Guidelines, Policies and Procedures
All of the documents listed on this page and our library of materials can be provided in different languages, lower reading levels and alternate formats upon request to help you better understand our guidelines, policies and procedures. Looking for a particular policy or document? Search our full list of medical policies and clinical utilization management (UM) guidelines or call the Customer Care Center at 800-407-4627 (TTY 711) for help.
Clinical UM Guidelines
Clinical UM Guidelines focus on detailed selection criteria, goal length of stay, and location for generally accepted technologies or services.
Policies and Procedures
Medical Policies address the medical necessity of new services or procedures and new applications of existing services or procedures.
Compliance
Coming soon
Quality Improvement and Health Equity (QIHEC)
Coming soon
Quality Improvement
- Assessment of Non-English Language Proficiency - CA
- Cultural and Linguistics Program - CA
- Alcohol and Drug Misuse Screening and Behavioral Counseling Interventions in Primary Care - CA
- Blood Lead Screening of Young Children - CA
- Call Campaigns with Vendors - CA
- Diabetes Prevention Program - CA
- Dyadic Services And Family Therapy Benefit - CA
- Member Rights and Responsibilities - CA
- Contracting - Health Management and Education – CA
- Health Education Class Referral and Registration Process - CA
- Members' and Providers' Requests for Health Education Materials - CA
- Delivery of Health Education Programs and Services - CA
- Readability and Suitability of Written Health Education Materials - CA
- Non-Monetary Member Incentives - CA
- Initial Health Appointments for Children and Adults - CA
- EPSDT – Requirements for Coverage of Early Periodic Screening, Diagnostic, and Treatment Services for Medi-Cal Members Under the Age of 21 - CA
- Adult Preventive Services - CA
- Tobacco Cessation Services - CA
- Primary Care Providers (PCP) Access Hours - CA
- DHCS and NCQA 25th percentile LA Care (LA County) - CA
- Termination of Practitioners for NonCompliance with Facility Site or Medical Record Reviews - CA
- Facility Site and Medical Record Review Process - CA
- Medical Record Documentation and Confidentiality Standards - CA
- Facility Site Reviewer Certification and Interrater Process - CA
- Monitoring the Facility Site Review Collaborative Process - CA
UM Program Requirements
- Second Medical Opinion - CA
- Genetic Screening - Newborn - CA
- Access to Specialty Care - CA
- CA Children's Services - CCS Referral and Coordination of Care with County CCS Offices and CA Children's Services - CCS Referral
- Enteral Nutrition - CA
- School-Linked Child Health and Disability Program (CHDP) Services - Care Coordination - CA
- Transgender Services - CA
- Transplants - CA
- Continued Stay Review/Care Coordination/Discharge Planning - CA
- Experimental and Investigational Treatment-CA
- Non-Authorization of Medical Services - CA
- Dental Care - Referrals and Reimbursements - CA
- Hospice Care - CA
- Transition Assistance Continuity of Care - CA
- Confidentiality in the Clinical Services Committee (CSC) - CA
- Pre-service Authorization of Services - CA
- Genetic Screening - Prenatal - CA
- Non-physician Review Audits - Process, Inter-rater, and Focused - CA
- Post-Service Clinical Claims Review - CA
- Under and Over Utilization of Services - Monitoring - CA
- Vision Services and Optical Eyewear - CA
- The Separation of Financial and Medical Necessity Decision-Making - CA
- Standing Referral to a Specialist- CA
- Abortion Services - CA
- Skilled Nursing and Long Term Care Services - CA
- Newborns’ and Mothers’ Health Act - CA
- Breast Cancer Patient Protection Act - CA
- Self Referable Services - CA
- Physician Review Audits - Inter-rater Reliability Assessment - CA
- Use of Consultant Physicians and Providers for Opinion - CA
- Application of Utilization Management Criteria - CA
- Second Medical Opinion - CA
- 24-hour Access to Emergency Department Services - CA
- Annual updated for policy- Tuberculosis Services - Provision Through Providers and Directly Observed Therapy (DOT) - CA
- Early Start Program - Referrals to - CA
- Adolescent “Confidential” Sensitive Services - CA
- Request for Medical Policies/Coverage Guidelines, Clinical Guidelines, Criteria or Benefits - CA
- Utilization Management Department Availability - CA
- Decision and Notification Timeframes - CA
- Utilization Management Decision and Screening Criteria - CA
- Cancer Clinical Trials - CA
- Prior Authorization For Non-Contracted Specialists/Facilities - CA
- Review of Non-English Medical Records-CA
- Prior Authorization Reduction Process - CA
- Health Plan Physician Availability for Communication with Emergency Room Personnel in the Post-stabilization Period-CA
- Emergency Room Post-Stabilization Process - After Hours Admissions - CA
- Family Planning Services (including Sexually Transmitted Infections) - Access to - CA
- EPSDT - CA
Member appeals procedure
Additional Resources
Provider Contracting/Network reports
Coming soon
CAHPS Survey Results
Coming soon