VHP Attains NCQA
Health Equity Accreditation
Valley Health Plan reached a significant milestone by earning Health Equity Accreditation from the National Committee for Quality Assurance (NCQA) in December 2023. We are proud of this achievement, and it demonstrates our dedication to ensuring that all individuals, irrespective of their backgrounds, have equal access to highquality healthcare services.
NCQA awards accreditation to organizations that meet or exceed its rigorous requirements for health equity. For Valley Health Plan, this accreditation signifies a pivotal step in our mission to provide comprehensive and equitable health insurance coverage to our diverse and dynamic community.
NCQA’s Health Equity Accreditation evaluates how well an organization complies with standards in the following areas: organizational readiness; race/ethnicity, language, gender identify and sexual orientation; access and availability of language services; practitioner network cultural responsiveness; culturally and linguistically appropriate services programs; and reducing health care disparities.
VHP’s accomplishment aligns with the broader industry’s growing emphasis on addressing health disparities, ensuring that health insurance organizations actively contribute to creating a landscape where healthcare is truly accessible and equitable for all.
For more information about accreditation, visit ncqa.org.
VHP Case Management Programs
REMOTE PATIENT MONITORING
Your practice can partner with Valley Health Plan to care for your patients with diabetes, hypertension, and heart failure. We have Remote Patient Monitoring (RPM) available to your VHP patients free of charge.
The program includes a monitoring device and a tablet delivered to your patient. Advanced Monitoring Caregiving (AMC) will monitor patients, while a VHP Registered Nurse (RN) Case Manager will provide additional support. The program includes a vast library of online patient education on the tablet and outreach by a healthcare professional. As the primary care provider for the patient, you will receive quarterly reports and be alerted to any readings that may require your intervention.
To enroll your patient in RPM, send a referral to vhpcasemgmt@vhp.sccgov. org. A VHP RN Case Manager will then contact your patient to evaluate them for enrollment. The RPM program currently supports diabetes, hypertension, and
heart failure. If there are other conditions that you would propose for use of RPM, please contact VHP Case Management.
To learn more about the program, provide feedback, or refer your patient, please contact VHP Case Management at 669-220-5235 or vhpcasemgmt@vhp.sccgov.org.
TRANSITIONAL CARE SERVICES
The Transitional Care Services (TCS) program supports VHP patients who were recently released from a hospital or inpatient facility and need assistance during the first month.
VHP’s Case Management Team assists patients with transitioning back into the community and back with their assigned primary care provider (PCP) after discharge. If the patient does not have a PCP assigned, the team can help connect them to a new provider.
The TCS program provides dedicated phone support to VHP patients, which may include help from nurses or social workers. Services include:
• Identifying a patient’s assigned PCP
• Helping the patient schedule a follow-up visit with the PCP, ideally within 14 days of discharge
• Assisting with coordinating other visits to close gaps in care, including specialty appointments if needed
• Connecting patients to outside resources, including referrals to Enhanced Care Management (for Medi-Cal patients) or Complex Case Management services
Through this program, VHP aims to improve continuity of care for VHP patients and to reduce unnecessary emergency room visits and hospital admissions.
For more information or assistance, please contact VHP Case Management at 669-2205235 or vhpcasemgmt@vhp.sccgov.org.
VHP Tobacco Cessation Program
Smoking and Tobacco Use
Tobacco use is the number one cause of preventable diseases, disabilities, and deaths in the United States. According to the Centers for Disease Control and Prevention (CDC), about 28.3 million adults in the U.S. smoke cigarettes, and 16 million live with a serious illness caused by smoking (CDC, 2023). Additionally, of the approximately 480,000 Americans who die from smoking each year, 35% die from heart disease (American Heart Association, 2024).
Helping Patients
Tobacco dependence is a chronic disorder that often requires repeated treatments, interventions, and long-term support. Brief counseling during doctor visits can help encourage patients to quit smoking permanently. The U.S. Public Health Service Report includes guidelines for providers on evidence-based ways to encourage people to quit smoking.
Research shows people are more successful at quitting when they get assistance in multiple ways.
Tobacco Cessation
Valley Health Plan’s Health Education Department offers a free certified Tobacco Cessation Program to help your VHP patients quit smoking and using tobacco products.
This program helps identify and address individual triggers, reviews various Nicotine Replacement Therapy (NRT) options, and teaches participants how to safely use NRT. The goal is to teach members ways to quit smoking successfully, even if they have attempted to quit in the past.
VHP’s Tobacco Cessation Program consists of two individual sessions. Sessions are virtual but can be in person if requested. Those who attend both sessions will receive certificates of completion.
Tobacco-certified VHP Health Education Specialists provide direct support to patients by helping them to:
• Understand their smoking history and routine
• Learn the benefits of quitting and different strategies to quit
• Manage withdrawal symptoms and smoking “triggers”
• Understand options for NRT to discuss with their primary care provider
• Recognize the importance of selecting a “quit date”
To learn more about VHP’s Health and Wellness programs and how your VHP patients can enroll, visit: Health and Wellness | Valley Health Plan | VHP. If you have any questions, please contact VHP’s Health Education Department at healtheducation@vhp.sccgov.org or 669-2205235.
Proof of Timely Filing for Claim Disputes
Claims that are not filed within the contractual timely filing limit are denied. Timely filing denials are often due to incomplete or invalid documentation submitted with a late claim. The following information may help clarify the documentation required when submitting a claim dispute.
FOR CLAIMS PREVIOUSLY SUBMITTED ELECTRONICALLY:
Submit an electronic data interchange (EDI) acceptance report, Valley Health Plan’s 277 CA report. This must show that Valley Health Plan received, accepted, and/or acknowledged the claim submission. The acceptance report must:
• Include the actual wording that indicates the claim was either “accepted” or “received,” and/or “acknowledged.”
• Show that the claim was accepted, received, and/or acknowledged within the timely filing period.
• Have the correct patient’s name
• Have the correct date of service
• Include the claim submission date (must be within the timely filing period).
• Include the total billed charges.
• Include details of any extenuating circumstances that led to untimely claim submission, along with all supporting documentation.
Note: A submission report from the provider’s billing system alone is not considered proof of timely filing for electronic claims. It must be accompanied by an acceptance report. A 277 report can be obtained directly from your EDI clearinghouse.
FOR CLAIMS PREVIOUSLY SUBMITTED VIA PAPER:
Submit a screen capture from provider’s billing system that shows the complete billing history. The screen capture must show:
• Correct patient name
• Correct date of service
• Submission date of claim (the submission date must be within the timely filing period)
• Total billed charges
• Details of any extenuating circumstances that led to untimely claim submission, along with all supporting documentation
OTHER VALID PROOF OF TIMELY FILING DOCUMENTATION:
The following is valid proof when incorrect insurance information was provided by the patient at the time the service was rendered:
• A denial/rejection letter from another insurance carrier
• Another insurance carrier’s explanation of benefits
• Letter from another insurance carrier or employer group indicating coverage termination prior to the date of service of the claim
• Letter from another insurance carrier or employer group indicating no coverage for the patient on the date of service of the claim
All of the above must include documentation that the claim is for the correct patient, the correct date of service, and correct billed charges. The date on the other carrier’s payment correspondence starts the timely filing period for submission to Valley Health Plan.
Targeted Rate Increase for Medi-Cal Services
The Department of Health Care Services (DHCS) developed targeted provider rate increases for primary care, obstetric, and non-specialty mental health services for Medi-Cal services rendered. The DHCS increased rates for targeted Medi-Cal services to no less than 87.5% of the Medicare rate. The provider rate increases were developed to improve access, quality, and equity for Medi-Cal patients and promote provider participation in the MediCal program.
The targeted rate increase applies to contracted providers for Medi-Cal services and is effective for dates of service on or after January 1, 2024.
FREQUENTLY ASKED QUESTIONS
1. Which contracted providers will receive the Targeted Rate Increase (TRI)?
• Physicians
• Physician Assistants
• Nurse Practitioners
• Podiatrists
• Certified Nurse Midwives
• Licensed Midwives
• Doula Providers
• Psychologists
• Licensed Professional Clinical Counselors
• Licensed Clinical Social Workers
• Marriage and Family Therapists
Only eligible contracted providers (defined in All Plan Letter 19-001) will receive the TRI. Non-contracted providers will continue to be reimbursed at the existing Medi-Cal rate for procedure codes identified as Primary/General Care.
2. Which CPT codes apply?
Refer to CY 2024 TRI Fee Schedule v1.06.01082024 for rate information.
3. When will fee-for-service claims that are processed by Valley Health Plan be paid at TRI rates?
TRI rates are effective Jan. 1, 2024. Plans have until July 31, 2024, to start paying at TRI rates for any new claims. Additionally, plans have until Oct. 31, 2024, to retroactively implement the rate increases for prior fee-for-service claims.
4. Will Valley Health Plan be amending fee-for-service contracts to include TRI rates?
We do not anticipate amending fee-forservice contracts but will notify fee-for-service providers in advance of making any changes.
5. Are Proposition 56 physicians’ services payments included in the TRI calculation?
Yes. Proposition 56 is incorporated into the TRI fee schedule. The provider will receive the contracted rate plus the Proposition 56 or TRI fee schedule, whichever is greater. The Assembly Bill 97 reduction does not apply to TRI codes.
6. Are incentive, bonus, and profit share payments excluded from the TRI calculations?
Yes.
For additional information about the targeted rate increase for Medi-Cal services, visit the DHCS website: Medi-Cal-TargetedProvider-Rate-Increases.
VHP Drug Formulary
The VHP Pharmacy and Therapeutics Committee reviews and updates the VHP Drug Formulary quarterly. The Pharmacy and Therapeutics Committee decides:
• Which new drugs to add to the formulary
• Which drugs need prior approval
• If a drug has quantity limits or requires step therapy
• If an alternative prescription medication can be used
• Which drugs not to cover
The Committee makes these decisions based on U.S. Food and Drug Administration (FDA) approval, scientific articles, drug safety, and whether similar drugs are available.
For more about VHP’s Pharmacy and Therapeutics Committee, view the VHP Provider Manual.
To view the VHP drug formulary visit: Pharmacy | Valley Health Plan | VHP.
If you would like a printed copy, call Navitus Customer Care at 1-866-333-2757 or VHP Service Operations at 1-888-421-8444.
PRIOR AUTHORIZATION/ EXCEPTION REQUESTS
If a drug on the formulary has “PA” in the “Special Code” column or if the drug is not on the formulary, then the provider must complete a Prescription Drug Prior Authorization or Step Therapy Exception Request Form. Providers must fill out the form completely with information supporting the request and submit it to Navitus, VHP’s pharmacy benefit manager.
Following receipt of any Prior Authorization or Exception Request forms, the pharmacist or physician will review and grant approval based on established criteria and medical necessity.
You can access information about VHP’s prior authorization criteria by logging into the Navitus Provider Portal with your National Provider Identifier (NPI) and selecting “Valley Health Plan.”
Navitus Health Solutions manages VHP’s pharmacy benefits, including customer service, formulary updates, prior authorizations, coverage exceptions, and drug recall notices. Navitus Customer Care is available 24/7 at 1-866-333-2757.
Navigating Referrals: Essential Tips and Guidelines
Referrals play a crucial role in ensuring patients receive timely and appropriate care. However, the process does have requirements and considerations.
To help streamline the referral process and ensure optimal patient outcomes, please keep these key referral guidelines in mind:
1. Enter urgent referrals appropriately:
Use the “urgent” designation only for requested services medically needed within 72 hours of submission. The “urgent” designation is intended for cases in which the requested service must be provided as quickly as possible to avoid harm to the patient.
2. Provider information requirements:
a. Referrals to providers must be complete with name, correct address, and specialty for both “refer by” and “refer to” providers.
b. For services performed by a vendor* (such as home care, hospice, durable medical equipment, and hearing aids), please enter the prescribing doctor or ordering practitioner name.
*If a referral is submitted by a vendor, please enter the prescribing doctor name.
3. Clinical notes requirements:
To prevent delays in referral processing, provide clinical records to support the request.
4. Contracted provider requirements:
Contracted providers must enter the referral in VHP Access (www.vhpaccess.org). For technical issues, such as problems with access, unable to match provider address/ place of service, attachment issues, or missing specialty, contact VHP Provider Relations at 408-885-2221 or providerrelations@vhp.sccgov.org.
5. Medi-Cal billing codes for therapy services:
Providers must use valid Medi-Cal billing codes for therapy services for Medi-Cal members. Below are links to Medi-Cal billing codes for therapy:
• Physical Therapy
• Occupational Therapy
• Speech Therapy
For questions or assistance with referrals, please contact VHP Provider Relations at 408-8852221 or providerrelations@vhp.sccgov.org.
Initial Health Appointment
On Jan. 1, 2023, the Initial Health Assessment was replaced with the Initial Health Appointment (IHA) by the Department of Health Care Services (DHCS). DHCS requires primary care providers to complete an Initial Health Appointment for all new plan members within 120 calendar days of enrolling in a Medi-Cal managed care health plan (such as Santa Clara Family Health Plan).
The Initial Health Appointment is conducted by the patient’s primary care provider and includes assessing and managing the patient’s immediate health needs, chronic conditions, and preventive care.
About the Initial Health Appointment:
• Must be performed by a primary care provider
• Is not needed if a patient’s medical records were fully updated within the previous 12 months
• Must be provided in a way that is culturally and linguistically appropriate for the patient
• Must be documented in the patient’s medical record
The Initial Health Appointment includes:
• Taking a history of the patient’s physical and mental health
• Identifying health risks
• Assessing the need for preventive screenings or services
• Providing health education
• Diagnosing and planning for treatment of any diseases
Benefits of Initial Health Appointments:
• Increases patient connection by using data for discussion
• Helps identify and prioritize patient health issues and goals
• Helps patients understand their current health status
• Reminds patients about habits that affect their health
• Identifies issues requiring patient referral to additional resources
The Initial Health Appointment policy, in line with the Population Health Management Guide and the Medi-Cal Managed Care Health Plan contract, is designed to enhance patient care and outcomes.
An Initial Health Appointment must be completed for all members within 120 days of enrollment and periodically re-administered according to the requirements above.
IHAs are not diagnostic tools or full health histories. Their purpose is to engage patients in their health and promote better long-term choices and behaviors.
For details regarding the DHCS All Plan Letter visit: All Plan Letter APL 22-030 Initial Health Appointment.
For more information about Initial Health Appointments, visit: IHA Provider Training.
For questions or assistance, please contact VHP Provider Relations at 408-885-2221 or providerrelations@vhp.sccgov.org.
Important Health Screenings for Patients
CHILDHOOD LEAD SCREENING
The California Department of Public Health regulations require health care providers to assess children between six months and six years old for childhood lead poisoning. These regulations apply to physicians, nurse practitioners, and physician assistants.
Why Screen and Assess?
• Even low levels of lead exposure have lasting neurodevelopmental effects.
• Children at risk of lead exposure may not receive appropriate treatment or investigation because low levels of lead exposure may not cause obvious symptoms.
• It is a state requirement.
Lead Screening Guide
• Screening Ages (for blood lead test):
• Children in publicly supported programs* at both 12 months and 24 months of age
• Children aged 24 months to 6 years in publicly supported programs* who were not tested at 24 months or later
*Examples of publicly supported programs include Medi-Cal, Child Health and Disability Prevention, and the Women, Infants, and Children Program.
• Assess if the child is not in a publicly supported program:
• Ask the parent, “Does your child live in or spend a lot of time in a place built before 1978 that has peeling or chipped paint and/or that has been recently remodeled?”
• If the answer is “yes” or “don’t know,” complete a blood lead test.
• Other indications for a blood lead test:
• Suspected lead exposure
• Parental request
• Recent immigration from a country with high levels of environmental lead
• Change in circumstances that has put the child at risk of lead exposure
Lead Testing
A finger-prick or heel-prick (capillary) sample is usually the first step to determine if children have lead in their blood. A finger-prick test can provide fast results. A finger-prick that shows a blood lead level at or above the U.S. Centers for Disease Control and Prevention blood lead reference value of 3.5 micrograms per deciliter is usually followed by a second test to confirm it.
Health care providers play an important role in preventing lead poisoning. Providers can identify children at higher risk, test their blood lead levels, and connect families with follow-up
services. Valley Health Plan covers the cost of lead screening for children.
For more information, visit:
• Standard of Care on Screening for Childhood Lead Poisoning
• ROUND 3 2023 Blood Lead Testing and Anticipatory Guidance.pdf (ca.gov)
CHLAMYDIA SCREENINGS FOR WOMEN
Did you know that chlamydia is the most common sexually transmitted infection (STI) in the United States?
In fact, in 2022, the Centers for Disease Control and Prevention (CDC) reported 1,642,716 chlamydia cases. In Santa Clara County, the number of chlamydia cases increased 34% from 2020 to 2022. Rates have also risen in Monterey and San Benito Counties.
Additionally, in 2022, the rate of chlamydia among Hispanic/Latinx in Santa Clara County was 573.5 cases per 100,000 people, which was 52% higher than the rate of African Americans/Black residents. And, the rate of chlamydia among Hispanic/ Latinx females in Santa Clara County was over three times higher than the rates among white females.
Furthermore, the number of reported cases is lower than the actual number of cases. This is because about 75% of infected people are asymptomatic and do not seek treatment until they have complications such as pelvic inflammatory disease (PID), infertility, ectopic pregnancy, or chronic pelvic pain.
Chlamydia Screenings
The United States Preventive Services Task Force (USPSTF) recommends yearly chlamydia screenings for sexually active women, including pregnant women, even without chlamydia signs and symptoms. Sexually active women 24 years or younger and women 25 years or older with an increased risk should be screened.
Increased risks include:
• Women aged 15 to 24 years old.
• Women 25 years or older are with:
• A previous or coexisting STI
• A new or more than one sex partner
• A sex partner who has other sex partners
• A sex partner with an STI
• Inconsistent condom use when not in a mutually monogamous relationship
• A history of exchanging sex for money or drugs
• A history of incarceration
In light of the rise in chlamydia cases, especially among Hispanic/Latinx populations in Santa Clara County, it is important for healthcare providers to prioritize chlamydia screening and prevention efforts. With a significant portion of cases going undiagnosed due to asymptomatic individuals, consistent screening is vital for early detection and prevention of complications. By proactively addressing risk factors and promoting regular screening, healthcare providers can play a role in curbing the spread of chlamydia and safeguarding the reproductive health of their patients.
For more details on chlamydia trends and screening, visit:
• USPSTF Chlamydia and Gonorrhea Screening
• CDC - Chlamydia
• SCC Public Health Epidemiology Annual Report 2022
• National Committee for Quality Assurance –Chlamydia Screening in Women
• Communicable Disease Dashboard | County of Monterey, CA
VHP Community Outreach
Our 2023 Covered California Open Enrollment season was very busy for the VHP Marketing Team. Our team attended events across the region, including local community college fairs, health fairs, wellness festivals, “National Night Out” events in multiple cities, pride celebrations, and Latino cultural festivities.
The VHP Marketing Team hosted information booths at the Monterey County Fair and sponsored the River Run in Hollister and the Dia De Los Muertos Community Walk/Run benefiting the Gardner Clinics. Community outreach events aim to bolster VHP’s local presence and increase engagement.
VHP enjoys participating in these events and partnering with organizations that are working to improve residents’ access to healthcare, wellness resources, mental health support, and physical fitness. Connecting with the community allows us to better understand and serve our members.
VHP participants at the Gardner Health Dia De Los Muertos 5k/10k: (from left) Mitzi Magos, Marketing and Communications Representative, Dr. Nidhi Gupta, Medical Director, Kat Chaney, Marketing Manager, Karen Grogg, Program Manager III, Business Development, and David Hurst, Chief Business Development Officer.