Resources

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   

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

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