansion of the Medi-Cal program resulted in the majority of EPSDT-
eligible children enrolled in an MCP.

The local CHDP program continues to provide care coordination for EPSDT-eligible children
who are enrolled in the Medi-Cal fee-for-service health care delivery system. Managed care
plans provide care coordination for MCP-enrolled members.
CHDP Program Responsibilities:
 The local county CHDP programs are responsible for day-to-day program
operations, including the following:
 Provider recruitment, review and approval
 Provider education and quality assurance
 Liaison with schools and various community agencies
 Education and outreach to eligible families
 Assistance to families in obtaining services, including transportation for medical
appointments and services
 Assistance to providers in contacting patients and scheduling appointments with
other providers
 Collaboration with the Department of Education to assist families with children
entering kindergarten or the first grade to obtain a health assessment and/or a
signed certification of health assessment

CHDP providers must:

  1. Participate in the Vaccines For Children (VFC) program.
  2. Successfully complete a medical record review by the local CHDP program.
    The medical record review is performed to assess format, documentation,
    coordination and continuity of care in order to ensure that children and youth
    receiving EPSDT/CHDP services are receiving the appropriate level of care.
  3. Successfully complete a facility site review to ensure each service location is
    safe and readily accessible to individuals with disabilities. This does not mean
    CHDP providers must make each of their existing facilities or every part of the
    facility accessible to and usable by people with disabilities if other methods

are effective in achieving compliance. A facility review may also include, but is
not limited to, the review of licensure and or certification, personnel
qualifications, site management, Clinical Laboratory Improvement
Amendments of 1988 (CLIA) compliance, and the availability of emergency
medical equipment and examination equipment appropriate to the population

  1. Utilize clinicians that meet CHDP standards.
    CHDP Health Assessment Guidelines
    The CHDP Health Assessment Guidelines incorporate the Bright Futures
    recommendations and include policies and procedures for provision of EPSDT/CHDP
    services. The guidelines include a detailed explanation of what is expected of a CHDP
    provider. A copy of the guidelines is available from local CHDP programs or may be
    accessed on the Child Health and Disability Prevention Program page of the DHCS
    website at
    Informing Patients
    Providers are responsible for informing patients about the availability of EPSDT/CHDP
    services and assisting recipients, in coordination with the local CHDP program, to obtain
    preventive health services for which they are eligible. Additional information about
    EPSDT informing requirements is located in the EPSDT section of this manual.
    Lead Poisoning Prevention Informing Requirement
    In accordance with California Health and Safety Code (H&S Code), Section 105286,
    health care providers must inform parents and guardians about all of the following:
    The risks and effects of childhood lead exposure.
    The requirement that children enrolled in Medi-Cal receive blood lead tests at specified
    The requirement that children not enrolled in Medi-Cal who are at high risk of lead
    exposure receive blood lead tests.
    Obtaining Consent: Providers must obtain voluntary written consent prior to
    examination and treatment, with appropriate regard to the recipient’s age and following
    State and Federal laws. Consent also must be obtained prior to release of recipient

Minor Consent
Minors (recipients younger than 18 years of age) may provide their own legal consent
for EPSDT/CHDP health assessment services, if:
 The minor is emancipated, as determined by the court.
 The minor is, or has been, married.
 Parental consent for the service is not necessary under State or Federal law.
Medi-Cal Managed Care Plans
Managed care plans (MCPs) that contract with the State to render care to Medi-Cal
recipients must provide EPSDT services for Medi-Cal recipients younger than 21 years
of age. The MCP may contract with providers to render those services and may require
those providers to enroll as CHDP providers.
Providers not required by their contractual arrangements with a Medi-Cal managed care
plan to be CHDP providers are encouraged to enroll as CHDP providers. Enrollment
helps ensure continuity of care for children that exit a Medi-Cal MCP and enables
providers to deliver expected levels of care to Medi-Cal fee-for-service recipients and
children enrolled in Medi-Cal through the CHDP Gateway.
Medi-Cal Marketing Guidelines
Providers are responsible for making sure member-facing materials meet the below guidelines

c/o Serra Medical Group
9375 San Fernando Rd., Sun Valley, CA 91352
Phone: 818-504-4569 ♦ Fax: 818-683-1076






Outpatient Inpatient LOS Anesthesiologist Name:
*All post-op services including office visits require the date of surgery to be indicated. All requests for obstetrical care should include the
last LMP, EDC and scheduled facility for delivery. All pertinent information should be stated on all requests. Attach progress notes and

additional reports if applicable.



    Requesting Provider Signature & Date:
    Supervising Physician/Medical Navigator Signature:
    Form completed by: Title: Tel #
    Please Note: This form should be filled out in its entirety. If the form is not completely filled out and legible, it may be returned to your

office for proper submittal, which will delay the authorization process.

Provider Cultural and Linguistic Responsibilities (2023)

Dear Provider:
The following guide summarizes the requirements for providing culturally sensitive and
linguistically appropriate services to your Medi-Cal patients. You may download any of the forms
that we reference in this sheet at For printed copies,
call the Cultural & Linguistic Department at 562-580-6077.
Language Preference
Record each patient’s language preference in their medical record.
Interpreter Services Poster
Post the “Free Language Assistance Notice” sign at key points of contact. This sign informs
patients who are Limited English Proficient (LEP), that free interpreter services are available to
Free Interpreter Services
We provide over-the-phone, face-to-face, and American Sign Language interpreter services for
patients who are LEP, hard-of-hearing, or deaf. These services are free to you and your
Patients who are LEP
 Over-the-phone interpreter services: These services are available 24 hours a day, 7
days a week. Please refer to the “Protocol for How to Access Interpreting Services”
 Face-to-face interpreter services: Call our Customer Care Department. Requests must
be made with advance notice of 5-7 business days.
Patients who are hard-of-hearing or deaf
 To communicate over the phone: You can place calls and receive calls from patients
using the California Relay Service (CRS) by dialing 711. The CRS is free and available
24 hours a day, 7 days a week.

 American Sign Language onsite interpreter services: Call our Customer Care
Department. Requests must be made with advance notice of 5-7 business days.
For interpreter services after business hours, call our Customer Care Department. Additionally,
please ensure the following:
 Your after-hours Answering Service staff and on-call physician/nurses know how to
connect with over-the-phone interpreter services and CRS. Please refer to the “Protocol
for How to Access Interpreting Services” sheet.
 Your answering machine message instructs patients to call their Health Plan to connect
with interpreter services.

Blue Shield of California Promise Health Plan

Customer Care

Medi-Cal 800-605-2556
Medi-Cal SD 855-699-5557

Request or Refusal of Interpreter Services
 Discourage patients from using friends and family members as interpreters. Do not use
minors to interpret unless there is an emergency.
 If a patient requests or refuses interpreter services after being informed of their right to
free interpreter services, file a completed “Request/Refusal Form for Interpretive
Services” in their medical chart. These forms are available in English and Spanish or in
threshold languages on the Blue Shield Promise provider website at policies-guidelines-standards-
forms/provider-forms under Other patient care forms.
Cultural & Language Related Complaints and Grievances
Your patients have a right to file a complaint and grievance if they feel their cultural or language
needs are not met in your office. Grievance forms are available in a variety of languages,
including county threshold languages at
Referrals to Culturally Appropriate Community Resources & Services
If a patient needs services from a community-based organization or a social service agency,
please visit or use the Blue Shield of California Promise Health Plan
Community Resource Directory to locate resources. The Blue Shield of California Promise
Health Plan Community Resource Directory is available on the website. Please document the
referral in the patient’s record.

Bilingual Providers & Staff
Providers and staff who communicate with patients in a language other than English, or who act
as interpreters are encouraged to take a language proficiency test by a qualified agency. At a
minimum, either of the following should be kept on file bilingual Providers and staff:
 Completed language capability self-assessment form. Providers and staff may use the
ICE “Provider & Staff Language Capability Self-Assessment” form.
o Those who report limited bilingual capabilities should not act as interpreters or
communicate with patients in a language other than English.
o Do not rely on staff other than qualified bilingual staff to communicate directly in a
non- English language with members.

 Certification of language proficiency or interpretation training (i.e., resume or curriculum
vitae which include number of years worked as interpreter).
Availability of member materials in threshold languages and alternative formats
Patients may request materials in their preferred language and in an alternative format.
Alternative formats include Audio CD, Data CD, Braille, and Large Print. For more information,
call the Cultural & Linguistic Department.
 Please distribute the Non-Discrimination Notice (NDN) and Language Assistance Notice
(LAN) to your providers.
 All member mailings must include the NDN and LAN.
Disability and Cultural Competency Training Programs
We encourage you and your staff to attend disability sensitivity and cultural competency
(diversity, equity, and inclusion) training programs at least annually. These trainings can help
enhance your interpersonal and intra-cultural skills, which can improve communication with your
culturally diverse patients, including Seniors and People with Disabilities. Programs are
available through Blue Shield of California Promise Health Plan, L.A. Care, and other agencies.
Please go to the links below to access disability Training:
n tSer vlet?fileName=BSP_2019_MakingDifficultConversationsaboutPalliativeCareEasier.pdf
n tServlet?fileName=BSP_2019_ADA_OlmsteadTraining.pdf
Please reach out to the Serra Medical Group team if we can help you or your office staff with
any Training for Health Education or Culturally and Linguistically Appropriate Services.

Medicare fraud, waste, and abuse compliance program
Both Chapter 21 of the Medicare Managed Care Manual and Chapter 9 of the Prescription Drug
Benefit Manual, collectively referred as the Compliance Program Guidelines and last revised on
January 11, 2013, contain requirements mandating Medicare Advantage plans and standalone

Part D plans to apply compliance training and communications, including fraud, waste and abuse
(FWA) requirements, to first-tier, downstream, and related entities.
The Compliance Program Guidelines also instruct Medicare Managed Care plans and their
contractors (first-tier), subcontractors (downstream), and other related business entities on how
to implement the regulatory requirements under 42 Code of Federal Regulations (C.F.R.)
§423.504(b)(4)(vi)(H), and how to implement a comprehensive FWA compliance plan to detect,
correct, and prevent fraud, waste, and abuse.
Components of a comprehensive program to detect, prevent, and control Medicare Fraud, Waste,
and Abuse are included as part of our General Compliance Plan Requirements.
Serra Medical Group prohibits fraud, waste, and abuse and is committed to responding
appropriately in the event that potential or suspected fraud, waste, or abuse is committed by its
employees, vendors, subcontractors, contracted providers, or business associates.
The Compliance Program Guidelines provisions are integrated into each element of Serra
Medical Group’s existing Medicare Compliance Program. Serra Medical Group’s FWA Program
is organized to follow the core elements of a compliance plan in accordance with the Office of
the Inspector General’s (OIG) Guidelines. 
Fraud, waste and abuse component elements
The core elements involved in developing the fraud, waste, and abuse component of Blue Shield
Promise’s Medicare Compliance Program include:

  1. Written policies and procedures
    Blue Shield Promise has developed policies and procedures, including a Standard of
    Conduct, demonstrating its compliance and commitment as an entity that is contracted
    with the federal government.
  2. Compliance Officer and Compliance Committee
  3. Training and education
    Serra Medical Group provides computer-based-training (CBT) and paper training to its
    employees and temporary/contracted workforce members, so as to comply with
    regulations and assist in fraud, waste, and abuse prevention efforts. CBT training
    addresses pertinent laws related to fraud and abuse (e.g., Anti-Kickback Statute, False
    Claims Act, etc.) and includes a discussion of Medicare vulnerabilities identified by
    Centers for Medicare & Medicaid Services (CMS), the Office of the Inspector General
    (OIG), the Department of Justice, and other organizations. In addition, Serra Medical
    Group provider communications also provide information to raise awareness of its fraud,
    waste, and abuse compliance requirements for its contracted and subcontracted entities.
  4. Effective lines of communication
    Serra Medical Group has established a hotline to receive, monitor, process, and resolve
    non-compliant activities. Report any suspected or potential fraud, waste, or abuse to Serra
    Medical Group via the following methods:

 Phone: 818-504-4569

  1. Enforcement standards through well-publicized disciplinary guidelines
    Serra Medical Group uses various avenues to encourage reporting of incidents of
    unethical or noncompliant behavior via annual mandatory general compliance training,
    newsletters, and department staff and committee meetings.
  2. Corrective action procedures
    Serra Medical Group corrects and mitigates, within set timelines, noncompliant activities
    or violations committed and identified. Detailed Corrective Action Plans (CAPs) are used
    to describe the actions that will be taken, including a targeted timeframe, to correct and
    complete the identified non-compliance violation.
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