Manuals, Policies and Guides

NOTICE: The Provider Manual and the PACE Resource Guide provide generalized information relative to the provision of healthcare goods and services to CalOptima Members. For detailed information on requirements, please refer to the applicable CalOptima Policies and Procedures. In the event of a conflict between the contents of CalOptima’s Provider Manuals or PACE Resource Guide, and CalOptima’s Policies and Procedures, the Policies and Procedures shall govern.

CalOptima Health provider manual The provider manual gives CalOptima Health providers the most current information about our Medi-Cal, OneCare (HMO D-SNP) and PACE programs. As a Medi-Cal managed care plan, the information in these resources is subject to change due to regulation or legislation. The manual references provider enrollment and registration responsibilities, claims submission information, member eligibility verification, and guidelines for submitting and processing medical authorizations.

PACE resource guide The PACE Resource Guide provides information that is important for provider office staff to conduct everyday operations. The guidelines provided in this Provider Resource Guide are not all inclusive. For more detailed information and/or to obtain applicable forms and attachments, please see CalOptima’s Provider Manual.

PPS program resources and information The Pediatric Preventive Services (PPS) program is an expansion of the Child Health and Disability Prevention (CHDP) program. The information in these resources is subject to change due to regulation or legislation.

The Long-Term Care Information section of this website has additional resources specifically for long term-care and hospice providers.

Policies and procedures

In addition to the provider manual, you may also access CalOptima's online policy and procedure database, hosted by Compliance 360.

CalOptima’s Policies and Procedures Access via the Compliance 360 website.

Other resources and guides

Population Needs Assessment

Community Health Assessments and Community Health Improvement Plans

CalOptima Health collaborates with the Orange County Health Care Agency (OCHCA) and Kaiser Permanente in the planning, development and implementation processes for the Orange County’s Community Health Assessment (CHA) and Community Health Improvement Plan (CHIP). This collaboration includes:

Participation in Steering Committee, monthly planning and implementation workgroup meetings
Providing a platform for OCHCA to seek public comments on CHIP priorities and goals from CalOptima Health Member Advisory Committee (MAC), Provider Advisory Committee (PAC), Population Health Management Committee (PHMC), and Quality Improvement and Health Equity Committee (QIHEC).
Sharing various data (e.g. Healthcare Effectiveness Data and Information Set (HEDIS), utilization data, etc.) to support identification of CHA priority areas and CHIP goals.

OC Health Care Agency 2023 Community Health Assessment

OC Community Health Improvement Plan 2024-2026

Orange County Referral Sources for Health Homes Program

CalAIM Enhanced Care Management Policy Guide

Medi-Cal In Lieu of Services (ILOS) Policy Guide

CalOptima Medi-Cal Standards of Access to Care Provider Reference Sheet

CalOptima OneCare Standards of Access to Care Provider Reference Sheet

Provider Quick Reference Guide Contact List

SSA Medi-Cal for Newborns

Well-Child Visits in the First 30 Months of Life HEDIS Measure Guide

CalOptima Health Pediatric Quality Measures Guide for HEDIS

Stay Compliant with State-Issued Lead Requirements

Providers and other health care professionals with questions regarding Medi-Cal, OneCare Connect, OneCare or PACE can call the Provider Relations department at 714-246-8600 or email providerservices@caloptima.org
Provider Reference Contact List

Provider Directory

Find a Provider
CalOptima Health works with over 3,700 Orange County physicians, making it easy for our members to get the care they need.

Check here for our extensive list of providers, health networks, medical groups, hospitals and pharmacies.

Claims

About Claims and Eligibility
Verify member eligibility or submit a request for treatment authorization.

Provider Trainings

Trainings by Topic
View the latest model of care and other educational materials designed to help you and your staff provide care for CalOptima Health members.

Materials available on this website in PDF format may require the free Adobe Reader to view. To download Adobe Reader for free from the Adobe website, click here.