Providers

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Suggested Topics: Claims, Training, Manuals

Access to Care

Timely Access to Care

Providers of AltaMed Health Net, Inc. (AHN) are expected to provide prompt access to care for members. There are limits on how long a member have to wait to get medical appointments, telephone advice, and other health care services. The table below is a reminder of the access standards for availability of services to AHN members.

Urgent Care

Standard

For services that don’t require prior authorization by your health plan

Within 2 days

For services that require prior authorization by your health plan

Within 4 days

Non-Urgent Care

Standard

Primary Care Physician Appointment

Within 10 business days

Specialty Care Physician Appointment

Within 15 business days

Mental Health Appointment (non-physician)

Within 10 business days

Appointment (ancillary provider)

Within 15 business days

Follow-up Care

Standard

Mental Health / Substance Use Disorder Follow-Up Appointment (non-physician)

Within 10 business days from prior appointment

Claims

Claims Resource Document

If you are a contracted or non-contracted provider seeking information about a claim, please view the Claims Resource Documents.

Non-Contracted Hospital Instructions

Non-contracted hospitals are required to obtain prior authorization for post-stabilization care of AltaMed Health Network members. For more information, please review the Non-Contracted Hospital Instructions.

Clinical Practice Guidelines

Clinical practice guidelines are evidence-based recommendations based on scientific evidence, review of the medical literature, or appropriately established authority. All recommendations based on published agreed on guidelines and do not favor any specific treatment based solely on cost considerations. To review listings of clinical practice guidelines, please refer to the links below:

Culture and Linguistics / Language Assistance

Every patient has the right to request free interpreter services to communicate with our providers and staff. If the patient belongs to a Health Plan, you may call the number on the back of the patient’s insurance card. For contact information, please view the Care in your Language.

Credentialling

Coming Soon

Policies

Code of Conduct

The Business Code of Conduct sets forth the operational procedures for ethical conduct. It applies to all employees, physicians, health care professionals, trainees, agents, board members, volunteers, representatives, contractors, vendors and other persons or companies working with AHN to provide products or services to or on behalf of AHN. For more information, please review the Business Code of Conduct

Exclusions

AltaMed Health Network, Inc. (AHN) will not do business with any Vendor if it or any of its officers, directors or employees are, or become excluded by, debarred from, or ineligible to participate in any Federal or State programs. Vendors must disclose to AHN if they are currently suspended, debarred or otherwise ineligible to participate in any Federal or State program.

Fair Hearing for Administrative/Business Decisions

Coming Soon

Fraud, Waste, Abuse and Noncompliance

AltaMed Health Network, Inc. (AHN) is dedicated to identifying, correcting, and preventing fraud, waste, abuse, and noncompliance as part of our ongoing efforts to enhance the healthcare system.

We promote the detection and prevention of fraud and abuse, as well as education about the risks of fraud and abuse. If AHN discovers compliance flaws in our healthcare operations, we will take the necessary corrective actions as required by law.

To report any suspected or potential fraud, waste, abuse, or noncompliance, please submit Report an Issue form.

Nationally Recognized Criteria for Delegated Medical Groups and Vendor UM Decisions

AltaMed Health Network (AHN) ensures its provider groups delegated for the Utilization Management (UM) function utilize evidenced based nationally recognized criteria. UM decision making for requested Medical and Behavioral Health services are based on the member’s need, benefit eligibility and/or medical necessity, and is consistent with guidelines and/or criteria that are supported by sound clinical principles and processes which are regularly reviewed and updated. Guideline and/or criteria application is used in decision making related to pre-service, concurrent review, and retrospective service requests.

Consistency in applying criteria by clinical and non-clinical staff is monitored and evaluated at least annually using Inter-Rater-Reliability (IRR). IRR results and the criteria used in UM decision making will be presented to the UM Committee for review on an annual basis.

AHN’s delegates disclose to network practitioners, members, member’s representatives, or the public, upon request, the clinical guideline or criteria used to make utilization review determinations.

AHN Approved and Adopted Criteria:

Centers for Medicare & Medicaid Services (CMS)
National Coverage Determinations
Local Coverage Determinations
CMS Benefit Interpretation Manuals
Medi-Cal Coverage Guidelines
Milliman Care Guidelines®
National Guideline Clearinghouse
Evidence in the peer-reviewed published medical literature

Access to Policies

Contact AltaMed Health Network, Inc. (AHN) Compliance and Privacy Office at compliance@altamedhn.com for information about or to request a copy of an AHN policy.

Provider Disputes

You may submit a provider dispute resolution (PDR) form to:

Challenge, appeal or request reconsideration of a claim that has been denied, adjusted or contested.
Challenge a request for reimbursement for an overpayment of a claim.
Seek resolution of a billing determination or other contractual dispute.

Click here to fill out and submit the PDR form.

Note: If you have multiple “LIKE” claims, in addition to filling out the PDR form, please also list the claims in the Provider Dispute Resolution Request Spreadsheet and attach it in “Attachments” tab located in the same PDR form.

Provider Manuals

Provider Manuals give you access to important information about policies, procedures, regulatory and contractual requirements to comply with applicable laws, rules, regulations, guidance, and accreditation standards. For more information, please refer to the links below:

Provider Tools / Tool Kits / Other Resources

All Plan Letters

All Plan Letters (APLs) are the means by which the California Department of Managed Care (DMHC) and the Department of Health Care Services (DHCS) notifies managed care plans about new guidelines and standards mandated by the state of California for managed care and/or Medi-Cal services. Click here to be directed to DMHC’s Managed Care All Plan Letters library for the period of 2015 to the present. Click here to be directed to DHCS’ Medi-Cal Managed Care All Plan Letters library for the period of 1998 to current date.

Health Information Management Request

For information about requesting medical records, please visit Provider Support.

Application Programming Interfaces (APIs)

Coming Soon

Initial Health Assessments

To view the Provider Bulletin regarding Initial Health Assessments, please click here.

Other Health Assessments

For more information about other health assessment recommended by the Department of Health Care Services (DHCS), please refer to the link(s) below:

Staying Healthy Assessment Questionnaires (ca.gov)

Provider Bulletins

Click on the link below to stay informed about important regulatory changes and updates.

Provider Bulletins

Provider Tool Kits and Resources

For more information and resources to assist you in providing quality care, please refer to the links below:

Resources

Coming Soon

Training

To access provider training materials and continuing medical education activities, please refer to the links below:

Join AHN

AHN Provider Network

The Provider Network

Visit Website

Website Under Development

Management Services Provider for AltaMed and OmniCare

Visit Website

Interested in Joining AHN

Thank you for your interest in joining AltaMed Health Network, Inc. network. Please follow the directions below depending on your
provider type.

Providers or Group Practices

Please fill out and submit the following documents to contracting@alturamso.com

Contract Request Form
Current W-9

Ancillary Providers

Click here for more information.

Hospital Providers

Click here for more information.