Member
Handbook
What you need to know about your benefits
CalViva Health Combined Evidence of
Coverage (EOC) and Disclosure Form
2021
Other languages
and formats
Other languages
You can get this Member Handbook and other plan
materials for free in other languages. Call 1-888-893-1569
(TTY/TDD 711). The call is toll free. Read this Member
Handbook to learn more about health care language
assistance services, such as interpreter and translation
services.
Other formats
You can get this information for free in other formats, such
as braille, 18-point font large print and audio. Call
1-888-893-1569 (TTY/TDD 711). The call is toll free.
Interpreter services
You do not have to use a family member or friend as an
interpreter. For free interpreter, linguistic and cultural
services and help available 24 hours a day, 7 days a
week, or to get this handbook in a different language, call
1-888-893-1569 (TTY/TDD 711). The call is toll free.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 1
Other languages and formats
English: If you, or someone you’re helping, has questions
about CalViva Health, you have the right to get help and
information in your language at no cost. To talk to an
interpreter, call 1-888-893-1569 (TTY/TDD 711).
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 2
Other languages and formats
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 3
Notice of
non-discrimination
Discrimination is against the law. CalViva Health follows State and Federal civil rights
laws. CalViva Health does not unlawfully discriminate, exclude people or treat them
differently because of sex, race, color, religion, ancestry, national origin, ethnic group
identification, age, mental disability, physical disability, medical condition, genetic information,
marital status, gender, gender identity or sexual orientation.
CalViva Health provides:
Free aids and services to people with disabilities to help them communicate
better, such as:
Qualified sign language interpreters
Written information in other formats (large print, audio, accessible
electronic formats and other formats)
Free language services to people whose primary language is not English,
such as:
Qualified interpreters
Information written in other languages
If you need these services, contact CalViva Health 24 hours a day, 7 days a week by
calling 1-888-893-1569. Or, if you cannot hear or speak well, please call (TTY/TDD 711)
to use the California Relay Service. Upon request, this document can be made available
to you in braille, large print, audiocassette, or electronic form. To obtain a copy in one of
these alternative formats, please call or write to:
CalViva Health
7625 N. Palm Ave., Suite #109
Fresno, CA 93711
1-888-893-1569
California Relay 711
HOW TO FILE A GRIEVANCE
If you believe that CalViva Health has failed to provide these services or unlawfully
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 4
Notice of non-discrimination
discriminated in another way on the basis of sex, race, color, religion, ancestry, national
origin, ethnic group identification, age, mental disability, physical disability, medical
condition, genetic information, marital status, gender, gender identity or sexual
orientation, you can file a grievance with CalViva Health Member Services. You can file
a grievance in writing, in person, or electronically:
By phone: Contact us 24 hours a day, 7 days a week by calling
1-888-893-1569. Or, if you cannot hear or speak well, please call (TTY/TDD
711) to use the California Relay Service.
In writing: Fill out a complaint form or write a letter and send it to:
CalViva Health
Appeals and Grievance Department
P.O. Box 10348
Van Nuys, CA 91410-0348
1-888-893-1569 (TTY/TDD 711)
Fax: 1-877-831-6019
In person: Visit your doctor’s office or CalViva Health and say you want to file
a grievance.
Electronically: Visit CalViva Health’s website at www.CalVivaHealth.org.
OFFICE OF CIVIL RIGHTS – CALIFORNIA DEPARTMENT OF HEALTH CARE
SERVICES
You can also file a civil rights complaint with the California Department of Health Care
Services, Office of Civil Rights by phone, in writing, or electronically:
By phone: Call 916-440-7370. If you cannot speak or hear well, please call
711 (Telecommunications Relay Service).
In writing: Fill out a complaint form or send a letter to:
Deputy Director, Office of Civil Rights
Department of Health Care Services
Office of Civil Rights
P.O. Box 997413, MS 0009
Sacramento, CA 95899-7413
Complaint forms are available at
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 5
Notice of non-discrimination
http:www.dhcs.ca.gov/Pages/Language_Access.aspx.
Electronically: Send an email to CivilRights@dhcs.ca.gov
OFFICE OF CIVIL RIGHTS – U.S. DEPARTMENT OF HEALTH AND HUMAN
SERVICES
If you believe you have been discriminated against on the basis of race, color, national
origin, age, disability or sex, you can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Office for Civil Rights by phone, in writing
or electronically:
• By phone: Call 1-800-368-1019. If you cannot speak or hear well, please call
TTY/TDD 1-800-537-7697 or 711 to use the California Relay Service.
• In writing: Fill out a complaint form or send a letter to:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
Complaint forms are available at http:www.hhs.gov/ocr/office/file/index.html.
• Electronically: Visit the Office for Civil Rights Complaint Portal at
https://ocrportal.hhs.gov/ocr/cp
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 6
Welcome to CalViva
Health!
Thank you for joining CalViva Health. CalViva Health is a health plan for people who
have Medi-Cal. CalViva Health works with the State of California to help you get the
health care you need. Certain administrative and support services are provided to
CalViva Health under contractual arrangements with various third parties.
Member Handbook
This Member Handbook tells you about your coverage under CalViva Health. Please
read it carefully and completely. It will help you understand and use your benefits and
services. It also explains your rights and responsibilities as a member of CalViva Health.
If you have special health needs, be sure to read all sections that apply to you.
This Member Handbook is also called the Combined Evidence of Coverage (EOC) and
Disclosure Form. It is a summary of CalViva Health rules and policies and based on the
contract between CalViva Health and Department of Health Care Services (DHCS). If
you would like more information, call CalViva Health at 1-888-893-1569 (TTY/TDD 711).
Call 1-888-893-1569 (TTY/TDD 711) to ask for a copy of the contract between CalViva
Health and DHCS. You may also ask for another copy of the Member Handbook at no
cost to you or visit the CalViva Health website at www.CalVivaHealth.org to view the
Member Handbook. You may also request, at no cost, a copy of the CalViva Health
non-proprietary clinical and administrative policies and procedures, or how to access
this information on the CalViva Health website.
Contact us
CalViva Health is here to help. If you have questions, call 1-888-893-1569 (TTY/TDD
711). CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 7
Welcome to CalViva Health!
You can also visit online at any time at www.CalVivaHealth.org.
Thank you,
CalViva Health
7625 N. Palm Ave., Suite #109
Fresno, CA 93711
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 8
Table of contents
Other languages and formats ...................................................................................... 1
Other languages .........................................................................................1
Other formats..............................................................................................1
Interpreter services.....................................................................................1
Notice of non-discrimination........................................................................................ 4
Welcome to CalViva Health! ......................................................................................... 7
Member Handbook .....................................................................................7
Contact us ..................................................................................................7
Table of contents........................................................................................................... 9
1. Getting started as a member................................................................................. 11
How to get help.........................................................................................11
Who can become a member.....................................................................11
Identification (ID) cards.............................................................................12
Ways to get involved as a member...........................................................13
2. About your health plan.......................................................................................... 15
Health plan overview ................................................................................15
How your plan works ................................................................................16
Changing health plans..............................................................................17
College students who move to a new county or out of California .............17
Continuity of care......................................................................................18
Costs ........................................................................................................19
3. How to get care ...................................................................................................... 21
Getting health care services .....................................................................21
Where to get care .....................................................................................27
Provider network.......................................................................................28
Primary care provider (PCP).....................................................................33
4. Benefits and services ............................................................................................ 40
What your health plan covers ...................................................................40
Medi-Cal benefits covered by CalViva Health ..........................................41
Care coordination .....................................................................................61
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 9
Table of contents
Other Medi-Cal programs and services ....................................................61
Services you cannot get through CalViva Health or Medi-Cal ..................67
Evaluation of new and existing technologies ............................................
67
5. Rights and responsibil
ities ................................................................................... 69
Your rights ................................................................................................69
Your responsibilities .................................................................................70
Notice of privacy practices........................................................................71
Notice about laws .....................................................................................75
Notice about Medi-Cal as a payer of last resort........................................76
Notice about estate recovery ....................................................................76
Notice of Action ........................................................................................77
Third party liability.....................................................................................77
Independent contractors...........................................................................77
Health care plan fraud ..............................................................................78
Circumstances beyond CalViva Health’s control ......................................78
6. Reporting and solving problems .......................................................................... 79
Complaints................................................................................................80
Appeals ....................................................................................................81
What to do if you do not agree with an appeal decision
...........................82
Complaints and Independent Medical Reviews (IMR)
with the Department of Managed Health Care..........................................82
State Hearings..........................................................................................83
Fraud, waste and abuse ...........................................................................84
7. Important numbers and words to know............................................................... 86
Important phone numbers ........................................................................86
Words to know..........................................................................................87
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 10
1. Getting started as
a member
How to get help
CalViva Health wants you to be happy with your health care. If you have any questions
or concerns about your care, CalViva Health wants to hear from you!
Member services
CalViva Health member services is here to help you. CalViva Health can:
Answer questions about your health plan and covered services
Help you choose or change a primary care provider (PCP)
Tell you where to get the care you need
Help you get interpreter services if you do not speak English
Help you get information in other languages and formats
If you need help, call 1-888-893-1569 (TTY/TDD 711). CalViva Health is here 24 hours
a day, 7 days a week. The call is toll free.
You can also visit online at any time at www.CalVivaHealth.org.
Who can become a member
You qualify for CalViva Health because you qualify for Medi-Cal and live in one of these
counties: Fresno, Kings, or Madera. You may also qualify for Medi-Cal through Social
Security because you are receiving SSI/SSP. Social Security Administration /
Supplemental Security Income (SSI) can be contacted at 1-800-772-1213
(TTY: 1-800-325-0778).
For questions about enrollment, call Health Care Options at 1-800-430-4263 (TTY/TDD
1-800-430-7077 or 711). Or visit www.healthcareoptions.dhcs.ca.gov.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 11
1 | Getting started as a member
Transitional Medi-Cal
Transitional Medi-Cal is also called “Medi-Cal for working people.” You may be able to
get Transitional Medi-Cal if you stop getting Medi-Cal because:
You started earning more money.
Your family started receiving more child or spousal support.
You can ask questions about qualifying for Transitional Medi-Cal at your local county
health and human services office at www.dhcs.ca.gov/services/medi-
cal/Pages/CountyOffices.aspx or call Health Care Options at 1-800-430-4263
(TTY/TDD 1-800-430-7077 or 711).
Identification (ID) cards
As a member of CalViva Health, you will get a CalViva Health ID card. You must show
your CalViva Health ID card and your Medi-Cal Benefits Identification Card (BIC) when
you get any health care services or prescriptions. You should carry all health cards with
you at all times. Here is a sample BIC and CalViva Health ID card to show you what
yours will look like:
Your CalViva Health ID card has important information on it, including:
Your Primary Care Provider’s (PCP) name (or the name of your Clinic or Medical
Group). This information does not appear on ID cards for Members who have
both Medicare (Part A and Part B) and Medi-Cal coverage. The PCP information
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 12
1 | Getting started as a member
will say “See Your Medicare Doctor.” This information also does not appear on ID
cards for newborns who have been assigned a CIN by DHCS. The PCP
information will say “No Primary MD.”
Your PCP’s address and phone number. This information does not appear on ID
cards for Members who have both Medicare (Part A and Part B) and Medi-Cal
coverage. The PCP information will say “See Your Medicare Doctor.” This
information also does not appear on ID cards for newborns who have been
assigned a CIN by DHCS. The PCP information will say “Please Call Member
Services.”
If your PCP and/or medical group information is wrong or if you have changed
your PCP and/or medical group since your last ID card was issued, call Member
Services at 1-888-893-1569 (TTY/TDD 711) to get a new card with the correct
PCP information.
If you have any questions regarding your ID card, please call Member Services
at 1-888-893-1569 (TTY/TDD 711).
Here’s what to do with your CalViva Health ID card:
Check to make sure the information on your ID card is correct. If anything on
your ID card is wrong, call Member Services at 1-888-893-1569 (TTY/TDD 711)
right away. If your name is not spelled right or incorrect, we will connect you to
your county Department of Public Social Services office to get it fixed.
Show your CalViva Health ID card whenever you:
have a doctor’s appointment,
go to the hospital, or
need urgent care/emergency services.
If you do not get your CalViva Health ID card within a few weeks of enrolling, or if your
card is damaged, lost or stolen, call Member Services right away. CalViva Health will
send you a new card for free. Call 1-888-893-1569 (TTY/TDD 711). Once you get your
new ID card, you should destroy any old ID cards or cards that are no longer valid to
protect your identity.
Ways to get involved as a member
CalViva Health wants to hear from you. Each quarter, CalViva Health has meetings to
talk about what is working well and how CalViva Health can improve. Members are
invited to attend. Come to a meeting!
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 13
1 | Getting started as a member
Public Policy Committee
CalViva Health has a group called Public Policy Committee. This group is made up of
member advocates (supporters), CalViva Health members, a CalViva Health Governing
Board Commissioner, and a CalViva Health provider of health care services. You can
join this group if you would like. The group talks about how to improve CalViva Health
policies and is responsible for:
Input on CalViva Health’s grievance and health education efforts
Input on CalViva Health’s cultural and linguistic services program
Identification of barriers to care due to culture, discrimination, language, or
disability
Other matters pertinent to developing the public policy of the plan.
This group also allows committee members to network and learn about community
resources. If you would like to be a part of this group, call 1-888-893-1569 (TTY/TDD
711).
You can also call Member Services if you have any questions about
the group.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 14
2. About your
health plan
Health plan overview
CalViva Health is a health plan for people who have Medi-Cal in these service areas:
Fresno, Kings, or Madera counties. CalViva Health works with the State of California to
help you get the health care you need.
You may talk with one of the CalViva Health Member Services representatives to learn
more about the health plan and how to make it work for you. Call 1-888-893-1569
(TTY/TDD 711).
When your coverage starts and ends
When you enroll in CalViva Health, you will get a CalViva Health member ID card within
two weeks of enrollment. You must show your CalViva Health ID card and your Medi-
Cal Benefits Identification Card (BIC) when you get any health care services or
prescriptions.
Your Medi-Cal coverage will need to be renewed every year. The county will send you a
Medi-Cal renewal form. Complete this form and return it to your local county human
services agency.
Your care through CalViva Health starts when your enrollment in CalViva Health is
complete. You can start using your Medi-Cal benefits through CalViva Health on your
effective date of coverage. Your effective date of coverage is the 1st day of the month
following completion of enrollment in CalViva Health. Check the CalViva Health member
ID card mailed to you for the effective date of coverage.
You may ask to end your CalViva Health coverage and choose another health plan at
any time. For help choosing a new plan, call Health Care Options at
1-800-430-4263 (TTY/TDD 1-800-430-7077 or 711). Or visit
www.healthcareoptions.dhcs.ca.gov. You can also ask to end your Medi-Cal.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 15
2 | About your health plan
CalViva Health is the health plan for Medi-Cal members in Fresno, Kings, and Madera
counties. Your coverage with CalViva Health might change if you no longer have Medi-
Cal or if you move out of the county. CalViva Health coverage may also end if your local
county health and hum an services office receives information that changes your
eligibility for Medi-Cal. Find your local office at www.dhcs.ca.gov/services/medi-
cal/Pages/CountyOffices.aspx. If you go to jail or prison, your coverage with CalViva
Health will end. If you become eligible for a waiver program, your coverage with CalViva
Health will end, but you will still be enrolled in Medi-Cal. If you are not sure if you are
still covered by CalViva Health, please call 1-888-893-1569 (TTY/TDD 711).
Managed Long-Term Services and Supports (MLTSS)
Individuals dually eligible for Medicare and Medi-Cal must join a Medi-Cal managed
care plan to receive their Medi-Cal benefits, including LTSS and Medicare wrap-around
benefits.
Special Considerations for American Indians in Managed Care
American Indians have a right to not enroll in a Medi-Cal managed care plan or they
may leave their Medi-Cal managed care plan and return to Fee-For-Service (FFS) Medi-
Cal at any time and for any reason.
If you are an American Indian, you have the right to get health care services at Indian
Health Clinics (IHC). You may also stay with or disenroll from CalViva Health while
getting health care services from these locations. For information on enrollment and
disenrollment call 1-888-893-1569 (TTY/TDD 711).
How your plan works
CalViva Health is a health plan contracted with DHCS. CalViva Health is a managed
care health plan. Managed care plans are a cost-effective use of health care resources
that improve health care access and assure quality of care. CalViva Health works with
doctors, hospitals, pharmacies and other health care providers in the CalViva Health
service area to give health care to you, the member.
Member Services will tell you how CalViva Health works, how to get the care you need,
how to schedule provider appointments within standard access times, and how to find
out if you qualify for transportation services.
To learn more, call 1-888-893-1569 (TTY/TDD 711). You can also find member service
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 16
2 | About your health plan
information online at www.CalVivaHealth.org.
Changing health plans
You may leave CalViva Health and join another health plan in your county of residence
at any time. Call Health Care Options at 1-800-430-4263 (TTY/TDD 1-800-430-7077 or
711) to choose a new plan. You can call between 8:00 a.m. and 6:00 p.m. Monday
through Friday. Or visit www.healthcareoptions.dhcs.ca.gov.
It takes up to 30 days to process your request to leave CalViva Health and enroll in
another plan in your county if there are no issues with the request. To find out the status
of your request, call Health Care Options at 1-800-430-4263 (TTY/TDD 1-800-430-7077
or 711).
If you want to leave CalViva Health sooner, you may ask Health Care Options for an
expedited (fast) disenrollment. If the reason for your request meets the rules for
expedited disenrollment, you will get a letter to tell you that you are disenrolled.
Members who can request expedited disenrollment include, but are not limited to,
children receiving services under the Foster Care or Adoption Assistance programs,
members with special health care needs, and members already enrolled in Medicare or
another Medi-Cal or commercial managed care plan.
You may ask to leave CalViva Health in person at your local county health and human
services office. Find your local office at www.dhcs.ca.gov/services/medi-
cal/Pages/CountyOffices.aspx. Or call Health Care Options at 1-800-430-4263
(TTY/TDD 1-800-430-7077 or 711).
College students who move to a new county or out of
California
If you move to a new county in California to attend college, CalViva Health will cover
emergency room and urgent care services in your new county for some conditions.
If you are enrolled in Medi-Cal and will attend college in a different county in California,
you do not need to apply for Medi-Cal in that county.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 17
2 | About your health plan
When you temporarily move away from home to go to college in another county in
California there are two options available to you. You may:
Notify your local county social services office that you are temporarily moving
to attend college and provide your address in the new county. The county will
update the case records with your new address and county code in the
State’s database. Use this choice if you want to get routine or preventive care
in your new county. You may have to change health plans. For questions and
to prevent any delay in enrolling in the new health plan, call Health Care
Options at 1-800-430-4263 (TTY/TDD 1-800-430-7077 or 711).
OR
Choose not to change your health plan when you temporarily move to attend
college in a different county. You will only be able to access emergency room
and urgent care services in the new county for some conditions. To learn
more, go to Section 3, “How to get care.” For routine or preventive health
care, you would need to use the CalViva Health regular network of providers
located in the head of the household’s county of residence.
If you are leaving California temporarily to attend college in another state and you want
to keep your Medi-Cal coverage, contact your eligibility worker at your local social
services county office. As long as you are eligible, Medi-Cal will cover emergencies in
another state, and emergencies requiring hospitalization in Canada and Mexico if the
service is approved and the doctor and hospital meet Medi-Cal rules. If you want
Medicaid in another state, you will need to apply in that state. You will not be eligible for
Medi-Cal and CalViva Health will not pay for your healthcare.
Continuity of care
As a member of CalViva Health, you will get your health care from providers in CalViva
Health network. In some cases, you may be able to go to providers who are not in the
CalViva Health network, which is called continuity of care. If you have continuity of care,
you will be able to go to the provider for up to 12 months, or more in some cases. If your
providers do not join the CalViva Health network by the end of 12 months, you will need
to switch to providers in the CalViva Health network.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 18
2 | About your health plan
Providers who leave CalViva Health
If your provider stops working with CalViva Health, you may be able to keep getting
services from that provider. This is another form of continuity of care. Services CalViva
Health provides for continuity of care include but are not limited to:
Acute conditions
Chronic physical and behavioral conditions
Pregnancy
Maternal mental health services
Terminal illness
Care of a newborn child between birth and age 36 months
Performance of a surgery or other procedure that is authorized by
CalViva Health as part of a documented course of treatment and has been
recommended and documented by the provider
For other conditions that may qualify, contact CalViva Health Member
Services.
Continuity of care is not available if you have not seen your doctor at least once during
the last 12 months; your doctor is not willing to work with CalViva Health or if
CalViva Health has documented quality of care concerns with your doctor.
To learn more about continuity of care and eligibility qualifications, and to hear about all
available services, call Member Services.
Costs
Member costs
CalViva Health serves people who qualify for Medi-Cal. In most cases, CalViva Health
members do not have to pay for covered services, premiums or deductibles. Members
enrolled in California Children’s Health Insurance Program (CCHIP) in Santa Clara, San
Francisco and San Mateo counties and members in the Medi-Cal for Families Program
may have a monthly premium and copayments. Except for emergency care, you may
have to pay for care from providers who are out of the network. For a list of covered
services, go to “Benefits and services.”
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 19
2 | About your health plan
For members with a share of cost
You may have to pay a share of cost each month. The amount of your share of cost
depends on your income and resources. Each month you will pay your own medical bills
until the amount that you have paid equals your share of cost. After that, your care will
be covered by CalViva Health for that month. You will not be covered by CalViva Health
until you have paid your entire share of cost for the month. After you meet your share of
cost for the month, you can go to any CalViva Health doctor. If you are a member with a
share of cost, you do not need to choose a PCP.
How a provider gets paid
CalViva Health pays providers in these ways:
Capitation payments
CalViva Health pays some providers a set amount of money every
month for each CalViva Health member. This is called a capitation
payment. CalViva Health and providers work together to decide on the
payment amount.
Fee-for-service payments
Some providers give care to CalViva Health members and then send
CalViva Health a bill for the services they provided. This is called a fee-
for-service payment. CalViva Health and providers work together to
decide how much each service costs.
CalViva Health may also pay providers for meeting certain quality
benchmarks.
To learn more about how CalViva Health pays providers, call 1-888-893-1569
(TTY/TDD 711).
Asking CalViva Health to pay a bill
If you get a bill for a covered service, do not pay the bill. Call Member Services right
away at 1-888-893-1569 (TTY/TDD 711).
If you pay for a service that you think CalViva Health should cover, you can file a claim.
Use a claim form and tell CalViva Health in writing why you had to pay. Call
1-888-893-1569 (TTY/TDD 711) to ask for a claim form. CalViva Health will review your
claim to decide if you can get money back.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 20
3. How to get care
Getting health care services
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM
WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED.
You can begin to get health care services on your effective date of coverage. Always
carry your CalViva Health ID card, Medi-Cal Benefits Identification Card (BIC), and any
other health insurance cards you have with you. Never let anyone else use your BIC or
CalViva Health ID card.
New members must choose a primary care provider (PCP) in the CalViva Health
network. The CalViva Health network is a group of doctors, hospitals and other
providers who work with CalViva Health. You must choose a PCP within 30 days from
the time you become a member in CalViva Health. If you do not choose a PCP,
CalViva Health will choose one for you.
You may choose the same PCP or different PCPs for all family members in
CalViva Health.
If you have a doctor you want to keep, or you want to find a new PCP, you can look in
the Provider Directory. It has a list of all PCPs in the CalViva Health network. The
Provider Directory has other information to help you choose a PCP. If you need a
Provider Directory, call 1-888-893-1569 (TTY/TDD 711). You can also find the Provider
Directory on the CalViva Health website at www.CalVivaHealth.org.
If you cannot get the care you need from a participating provider in the CalViva Health
network, your PCP must ask CalViva Health for approval to send you to an out-of-
network provider.
Read the rest of this chapter to learn more about PCPs, the Provider Directory and the
provider network.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 21
3 | How to get care
Initial health assessment (IHA)
CalViva Health recommends that, as a new member, you visit your new PCP within the
first 120 days for an initial health assessment (IHA). The purpose of the IHA is to help
your PCP learn your health care history and needs. Your PCP may ask you some
questions about your health history or may ask you to complete a questionnaire. Your
PCP will also tell you about health education counseling and classes that may help you.
When you call to schedule your IHA appointment, tell the person who answers the
phone that you are a member of CalViva Health. Give your CalViva Health ID number.
Take your BIC and CalViva Health ID card to your appointment. It is a good idea to take
a list of your medications and questions with you to your visit. Be ready to talk with your
PCP about your health care needs and concerns.
Be sure to call your PCP’s office if you are going to be late or cannot go to your
appointment.
Routine care
Routine care is regular health care. It includes preventive care, also called wellness or
well care. It helps you stay healthy and helps keep you from getting sick. Preventive
care includes regular checkups and health education and counseling. Children are able
to receive much needed early preventive services like hearing and vision screening,
assessments of developmental process and many more services that are
recommended by pediatricians’ Bright Futures guidelines. In addition to preventive care,
routine care also includes care when you are sick. CalViva Health covers routine care
from your PCP.
Your PCP will:
Give you all your routine care, including regular checkups, shots, treatment,
prescriptions and medical advice
Keep your health records
Refer (send) you to specialists if needed
Order X-rays, mammograms or lab work if you need them
When you need routine care, you will call your PCP for an appointment. Be sure to call
your PCP before you get medical care, unless it is an emergency. For an emergency,
call 911 or go to the nearest emergency room.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 22
3 | How to get care
To learn more about health care and services your plan covers, and what it does not
cover, read “Benefits and services” in this handbook.
Urgent care
Urgent care is not for an emergency or life-threatening condition. It is for services you
need to prevent serious damage to your health from a sudden illness, injury or
complication of a condition you already have. Urgent care appointments that do not
need pre-approval (prior authorization) are available within 48 hours of your request for
an appointment. If the urgent care services you need require pre-approval, you will be
offered an appointment within 96 hours of your request.
For urgent care, call your PCP. If you cannot reach your PCP, call 1-888-893-1569
(TTY/TDD 711). Or you can call the nurse advice line by calling the Member Services
phone number at 1-888-893-1569 (TYY/TDD 711). Choose the 24-hour nurse advice
line option in the menu.
If you need urgent care out of the area, go to the nearest urgent care facility. Urgent
care needs could be a cold, sore throat, fever, ear pain, sprained muscle or maternity
services. You do not need pre-approval (prior authorization). If you need mental health
urgent care, call your county Mental Health Plan or Member Services at
1-888-893-1569 (TTY/TDD 711). You may call your county Mental Health Plan or your
CalViva Health Behavioral Health Organization any time, 24 hours a day, 7 days a
week. To find all counties’ toll-free telephone numbers online, visit
www.dhcs.ca.gov/individuals/Pages/MHPContactList.aspx.
Emergency care
For emergency care, call 911 or go to the nearest emergency room (ER). For
emergency care, you do not need pre-approval (prior authorization) from
CalViva Health. You have the right to use any hospital or other setting for emergency
care.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 23
3 | How to get care
Emergency care is for life-threatening medical conditions. This care is for an illness or
injury that a prudent (reasonable) layperson (not a health care professional) with
average knowledge of health and medicine could expect that, if you don’t get care right
away, your health (or your unborn baby’s health) could be in danger, or a body function,
body organ or body part could be seriously harmed. Examples may include, but are not
limited to:
Active labor
Broken bone
Severe pain
Chest pain
Severe burn
Drug overdose
Fainting
Severe bleeding
Psychiatric emergency conditions, such as severe depression or suicidal
thoughts
Do not go to the ER for routine care. You should get routine care from your PCP, who
knows you best. If you are not sure if your medical condition is an emergency, call your
PCP. You may also call the 24/7 nurse advice line at 1-888-893-1569 (TYY/TDD 711).
Choose the 24-hour nurse advice line option in the menu.
If you need emergency care away from home, go to the nearest emergency room (ER),
even if it is not in the CalViva Health network. If you go to an ER, ask them to call
CalViva Health. You or the hospital to which you were admitted should call
CalViva Health within 24 hours after you get emergency care. If you are traveling
outside the U.S., other than to Canada or Mexico, and need emergency care,
CalViva Health will not cover your care.
If you need emergency transportation, call 911. You do not need to ask your PCP or
CalViva Health first before you go to the ER.
If you need care in an out-of-network hospital after your emergency (post-stabilization
care), the hospital will call CalViva Health.
Remember: Do not call 911 unless it is an emergency. Get emergency care only for an
emergency, not for routine care or a minor illness like a cold or sore throat. If it is an
emergency, call 911 or go to the nearest emergency room.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 24
3 | How to get care
Sensitive care
Minor consent services
You may only get the following services without your parent or guardian’s permission if
you are 12 years old or older:
Outpatient mental health care for:
Sexual assault
Physical assault
When you have thoughts of hurting yourself or others
HIV/AIDS prevention/testing/treatment
Sexually transmitted infections prevention/testing/treatment
Substance use disorder services
If you are under 18 years old, you can go to a doctor without permission from your
parents or guardian for these types of care:
Family planning/birth control (including sterilization)
Abortion services
For pregnancy testing, family planning services, birth control, or sexually transmitted
infection services, the doctor or clinic does not have to be part of the CalViva Health
network. You can choose any provider and go to them for these services without a
referral or pre-approval (prior authorization). Services from an out-of-network provider
not related to sensitive care may not be covered. For help finding a doctor or clinic
giving these services, or for help getting to these services (including transportation), you
can call 1-888-893-1569 (TTY/TDD 711). You may also call the 24/7 nurse advice line
by calling the Member Services phone number at 1-888-893-1569 (TYY/TDD 711).
Choose the 24-hour nurse advice line option in the menu.
Minors can talk to a representative in private about their health concerns by calling the
24/7 nurse advice line at 1-888-893-1569 (TTY/TDD 711). Choose the 24-hour nurse
advice line option in the menu.
Adult sensitive services
As an adult (18 years or older), you may not want to go to your PCP for certain sensitive
or private care. If so, you may choose any doctor or clinic for the following types of care:
Family planning and birth control (including sterilization)
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 25
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org.
3 | How to get care
Pregnancy testing and counseling
HIV/AIDS prevention and testing
Sexually transmitted infections prevention, testing and treatment
Sexual assault care
Outpatient abortion services
The doctor or clinic does not have to be part of the CalViva Health network. You can
choose any provider and go to them without a referral or pre-approval (prior
authorization) for these services. Services from an out-of-network provider not related to
sensitive care may not be covered. For help finding a doctor or clinic giving these
services, or for help getting to these services (including transportation), you can call
1-888-893-1569 (TTY/TDD 711). You may also call the 24/7 nurse advice line by calling
1-888-893-1569 (TTY/TDD 711). Choose the 24-hour nurse advice line option in the
menu.
Advance directives
An advance health directive is a legal form. On it, you can list what health care you want
in case you cannot talk or make decisions later on. You can list what care you do not
want. You can name someone, such as a spouse, to make decisions for your health
care if you cannot.
You can get an advance directive form at drugstores, hospitals, law offices and doctors’
offices. You may have to pay for the form. You can also find and download a free form
online. You can ask your family, PCP or someone you trust to help you fill out the form.
You have the right to have your advance directive placed in your medical records. You
have the right to change or cancel your advance directive at any time.
You have the right to learn about changes to advance directive laws. CalViva Health will
tell you about changes to the state law no longer than 90 days after the change.
You can call CalViva Health at 1-888-893-1569 for more information.
26
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 27
3 | How to get care
Organ and tissue donation
Adults can help save lives by becoming an organ or tissue donor. If you are between 15
and 18 years old, you can become a donor with the written consent of your parent or
guardian. You can change your mind about being an organ donor at any time. If you
want to learn more about organ or tissue donation, talk to your PCP. You can also visit
the United States Department of Health and Human Services website at
www.organdonor.gov.
Where to get care
You will get most of your care from your PCP. Your PCP will give you all of your routine
preventive (wellness) care. You will also go to your PCP for care when you are sick.
Be sure to call your PCP before you get non-emergency medical care. Your PCP will
refer (send) you to specialists if you need them.
To get help with your health questions, you can also call the nurse advice line by calling
1-888-893-1569 (TTY/TDD 711). Choose the 24-hour nurse advice line option in the
menu.
If you need urgent care, call your PCP. Urgent care is care you need within 48 hours but
is not an emergency. It includes care for such things as cold, sore throat, fever, ear pain
or sprained muscle.
For emergencies, call 911 or go to the nearest emergency room.
Moral objection
Some providers have a moral objection to some covered services. This means they
have a right to not offer some covered services if they morally disagree with the
services. If your provider has a moral objection, they will help you find another provider
for the needed services. CalViva Health can also work with you to find a provider.
Some hospitals and other providers do not offer one or more of the services listed
below. These services are available and CalViva Health must ensure you or your family
member sees a provider or is admitted to a hospital that will perform the following
covered services:
Family planning and contraceptive services, including emergency
contraception
Sterilization, including tubal ligation at the time of labor and delivery
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 28
3 | How to get care
Infertility treatments
Abortion
You should get more information before you enroll. Call the new doctor, medical group,
independent practice association or clinic that you want. Or call CalViva Health at
1-888-893-1569 (TTY/TDD 711) to make sure you can get the health care services you
need.
Provider Directory
The CalViva Health Provider Directory lists providers that participate in the
CalViva Health network. The network is the group of providers that work with CalViva
Health.
The CalViva Health Provider Directory lists hospitals, pharmacies, PCPs, specialists,
nurse practitioners, nurse midwives, physician assistants, family planning providers,
optometrists, acupuncturists, Federally Qualified Health Centers (FQHCs), outpatient
mental health providers, long-term services and supports (LTSS), Freestanding Birth
Centers (FBCs), Indian Health Clinics (IHCs) and Rural Health Clinics (RHCs).
The Provider Directory has CalViva Health network provider names, specialties,
addresses, phone numbers, business hours and languages spoken. It tells if the
provider is taking new patients. It also gives the level of physical accessibility for the
building, such as parking, ramps, stairs with handrails, and restrooms with wide doors
and grab bars. If you want information about a doctor’s education, training, and board
certification, please call 1-888-893-1569 (TTY/TDD 711).
You can find the online Provider Directory at www.CalVivaHealth.org.
If you need a printed Provider Directory, call 1-888-893-1569 (TTY/TDD 711).
Provider network
The provider network is the group of doctors, hospitals and other providers that work
with CalViva Health. You will get your covered services through the CalViva Health
network.
Note: American Indians may choose an IHC as their PCP.
If your PCP, hospital or other provider has a moral objection to providing you with a
covered service, such as family planning or abortion, call 1-888-893-1569 (TTY/TDD
3 | How to get care
711). For more about moral objections, read the “Moral objection” section earlier in this
chapter.
If your provider has a moral objection, he or she can help you find another provider who
will give you the services you need. CalViva Health can also help you find a provider
who will perform the service.
In network providers
You will use providers in the CalViva Health network for your health care needs. You
will get preventive and routine care from your PCP. You will also use specialists,
hospitals and other providers in the CalViva Health network.
To get a Provider Directory of network providers, call 1-888-893-1569 (TTY/TDD 711).
You can also find the Provider Directory online at www.CalVivaHealth.org.
For emergency care, call 911 or go to the nearest emergency room.
Except for emergency care, you may have to pay for care from providers who are out of
network.
Out-of-network providers who are inside the service area
Out-of-network providers are those that do not have an agreement to work with
CalViva Health. Except for emergency care, you may have to pay for care from
providers who are out of the network. If you need covered health care services, you
may be able to get them out of the network at no cost to you as long as they are
medically necessary and not available in the network.
CalViva Health may give you a referral to an out-of-network provider if the services you
need are not available in-network or are located very far from your home. If we give you
a referral to an out-of-network provider, we will pay for your care.
If you need help with out-of-network services, call 1-888-893-1569 (TTY/TDD 711).
Outside the service area
If you are outside of the CalViva Health service area and need care that is not an
emergency or urgent, call your PCP right away. Or call 1-888-893-1569 (TTY/TDD 711).
For emergency care, call 911 or go to the nearest emergency room. CalViva Health
covers out-of-network emergency care. If you travel to Canada or Mexico and need
emergency services requiring hospitalization, CalViva Health will cover your care. If you
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 29
3 | How to get care
are traveling internationally outside of Canada or Mexico and need emergency care,
CalViva Health will not cover your care.
Note: American Indians may get services at out-of-network IHCs.
If you have questions about out-of-network or out-of-service area care, call
1-888-893-1569 (TTY/TDD 711). If the office is closed and you want help from a
representative, call the nurse advice line at 1-888-893-1569 (TTY/TDD 711).
Doctors
You will choose your doctor or a primary care provider (PCP) from the CalViva Health
Provider Directory. The doctor you choose must be a participating provider. This means
the provider is in the CalViva Health network. To get a copy of the CalViva Health
Provider Directory, call 1-888-893-1569 (TTY/TDD 711). Or find it online at
www.CalVivaHealth.org.
If you are choosing a new doctor, you should also call to make sure the PCP you want
is taking new patients.
If you had a doctor before you were a member of CalViva Health, and that doctor is not
part of the CalViva Health network, you may be able to keep that doctor for a limited
time. This is called continuity of care. CalViva Health provides continuity of care for the
following:
Acute conditions (a serious and sudden condition that lasts a short time like a
heart attack or pneumonia) – For the time the condition lasts
Chronic physical and behavioral conditions – For up to 12 months. Usually
until you complete a course of treatment and your doctor can safely transfer
you to another provider
Pregnancy– During the pregnancy and immediate post-partum care (six
weeks after a vaginal birth or 8 weeks after a C-section).
Maternal mental health services (For up to 12 months from the diagnosis or
from the end of pregnancy, whichever occurs later).
Terminal illness/conditions – For the length of the illness.
Care of a newborn child between birth and age 36 months – For up to 12
months or until age 36 months, whichever comes first
Performance of a surgery or other procedure that is authorized by CalViva
Health as part of a documented course of treatment and has been
recommended and documented by the provider. This treatment was set to
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 30
3 | How to get care
occur within 180 days of the time the doctor or hospital stops working with our
plan or within 180 days of the time you began coverage with us.
For other conditions that may qualify, contact CalViva Health Member Services.
However, the continuity of care benefit does not include the following services:
Durable Medical Equipment
Transportation
Other ancillary services, and
Services provided by Fee-for-Service Medi-Cal program and not covered by
the plan.
To get continuity of care, the following conditions must be met:
You must have seen the out-of-network provider at least once during the
twelve (12) months before the date of your enrollment with our plan, for a
non-emergency visit;
The out-of-network provider must agree to the usual payment rate or the
Medi-Cal payment rate;
The out-of-network provider is a California State plan approved provider.
In addition, some members may keep seeing their provider as follows:
Seniors and persons with disabilities who have just joined our plan may ask to
keep seeing their doctor if there is an active Medi-Cal Fee-For-Service
treatment authorization request.
If you have just joined our plan due to a required switch from Covered
California to Medi-Cal Managed Care, you have the right to complete
previously approved and medically necessary care from your treating provider
for up to 60 days from the date you join our plan, or until our plan completes a
new assessment without a request by you or the provider.
Members under 21 who get Behavioral Health Treatment can keep seeing
their out-of-network Behavioral Health provider for up to 12 months. They
must have an existing relationship with the Behavioral Health provider. This
means the member has seen that provider at least once during the 6 months
before enrollment in our plan or transition from a Regional Center.
You can read more about continuity of care in this handbook. To learn more, call
1-888-893-1569 (TTY/TDD 711).
If you need a specialist, your PCP will refer you to a specialist in the CalViva Health
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 31
3 | How to get care
network.
Remember, if you do not choose a PCP, CalViva Hea
lth will choose one for you. You
know your health care needs best, so it is best if you choose. If you are in both
Medicare and Medi-Cal, you do not have to choose a PCP.
If you want to change your PCP, you must choose a PCP from the CalViva Health
Provider Directory. Be sure the PCP is taking new patients. To change your PCP, call
1-888-893-1569 (TTY/TDD 711).
Hospitals
In an emergency, call 911 or go to the nearest hospital.
If it is not an emergency and you need hospital care, your PCP will decide which
hospital you go to. You will need to go to a hospital in the network. The hospitals in the
CalViva Health network are listed in the Provider Directory. Hospital services, other than
emergencies, must have pre-approval (prior authorization).
Timely access to care
Appointment Type You Should Be Able to Get an
Appointment Within:
Urgent care appointments that do not require pre-
approval (prior authorization)
48 hours
Urgent care appointment that do require pre-
approval (prior authorization)
96 hours
Non-urgent primary care appointments 10 business days
Non-urgent specialist 15 business days
Non-urgent mental health provider (non-doctor) 10 business days
Non-urgent appointment for ancillary (supporting)
services for the diagnosis or treatment of injury,
illness or other health condition
15 business days
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 32
3 | How to get care
Appointment Type
You Should Be Able to Get an
Appointment Within:
Telephone wait times during normal business
hours
10 minutes
Triage – 24/7 services
24/7 services – No more than
30 minutes
Travel time and distance to care
CalViva Health must follow travel time and distance standards for your care. Those
standards help to make sure you can get care without having to travel too long or too far
from where you live. Travel time and distance standards depend on the county you live
in.
If CalViva Health is not able to provide care to you within these travel time and distance
standards, DHCS may approve a different standard, called an alternative access
standard. For CalViva Health’s time and distance standards for where you live, visit
www.CalVivaHealth.org. Or call 1-888-893-1569 (TTY/TDD 711).
If you need care from a provider and that provider is located far from where you live, call
Member Services at 1-888-893-1569 (TTY/TDD 711). They can help you find care with
a provider located closer to you. If CalViva Health cannot find care for you with a closer
provider, you can ask CalViva Health to arrange transportation for you to go to your
provider, even if that provider is located far from where you live.
It is considered far if you cannot get to that provider within the CalViva Health’s travel
time and distance standards for your county, regardless of any alternative access
standard CalViva Health may use for your ZIP Code.
Primary care provider (PCP)
You must choose a PCP within 30 days of enrolling in CalViva Health. Depending on
your age and sex, you may choose a general practitioner, ob/gyn, family practitioner,
internist or pediatrician as your primary care provider (PCP). You may also choose a
specialist as a PCP if the specialist is listed as a PCP in the Provider Directory. A nurse
practitioner (NP), physician assistant (PA) or certified nurse midwife may also act as
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 33
3 | How to get care
your PCP. If you choose an NP, PA or certified nurse midwife, you may be assigned a
doctor to oversee your care.
You can choose an Indian Health Clinic (IHC), Federally Qualified Health Center
(FQHC) or Rural Health Clinic (RHC) as your PCP. Depending on the type of provider,
you may be able to choose one PCP for your entire family who are members of CalViva
Health.
If you do not choose a PCP within 30 days of enrollment, CalViva Health will assign you
to a PCP. If you are assigned to a PCP and want to change, call 1-888-893-1569
(TTY/TDD 711). The change happens the first day of the next month.
Your PCP will:
Get to know your health history and needs
Keep your health records
Give you the preventive and routine health care you need
Refer (send) you to a specialist if you need one
Arrange for hospital care if you need it
You can look in the Provider Directory to find a PCP in the CalViva Health network. The
Provider Directory has a list of IHFs, FQHCs and RHCs that work with CalViva Health.
You can find the CalViva Health Provider Directory online at www.CalVivaHealth.org. Or
you can request a Provider Directory to be mailed to you by calling 1-888-893-1569
(TTY/TDD 711). You can also call to find out if the PCP you want is taking new patients.
Choice of doctors and other providers
You know your health care needs best, so it is best if you choose your PCP.
It is best to stay with one PCP so he or she can get to know your health care needs.
However, if you want to change to a new PCP, you can change anytime. You must
choose a PCP who is in the CalViva Health provider network and is taking new patients.
Your new choice will become your PCP on the first day of the next month after you
make the change.
To change your PCP, call 1-888-893-1569 (TTY/TDD 711).
CalViva Health may ask you to change your PCP if the PCP is not taking new patients,
has left the CalViva Health network or does not give care to patients your age. CalViva
Health or your PCP may also ask you to change to a new PCP if you cannot get along
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 34
3 | How to get care
with or agree with your PCP, or if you miss or are late to appointments. If CalViva
Health needs to change your PCP, CalViva Health will tell you in writing.
If you change PCPs, you will get a new CalViva Health member ID card in the mail. It
will have the name of your new PCP. Call Member Services if you have questions about
getting a new ID card.
Appointments
When you need health care:
Call your PCP
Have your CalViva Health ID number ready on the call
Leave a message with your name and phone number if the office is closed
Take your BIC and CalViva Health ID card to your appointment
Ask for transportation to your appointment, if needed
Ask for language assistance or interpreting services, if needed
Be on time for your appointment
Call right away if you cannot keep your appointment or will be late
Have your questions and medication information ready in case you need
them
If you have an emergency, call 911 or go to the nearest emergency room.
Payment
You do not have to pay for covered services. In most cases, you will not get a bill from
a provider. You may get an Explanation of Benefits (EOB) or a statement from a
provider. EOBs and statements are not bills.
If you do get a bill, call 1-888-893-1569 (TTY/TDD 711). Tell CalViva Health the amount
charged, the date of service and the reason for the bill. You are not responsible to pay
a provider for any amount owed by CalViva Health for any covered service. Except for
emergency care or urgent care, you may have to pay for care from providers who are
not in the network. If you need covered health care services, you may be able to get
them at an out-of-network provider at no cost to you, as long as they are medically
necessary, not available in the network and pre-approved by CalViva Health.
If you get a bill or are asked to pay a co-pay that you think you did not have to pay, you
can also file a claim form with CalViva Health. You will need to tell CalViva Health in
writing why you had to pay for the item or service. CalViva Health will read your claim
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 35
3 | How to get care
and decide if you can get money back. For questions or to ask for a claim form, call
1-888-893-1569 (TTY/TDD 711).
Referrals
Your PCP will give you a referral to send you to a specialist if you need one. A specialist
is a doctor who has extra education in one area of medicine. Your PCP will work with
you to choose a specialist. Your PCP’s office can help you set up a time to go to the
specialist.
Other services that might need a referral include in-office procedures, X-rays, lab work
and some services from a specialist.
Your PCP may give you a form to take to the specialist. The specialist will fill out the
form and send it back to your PCP. The specialist will treat you for as long as he or she
thinks you need treatment.
Your PCP will start the referral process. Your PCP will know whether you need an
authorization or whether you can make the appointment directly. If you have any
questions about whether care from a specialist or from a hospital needs approval, you
can call Member Services at 1-888-893-1569 (TTY/TDD 711). Routine referrals take up
to 5 working days to process (“working days” are Monday through Friday), but may take
up to 28 calendar days (14 days from the date of the original request plus an additional
14 days if an extension is requested) if more information is needed from your PCP. In
some cases, your PCP may ask to rush your referral. Expedited (rush) referrals may not
take more than 72 hours. Please call our plan if you do not get a response by these
times.
If you have a health problem that needs special medical care for a long time, you may
need a standing referral. This means you can go to the same specialist more than once
without getting a referral each time.
If you have trouble getting a standing referral or want a copy of the CalViva Health
referral policy, call 1-888-893-1569 (TTY/TDD 711).
You do not need a referral for:
PCP visits
Obstetrics/Gynecology (OB/GYN) visits
Urgent or emergency care visits
Adult sensitive services, such as sexual assault care
Family planning services (to learn more, call Office of Family Planning
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 36
3 | How to get care
Information and Referral Service at 1-800-942-1054)
HIV testing and counseling (12 years or older)
Sexually transmitted infection services (12 years or older)
Acupuncture (the first two services per month; additional appointments will
need a referral)
Chiropractic services (a referral may be required when provided by out-of-
network FQHCs, RHCs and IHCs)
Podiatry services
Eligible dental services
Initial mental health assessment
Routine perinatal care from a doctor that works with CalViva Health
Certified nurse midwife services
Initial behavior health assessment from a behavioral health provider that
works with CalViva Health
Minors also do not need a referral for:
Outpatient mental health services for:
Sexual assault
Physical assault
When you have thoughts of hurting yourself or others (minors 12 years
or older)
Pregnancy care
Sexual assault care
Substance use disorder treatment (minors 12 years or older)
Pre-approval (prior authorization)
For some types of care, your PCP or specialist will need to ask CalViva Health for
permission before you get the care. This is called asking for prior authorization, prior
approval, or pre-approval. It means that CalViva Health must make sure that the care is
medically necessary or needed.
Care is medically necessary if it is reasonable and necessary to protect your life, keeps
you from becoming seriously ill or disabled, or reduces severe pain from a diagnosed
disease, illness or injury.
The following services always need pre-approval (prior authorization), even if you get
them from a provider in the CalViva Health network:
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 37
3 | How to get care
Hospitalization, if not an emergency
Services out of the CalViva Health service area, if not an emergency or
urgent
Outpatient surgery
Long-term care at a nursing facility
Specialized treatments
For some services, you need pre-approval (prior authorization). Under Health and
Safety Code Section 1367.01(h)(1), CalViva Health will decide routine pre-approvals
(prior authorizations) within 5 working days of when CalViva Health gets the information
reasonably needed to decide.
For requests in which a provider indicates or CalViva Health determines that following
the standard timeframe could seriously jeopardize your life or health or ability to attain,
maintain, or regain maximum function, CalViva Health will make an expedited (fast) pre-
approval (prior authorization) decision. CalViva Health will give notice as quickly as your
health condition requires and no later than 72 hours after getting the request for
services.
CalViva Health does not pay the reviewers to deny coverage or services. If CalViva
Health does not approve the request, CalViva Health will send you a Notice of Action
(NOA) letter. The NOA letter will tell you how to file an appeal if you do not agree with
the decision.
CalViva Health will contact you if CalViva Health needs more information or more time
to review your request.
You never need pre-approval (prior authorization) for emergency care, even if it is out of
the network and out of your service area. This includes labor and delivery if you are
pregnant. You do not need pre-approval (prior authorization) for sensitive services, such
as family planning, HIV/AIDS services, and outpatient abortions.
Second opinions
You might want a second opinion about care your provider says you need or about your
diagnosis or treatment plan. For example, you may want a second opinion if you are not
sure you need a prescribed treatment or surgery, or you have tried to follow a treatment
plan and it has not worked.
If you want to get a second opinion, you can choose an in-network provider of your
choice. If you are requesting a second opinion about a diagnosis or treatment plan that
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 38
3 | How to get care
your PCP made, the second opinion shall be from another PCP within our plan’s
network of physicians. The second opinion can also be from a specialty physician who
is familiar with the medical problem you have. If you are requesting a second opinion
about a diagnosis or treatment plan that your specialist made, a second opinion must
come from any Independent Physician Association (IPA) or medical group within our
plan’s network for the same specialty. If there is no “qualified health care professional”
within your plan’s network, we will authorize (approve) a second opinion by a qualified
provider outside the network. Your PCP can refer you to a network provider for a
second opinion. For help choosing a provider, call 1-888-893-1569 (TTY/TDD 711).
CalViva Health will pay for a second opinion if you or your network provider asks for it
and you get the second opinion from a network provider. You do not need permission
from CalViva Health to get a second opinion from a network provider. However, if you
need a referral, your network provider can help you get a referral for a second opinion if
you need one.
If there is no provider in the CalViva Health network to give you a second opinion,
CalViva Health will pay for a second opinion from an out-of-network provider. CalViva
Health will tell you within 5 business days if the provider you choose for a second
opinion is approved. If you have a chronic, severe or serious illness, or face an
immediate and serious threat to your health, including, but not limited to, loss of life,
limb, or major body part or bodily function, CalViva Health will decide within 72 hours.
If CalViva Health denies your request for a second opinion, you may appeal. To learn
more about appeals, go to “Appeals” in this handbook.
Women’s health specialists
You may go to a women’s health specialist within CalViva Health network for covered
care necessary to provide women’s routine and preventive health care services. You do
not need a referral from your PCP to get these services. For help finding a women’s
health specialist, you can call 1-888-893-1569 (TTY/TDD 711). You may also call the
24/7 nurse advice line by calling 1-888-893-1569 (TTY/TDD 711). Choose the 24-hour
nurse advice line option in the menu.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 39
4. Benefits an d
services
What your health plan covers
This section explains your covered services as a member of CalViva Health. Your
covered services are free as long as they are medically necessary and provided by an
in-network provider. You must ask us for pre-approval (prior authorization) if the care is
out-of-network except for sensitive services, emergencies or urgent care services. Your
health plan may cover medically necessary services from an out-of-network provider.
But you must ask CalViva Health for this. Care is medically necessary if it is reasonable
and necessary to protect your life, keeps you from becoming seriously ill or disabled, or
reduces severe pain from a diagnosed disease, illness or injury. For more details on
your covered services, call 1-888-893-1569 (TTY/TDD 711).
CalViva Health offers services such as:
Outpatient (ambulatory) services
Telehealth services
Mental health services (outpatient)
Emergency services
Hospice and palliative care
Hospitalization
Maternity and newborn care
Transgender services
Rehabilitative and habilitative (therapy) services and devices
Laboratory and radiology services, such as X-rays
Preventive and wellness services and chronic disease management
Diabetes Prevention Program
Substance use disorder treatment services
Pediatric services
Vision services
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 40
4 | Benefits and services
Non-emergency medical transportation (NEMT)
Non-medical transportation (NMT)
Long-term services and supports (LTSS)
Read each of the sections below to learn more about the services you can get.
Medi-Cal benefits covered by CalViva Health
Outpatient (ambulatory) services
Adult Immunizations
You can get adult immunizations (shots) from a network pharmacy or network
provider without pre-approval. CalViva Health covers those shots recommended
by the Advisory Committee on Immunization Practices (ACIP) of the Centers for
Disease Control and Prevention (CDC).
Allergy care
CalViva Health covers allergy testing and treatment, including allergy
desensitization, hyposensitization or immunotherapy.
Anesthesiologist services
CalViva Health covers anesthesia services that are medically necessary when
you get outpatient care.
For dental procedures, we cover the following services when authorized by
CalViva Health:
IV sedation or general anesthesia services administered by a medical
professional
Facility services related to the sedation or anesthesia in an outpatient
surgical center, Federally Qualified Health Center (FQHC), dental office,
or hospital setting
Chiropractic services
CalViva Health covers chiropractic services, limited to the treatment of the spine
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 41
4 | Benefits and services
by manual manipulation. Chiropractic services are limited to two services per
month in combination with acupuncture, audiology, occupational therapy and
speech therapy services. CalViva Health may pre-approve other services as
medically necessary.
The following members are eligible for chiropractic services:
Children under age 21
Pregnant women through the end of the month that includes 60-days
following the end of a pregnancy
Residents in a skilled nursing facility, intermediate care facility, or
subacute care facility
All members when services are provided at hospital outpatient
departments, FQHCs or RHCs that are in the CalViva Health’s network
Dialysis/hemodialysis services
CalViva Health covers dialysis treatments. CalViva Health also covers
hemodialysis (chronic dialysis) services if your PCP and CalViva Health approve
it.
Outpatient surgery
CalViva Health covers outpatient surgical procedures. Those needed for
diagnostic purposes, procedures considered to be elective, and specified
outpatient medical procedures must have pre-approval (prior authorization).
Physician services
CalViva Health covers physician services that are medically necessary.
Podiatry (foot) services
CalViva Health covers podiatry services as medically necessary for diagnosis
and medical, surgical, mechanical, manipulative and electrical treatment of the
human foot. This includes the ankle and tendons that insert into the foot and the
nonsurgical treatment of the muscles and tendons of the leg controlling the
functions of the foot.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 42
4 | Benefits and services
Treatment therapies
CalViva Health covers different treatment therapies, including:
Chemotherapy
Radiation therapy
Telehealth services
Telehealth is a way of getting services without being in the same physical location as
your provider. Telehealth may involve having a live conversation with your provider. Or
telehealth may involve sharing information with your provider without a live
conversation. You can receive many services through telehealth. It is important that
both you and your provider agree that the use of telehealth for a particular service is
appropriate for you. You can contact your provider to learn which types of services may
be available through telehealth.
Mental health services
Outpatient mental health services
The CalViva Health covers a member for an initial mental health
assessment without needing pre-approval (prior authorization). You may
get a mental health assessment at any time from a licensed mental health
provider in the CalViva Health network without a referral.
Your PCP or mental health provider will make a referral for additional
mental health screening to a specialist within the CalViva Health network
to determine your level of impairment. If your mental health screening
results determine you are in mild or moderate distress or have impairment
of mental, emotional or behavioral functioning, CalViva Health can provide
mental health services for you. CalViva Health covers mental health
services such as:
Individual and group mental health evaluation and treatment
(psychotherapy)
Psychological testing when clinically indicated to evaluate a mental
health condition
Development of cognitive skills to improve attention, memory and
problem solving
Outpatient services for the purposes of monitoring medication
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 43
4 | Benefits and services
therapy
Outpatient laboratory, medications, supplies and supplements
Psychiatric consultation
For help finding more information on mental health services provided by
CalViva Health, call 1-888-893-1569 (TTY/TDD 711).
If your mental health screening results determine you may have a higher
level of impairment and need specialty mental health services (SMHS),
your PCP or your mental health provider will refer you to the county
mental health plan to get an assessment. To learn more, read “Specialty
mental health services” on page 62.
Emergency services
Inpatient and outpatient services needed to treat a medical emergency
CalViva Health covers all services that are needed to treat a medical emergency
that happens in the U.S. or requires you to be in a hospital in Canada or Mexico.
A medical emergency is a medical condition with severe pain or serious injury.
The condition is so serious that, if it does not get immediate medical attention, a
prudent layperson could expect it to result in:
Serious risk to your health; or
Serious harm to bodily functions; or
Serious dysfunction of any bodily organ or part; or
In the case of a pregnant woman in active labor, meaning labor at a time
when either of the following would occur:
There is not enough time to safely transfer you to another hospital
before delivery.
The transfer may pose a threat to your health or safety or to that of
your unborn child.
A pharmacist or hospital emergency room may give you a 72-hour emergency
supply of a prescription drug if they think you need it. CalViva Health will pay for
the emergency supply.
Emergency transportation services
CalViva Health covers ambulance services to help you get to the nearest place of
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 44
4 | Benefits and services
care in emergency situations. This means that your condition is serious enough
that other ways of getting to a place of care could risk your health or life. No
services are covered outside the U.S., except for emergency services that
require you to be in the hospital in Canada or Mexico.
Hospice and palliative care
CalViva Health covers hospice care and palliative care for children and adults, which
help reduce physical, emotional, social and spiritual discomforts. Adults may not receive
both hospice care and palliative care services at the same time.
Hospice care
Hospice care is a benefit that services terminally ill members. Hospice care
requires the member to have a life expectancy of 6 months or less. It is an
intervention that focuses mainly on pain and symptom management rather than
on a cure to prolong life.
Hospice care includes:
Nursing services
Physical, occupational or speech services
Medical social services
Home health aide and homemaker services
Medical supplies and appliances
Drugs and biological services
Counselling services
Continuous nursing services on a 24-hour basis during periods of crisis and
as necessary to maintain the terminally ill member at home
Inpatient respite care for up to five consecutive days at a time in a hospital,
skilled nursing facility or hospice facility
Short-term inpatient care for pain control or symptom management in a
hospital, skilled nursing facility or hospice facility
Palliative care
Palliative care is patient- and family-centered care that improves quality of life by
anticipating, preventing and treating suffering. Palliative care does not require the
member to have a life expectancy of six months or less. Palliative care may be
provided at the same time as curative care.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 45
4 | Benefits and services
Palliative care program (Care Connections) is a specialized home based
program for members with severe progressive disease. Our team works with the
member’s doctors to increase the quality of life through prevention, treatment and
support, symptom relief and improve quality of life for both the member and the
family.
Palliative care includes the following services:
Advance care planning
Palliative care assessment and consultation
Individualized plan of care
Palliative care team
Care coordination
Pain and symptom management
Mental health and medical social services
Chaplain services
24/7 Palliative care support by phone
Additional palliative care services medically necessary or reasonable
for eligible members (e.g. expressive therapy for the pediatric
population)
Members of any age can get palliative care services if they meet the required
criteria. Call CalViva Health to learn more about the program and eligibility.
Hospitalization
Anesthesiologist services
CalViva Health covers medically necessary anesthesiologist services during
covered hospital stays. An anesthesiologist is a provider who specializes in
giving patients anesthesia. Anesthesia is a type of medicine used during some
medical procedures.
Inpatient hospital services
CalViva Health covers medically necessary inpatient hospital care when you are
admitted to the hospital.
Surgical services
CalViva Health covers medically necessary surgeries performed in a hospital.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 46
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 47
4 | Benefits and services
Maternity and newborn care
CalViva Health covers these maternity and newborn care services:
Breastfeeding education and aids
Delivery and postpartum care
Breast pumps and supplies
Prenatal care
Birthing center services
Certified Nurse Midwife (CNM)
Licensed Midwife (LM)
Diagnosis of fetal genetic disorders and counseling
Up to 20 sessions of counseling for pregnant or postpartum women to prevent
perinatal depression
CalViva Health Pregnancy Program: a special program for women who are
pregnant. CalViva Health wants to help you take care of yourself and your baby
through your whole pregnancy. Information can be provided to you by mail or
telephone. Our case management staff can answer questions and give you support
if you need help with an issue during pregnancy. We can even arrange for a home
visit by our MemberConnections team, if needed.
We have many ways to help you have a healthy pregnancy. Before we can help, we
need to know you are pregnant. Please call Member Services at
1-888-893-1569 (TTY/TDD 711) as soon as you learn you are pregnant. We will
help you set up the special care you and your baby need.
Prescription drugs
Covered drugs
Your provider can prescribe you drugs that are on the CalViva Health preferred drug list
(PDL), subject to exclusions and limitations. The CalViva Health PDL is sometimes
called a formulary. Drugs on the PDL are safe and effective for their prescribed use. A
group of doctors and pharmacists update this list.
Updating this list helps make sure the drugs on it are safe and effective.
If your doctor thinks you need to take a drug that is not on this list, your doctor will
need to call CalViva Health to ask for pre-approval before you get the drug.
To find out if a drug is on the CalViva Health PDL or to get a copy of the PDL, call 1-
4 | Benefits and services
888-893-1569 (TTY/TDD: 711). You may also find the PDL at www.CalVivaHealth.org.
Sometimes CalViva Health needs to approve a drug before a provider can prescribe it.
CalViva Health will review and decide these requests within 24 hours.
A pharmacist or hospital emergency room may give you a 72-hour emergency
supply if they think you need it. CalViva Health will pay for the emergency supply.
If CalViva Health says no to the request, CalViva Health will send you a letter that
lets you know why and what other drugs or treatments you can try.
Pharmacies
If you are filling or refilling a prescription, you must get your prescribed drugs from a
pharmacy that works with CalViva Health. You can find a list of pharmacies that work
with CalViva Health in the CalViva Health Provider Directory at www.CalVivaHealth.org.
You can also find a pharmacy near you by calling 1-888-893-1569 (TTY/TDD: 711).
Once you choose a pharmacy, take your prescription to the pharmacy. Your provider
may also send it to the pharmacy for you. Give the pharmacy your prescription with
your CalViva Health ID card. Make sure the pharmacy knows about all medications
you are taking and any allergies you have. If you have any questions about your
prescription, make sure you ask the pharmacist.
The Provisional Postpartum Care Extension Program
The Provisional Postpartum Care Extension (PPCE) Program provides extended
coverage for Medi-Cal members who have a maternal mental health condition during
pregnancy or the time period after pregnancy.
CalViva Health covers maternal mental health care for women during pregnancy and for
up to two months after the end of pregnancy. The PPCE program extends that coverage
for up to 12 months after the diagnosis or from the end of the pregnancy, whichever is
later.
To qualify for the PPCE program, your doctor must confirm your diagnosis of a maternal
mental health condition within 150 days after the end of pregnancy. Ask your doctor
about these services if you think you need them. If your doctor thinks you should have
the services from PPCE, your doctor completes and submits the forms for you.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 48
4 | Benefits and services
Case management
We understand some members have special needs. In those cases, CalViva Health
offers our members case management services to assist with special healthcare
needs. If you have special healthcare needs, behavioral health needs, are pregnant or
have a disability, our case managers may be able to help you. Our case managers are
registered nurses or social workers. They can help you understand major health
problems and arrange care with your doctors. A case manager will work with you and
your doctor to help you get the care you need.
This service is for members with sudden or complex medical conditions and who often
need to see several doctors. They may need medical supplies or help at home.
Conditions may include:
Injuries
Cancer
Diabetes
Chronic Obstructive Pulmonary Disease (COPD)
End Stage Renal Disease
Heart Failure
Sickle cell disease
Multiple sclerosis
Kidney or renal disease
HIV/AIDS
Hemophilia
Possible transplant
Depression
Anxiety
High risk pregnancy
Rehabilitative and habilitative (therapy) services and devices
This benefit includes services and devices to help people with injuries, disabilities or
chronic conditions to gain or recover mental and physical skills.
The plan covers:
Acupuncture
CalViva Health covers acupuncture services to prevent, modify or alleviate the
perception of severe, persistent chronic pain resulting from a generally
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 49
4 | Benefits and services
recognized medical condition. Outpatient acupuncture services (with or without
electric stimulation of needles) are limited to two services per month, in
combination with audiology, chiropractic, occupational therapy and speech
therapy services when provided by a physician, dentist, podiatrist or
acupuncturist. CalViva Health may pre-approve (prior authorize additional
services as medically necessary.
Audiology (hearing)
CalViva Health covers audiology services. Outpatient audiology is limited to two
services per month, in combination with acupuncture, chiropractic, occupational
therapy and speech therapy services. CalViva Health may pre-approve (prior
authorize) additional services as medically necessary.
Behavioral health treatments
Behavioral health treatment (BHT) includes services and treatment programs,
such as applied behavior analysis and evidence-based behavior intervention
programs that develop or restore, to the maximum extent practicable, the
functioning of an individual.
BHT services teach skills using behavioral observation and reinforcement, or
through prompting to teach each step of a targeted behavior. BHT services are
based on reliable evidence and are not experimental. Examples of BHT services
include behavioral interventions, cognitive behavioral intervention packages,
comprehensive behavioral treatment and applied behavioral analysis.
BHT services must be medically necessary, prescribed by a licensed doctor or
psychologist, approved by the plan, and provided in a way that follows the
approved treatment plan.
Cancer clinical trials
CalViva Health covers routine patient care costs for patients accepted into Phase
I, Phase II, Phase III or Phase IV clinical trials if it is related to the prevention,
detection or treatment of cancer or other life-threatening conditions and if the
study is conducted by the U.S. Food and Drug Administration (FDA), Centers for
Disease Control and Prevention (CDC) or Centers for Medicare and Medicaid
Services (CMS). Studies must be approved by the National Institutes of Health,
the FDA, the Department of Defense or the Veterans Administration.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 50
4 | Benefits and services
Cardiac rehabilitation
CalViva Health covers inpatient and outpatient cardiac rehabilitative services.
Durable medical equipment (DME)
CalViva Health covers the purchase or rental of DME supplies, equipment and
other services with a prescription from a doctor. Prescribed DME items may be
covered as medically necessary to preserve bodily functions essential to
activities of daily living or to prevent major physical disability. CalViva Health
does not cover comfort, convenience or luxury equipment, features and supplies,
and other items not generally used primarily for health care.
Enteral and parenteral nutrition
These methods of delivering nutrition to the body are used when a medical
condition prevents you from eating food normally. Enteral and parenteral nutrition
products are covered when medically necessary.
Hearing aids
CalViva Health covers hearing aids if you are tested for hearing loss and have a
prescription from your doctor. CalViva Health may also cover hearing aid rentals,
replacements and batteries for your first hearing aid.
Home health services
CalViva Health covers health services provided in your home, when prescribed
by your doctor and found to be medically necessary.
Medical supplies, equipment and appliances
CalViva Health covers medical supplies that are prescribed by a doctor. CalViva
Health covers incontinence supplies when ordered by your doctor and provided
by a supplier contracted with the plan.
Occupational therapy
CalViva Health covers occupational therapy services, including occupational
therapy evaluation, treatment planning, treatment, instruction and consultative
services. Occupational therapy services are limited to two services per month in
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 51
4 | Benefits and services
combination with acupuncture, audiology, chiropractic and speech therapy
services. CalViva Health may pre-approve (prior authorize) additional services as
medically necessary.
Orthotics/prostheses
CalViva Health covers orthotic and prosthetic devices and services that are
medically necessary and prescribed by your doctor, podiatrist, dentist, or non-
physician medical provider. This includes implanted hearing devices, breast
prosthesis/mastectomy bras, compression burn garments and prosthetics to
restore function or replace a body part, or to support a weakened or deformed
body part.
Ostomy and urological supplies
CalViva Health covers ostomy bags, urinary catheters, draining bags, irrigation
supplies and adhesives. This does not include supplies that are for comfort,
convenience or luxury equipment or features.
Physical therapy
CalViva Health covers physical therapy services, including physical therapy
evaluation, treatment planning, treatment, instruction, consultative services and
application of topical medications.
Pulmonary rehabilitation
CalViva Health covers pulmonary rehabilitation that is medically necessary and
prescribed by a doctor.
Reconstructive Services
CalViva Health covers surgery to correct or repair abnormal structures of the
body to improve or create a normal appearance to the extent possible. Abnormal
structures of the body are those caused by congenital defects, developmental
abnormalities, trauma, infection, tumors, disease, or breast reconstruction after a
mastectomy. Some limitations and exceptions may apply.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 52
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 53
4 | Benefits and services
Skilled nursing facility services
CalViva Health covers skilled nursing facility services as medically necessary if
you are disabled and need a high level of care. These services include room and
board in a licensed facility with skilled nursing care on a 24-hour per day basis.
Speech therapy
CalViva Health covers speech therapy that is medically necessary. Speech
therapy services are limited to two services per month, in combination with
acupuncture, audiology, chiropractic and occupational therapy services. CalViva
Health may pre-approve (prior authorize) additional services as medically
necessary.
Transgender Services
CalViva Health covers transgender services (gender-affirming services) as a
benefit when they are medically necessary or when the services meet the criteria
for reconstructive surgery.
All covered benefits for the treatment for Gender Identity Disorder (GID) need
pre-approval (prior authorization). The treatment follows the latest version of the
World Professional Association for Transgender Health (WPATH) document,
Standards of Care for the Health of Transsexual, Transgender, and Gender-
Nonconforming People and Medi-Cal criteria. The Member must have a
diagnosis of gender dysphoria or GID that was made by an appropriate
professional with training in this field and according to WPATH guidelines and
Medi-Cal guidelines.
Covered benefits, include:
Psychotherapy,
Continuous hormonal therapy,
Laboratory testing to monitor hormone therapy, and
Gender reassignment surgery that is not cosmetic in nature.
Gender Reassignment Surgery (GRS) is covered when the member, diagnosed
with GID:
is at least 18 years of age,
has capacity for fully informed consent,
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
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4 | Benefits and services
and WPATH criteria for surgery has been met.
Breast implant surgery (and related medically necessary services) for male-to-
female members are covered only when a proper trial of hormone therapy has
not enlarged the breast.
For more information, call Member Services at 1-888-893-1569 (TTY/TDD
711).
Laboratory and radiology services
CalViva Health covers outpatient and inpatient laboratory and X-ray services when
medically necessary. Various advanced imaging procedures, such as CT scans, MRI
and PET scans, are covered based on medical necessity. These services are covered
when ordered by your doctor and provided by a provider contracted with the plan or in
the event of an emergency.
Preventive and wellness services and chronic disease management
The plan covers:
Advisory Committee for Immunization Practices recommended vaccines
Family planning services
American Academy of Pediatrics Bright Futures recommendations
Preventive services for women recommended by the American College of
Obstetricians and Gynecologists
Help to quit smoking, also called smoking cessation services
United States Preventive Services Task Force Grade A and B recommended
preventive services
Family planning services are provided to members of childbearing age to enable them
to determine the number and spacing of children. These services include all methods of
birth control approved by the Federal Food and Drug Administration. CalViva Health’s
PCP and ob/gyn specialists are available for family planning services.
For family planning services, you may also choose a doctor or clinic not connected with
CalViva Health without having to get pre-approval (prior authorization) from CalViva
Health. Services from an out-of-network provider not related to family planning may not
be covered. To learn more, call 1-888-893-1569 (TTY/TDD 711).
4 | Benefits and services
Diabetes Prevention Program
The Diabetes Prevention Program (DPP) is an evidence-based lifestyle change
program. It is designed to prevent or delay the onset of type 2 diabetes among
individuals diagnosed with prediabetes. The program lasts one year. It can last for a
second year for members who qualify. The program-approved lifestyle supports and
techniques include, but are not limited to:
Providing a peer coach
Teaching self-monitoring and problem solving
Providing encouragement and feedback
Providing informational materials to support goals
Tracking routine weigh-ins to help accomplish goals
Members must meet program eligibility requirements to join DPP. Call CalViva Health to
learn more about the program and eligibility.
Substance use disorder services
The plan covers:
Alcohol misuse screenings and illicit-drug screenings
Services for adults (age 18 and older) who have alcohol or other substance
use disorder conditions are offered to you at no cost. The covered services
for alcohol misuse are:
One expanded screening for risky alcohol use per year (a screening tool
that asks you for more information about your alcohol use)
Three 15-minute intervention sessions per year to talk about risky alcohol
use
The plan also covers inpatient treatment for acute drug or alcohol overdose when
medically necessary.
Pediatric services
The plan covers:
Early and periodic screening, diagnostic and treatment (EPSDT) services that
are recommended by pediatricians’ Bright Futures guidelines to help you or
your child stay healthy. These services are at no cost to you.
If you or your child are under 21 years old, CalViva Health covers well-child
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
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Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 55
4 | Benefits and services
visits. Well-child visits are a comprehensive set of preventive, screening,
diagnostic, and treatment services.
CalViva Health will make appointments and provide transportation to help
children get the care they need.
Preventive care can be regular health check-ups and screenings to help your
doctor find problems early. Regular check-ups help you or your child’s doctor
look for any problems with your or your child’s medical, dental, vision,
hearing, mental health, and any substance use disorders. CalViva Health
covers screening services (including blood lead level assessment) any time
there is a need for them, even if it is not during your or your child’s regular
check-up. Also, preventive care can be shots you or your child need.
CalViva Health must make sure that all enrolled children get needed shots at
the time of any health care visit. Preventive care services and screenings are
available at no cost and without pre-approval (prior authorization). However,
general developmental screenings for members age 6-20 will require prior
authorization.
When a physical problem or mental health issue is found during a check-up or
screening, there may be care that can fix or help the problem. If the care is
medically necessary and CalViva Health is responsible for paying for the
care, then CalViva Health covers the care at no cost to you. These services
include:
Doctor, nurse practitioner, and hospital care
Shots to keep you healthy
Physical, speech/language, and occupational therapies
Home health services, which could be medical equipment, supplies,
and appliances
Treatment for vision and hearing, which could be eyeglasses and
hearing aids
Behavioral Health Treatment for autism spectrum disorders and other
developmental disabilities
Case management and health education
Reconstructive surgery, which is surgery to correct or repair abnormal
structures of the body caused by congenital defects, developmental
abnormalities, trauma, infection, tumors, or disease to improve function
or create a normal appearance.
Care coordination to help you or your child get the right care even if CalViva
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 56
4 | Benefits and services
Health is not responsible for paying for that care. These services include:
Treatment and rehabilitative services for mental health and substance
use disorders
Treatment for dental issues, which could be orthodontics
Vision services
The plan covers:
Routine eye exam once every 24 months; CalViva Health may pre-approve
(prior authorize) additional services as medically necessary.
Eyeglasses (frames and lenses) once every 24 months; contact lenses when
required for medical conditions such as aphakia, aniridia, and keratoconus.
Non-emergency medical transportation (NEMT)
You are entitled to use non-emergency medical transportation (NEMT) to get to your
appointments when it's a Medi-Cal covered service. If you cannot get to your medical,
dental, mental health, substance use, and pharmacy appointment by car, bus, train or
taxi, you can ask your doctor for NEMT. Your doctor will decide the correct type of
transportation to meet your needs.
NEMT is an ambulance, litter van, wheelchair van or air transport. NEMT is not a car,
bus or taxi. CalViva Health allows the lowest cost NEMT for your medical needs when
you need a ride to your appointment. That means, for example, if you can physically or
medically be transported by a wheelchair van, CalViva Health will not pay for an
ambulance. You are only entitled to air transport if your medical condition makes any
form of ground transportation impossible.
NEMT must be used when:
It is physically or medically needed as determined with a written authorization
by a doctor or other provider; or you are not able to physically or medically
use a bus, taxi, car or van to get to your appointment.
You need help from the driver to and from your residence, vehicle or place of
treatment due to a physical or mental disability.
It is approved in advance by CalViva Health with a written authorization by a
doctor.
To ask for NEMT services that your doctor has prescribed, please call CalViva Health at
1-888-893-1569 (TTY/TDD: 711) at least 5 business days (Monday-Friday) before your
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 57
4 | Benefits and services
appointment. For urgent appointments, please call as soon as possible. Please have
your member ID card ready when you call.
Limits of NEMT
There are no limits for receiving NEMT to or from medical, dental, mental health and
substance use disorder appointments covered under Medi-Cal when a provider has
prescribed it for you. Some pharmacy services are covered under NEMT such as
pharmacy trips for medication. For more information or to ask for NEMT services related
to pharmacy, please call CalViva Health at 1-888-893-1569 (TYY/TDD 711). If the
appointment type is covered by Medi-Cal but not through the health plan, CalViva
Health will provide or help you schedule your transportation.
What does not apply?
Transportation will not be provided if your physical and medical condition allows you to
get to your medical appointment by car, bus, taxi or other easily accessible method of
transportation. Transportation will not be provided if the service is not covered by Medi-
Cal. A list of covered services is in this Member Handbook.
Cost to member
There is no cost when transportation is authorized by CalViva Health.
Non-medical transportation (NMT)
You can use non-medical transportation (NMT) when you are:
Traveling to and from an appointment for a Medi-Cal service authorized by
your provider.
Picking up prescriptions and medical supplies.
CalViva Health allows you to use a car, taxi, bus or other public/private way of getting to
your medical appointment for Medi-Cal-covered services. CalViva Health gives mileage
reimbursement when transportation is in a private vehicle arranged by the member and
not through a transportation broker, bus passes, taxi vouchers or train tickets.
If you cannot drive yourself to your medical appointment for Medi-Cal covered services,
CalViva Health can help you get a ride. CalViva Health will arrange a car, taxi, bus or
other public/private way of getting to your appointment. You may also have a family
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 58
4 | Benefits and services
member or a friend drive you to the appointment and CalViva Health will reimburse
them for the mileage. CalViva Health does not give mileage reimbursement when the
members drive themselves to or from their own appointment.
Before getting approval for mileage reimbursement, you must state to CalViva Health by
phone, by email or in person that you tried to get all other reasonable transportation
choices and could not get one. CalViva Health allows the lowest cost NMT type that
meets your medical needs.
To ask for NMT for services that have been authorized, call CalViva Health at
1-888-893-1569 (TTY/TDD 711) at least 5 business days (Monday-Friday) before your
appointment or call as soon as you can when you have an urgent appointment. Please
have your member ID card ready when you call.
Note: American Indians may contact their local IHC to request NMT services.
Limits of NMT
There are no limits for getting NMT to or from medical, dental, mental health and
substance use disorder appointments when CalViva Health has authorized it for you. If
the appointment type is covered by Medi-Cal but not through the health plan, your
health plan will provide or help you schedule your transportation. Members cannot drive
themselves or be reimbursed directly.
What does not apply?
NMT does not apply if:
An ambulance, litter van, wheelchair van, or other form of NEMT is medically
needed to get to a covered service.
You need assistance from the driver to and from the residence, vehicle or
place of treatment due to a physical or medical condition.
You are in a wheelchair and are unable to move in and out of the vehicle
without help from the driver.
The service is not covered by Medi-Cal.
Cost to member
There is no cost when transportation is authorized by CalViva Health.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 59
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 60
4 | Benefits and services
Long-term services and supports (LTSS)
CalViva Health covers these LTSS benefits for members who qualify:
Skilled nursing facility services as approved by CalViva Health
Home and Community Based Services as approved by CalViva Health
Community-Based Adult Services (CBAS): You may qualify for CBAS if
you are 18 years and older, and need extra help because you have health
problems that make it hard for you to take care of yourself. If you qualify, we
will help you find a center that best meets your needs. If there is no CBAS
center in your area, we will help you find other home and community based
services.
You can get the following services at the CBAS center:
An individual assessment
Professional nursing services
Physical, occupational and speech therapies
Mental health services
Therapeutic activities
Social services
Personal Care
Meals
Nutritional counseling
Transportation to and from your home and the CBAS center
Skilled Nursing Facility or “SNF” Care (Subacute/Intermediate Facility
Care) – Our plan covers Skilled Nursing Facility (SNF) services. SNF services
may be available to you if you are physically disabled and require a high level
of care. SNF Services must be prescribed by a physician or Certified Nurse
Practitioner and provided in a licensed Skilled Nursing Facility (SNF).
Covered Services include:
Skilled nursing care on a 24 hour per day basis.
Room and board (daily meals).
Case Management.
X-ray and laboratory procedures.
Physical, Speech, and Occupational Therapy.
Prescribed drugs and medications administration.
Medical supplies, appliances and equipment.
4 | Benefits and services
Care coordination
CalViva Health offers services to help you coordinate your health care needs at no cost
to you.
If you have questions or concerns about your health or the health of your child, call
1-888-893-1569 (TTY/TDD 711).
Other Medi-Cal programs and services
Specialty mental health services
Some mental health services are provided by county mental health plans instead of
CalViva Health. These include specialty mental health services (SMHS) for Medi-Cal
members who meet medical necessity rules. SMHS may include these outpatient,
residential and inpatient services:
Outpatient services:
Mental health services (assessments, plan development, therapy,
rehabilitation and collateral)
Medication support services
Day treatment intensive services
Day rehabilitation services
Crisis intervention services
Crisis stabilization services
Targeted case management services
Therapeutic behavioral services (covered for members under 21 years
old)
Intensive care coordination (ICC) (covered for members under 21
years old)
Intensive home-based services (IHBS) (covered for members under 21
years old)
Therapeutic foster care (TFC) (covered for members under 21 years
old)
Residential services:
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 61
4 | Benefits and services
Adult residential treatment services
Crisis residential treatment services
Inpatient services:
Acute psychiatric inpatient hospital services
Psychiatric inpatient hospital professional services
Psychiatric health facility services
To learn more about specialty mental health services the county mental health plan
provides, you can call your county mental health plan. To find all counties’ toll-free
telephone numbers online, visit
www.dhcs.ca.gov/individuals/Pages/MHPContactList.aspx.
Substance use disorder services
The county provides substance use disorder services to Medi-Cal members who meet
medical necessity rules. Members who are identified for substance use disorder
treatment services are referred to their county department for treatment. To find all
counties’ telephone numbers online, visit
www.dhcs.ca.gov/individuals/Pages/SUD_County_Access_Lines.aspx.
Except as shown under the “Medi-Cal benefits covered by CalViva Health” subsection,
all other alcohol and drug treatment services and outpatient heroin detoxification
services are not covered by the health plan. Members requiring these services will be
referred to a Voluntary Inpatient Detox (VID) provider or their county alcohol and drug
treatment program for treatment. Our plan will continue to work with your PCP to cover
primary care and other services unrelated to the alcohol and substance abuse treatment
and will coordinate services with the treatment program(s), as necessary.
Dental services
Medi-Cal covers some dental services, including:
Diagnostic and preventive dental hygiene (such as examinations, X-rays and
teeth cleanings)
Emergency services for pain control
Tooth extractions
Fillings
Root canal treatments (anterior/posterior)
Crowns (prefabricated/laboratory)
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 62
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 63
4 | Benefits and services
Scaling and root planning
Periodontal maintenance
Complete and partial dentures
Orthodontics for children who qualify
Topical fluoride
If you have questions or want to learn more about dental services, call the Medi-Cal
Dental Program at 1-800-322-6384 (TTY/TDD 1-800-735-2922 or 711). You may also
visit the Medi-Cal Dental Program website at www.denti-cal.ca.gov.
California Children’s Services (CCS)
CCS is a Medi-Cal program that treats children under 21 years of age with certain
health conditions, diseases or chronic health problems and who meet the CCS program
rules. If CalViva Health or your PCP believes your child has a CCS-eligible condition, he
or she will be referred to the CCS county program to be assessed for eligibility.
CCS program staff will decide if your child qualifies for CCS services. If your child
qualifies to get this type of care, CCS providers will treat him or her for the CCS
condition. CalViva Health will continue to cover the types of service that do not have to
do with the CCS condition such as physicals, vaccines and well-child checkups.
CalViva Health does not cover services provided by the CCS program. For CCS to
cover these services, CCS must approve the provider, services and equipment.
CCS does not cover all health conditions. CCS covers most health conditions that
physically disable or that need to be treated with medicines, surgery or rehabilitation
(rehab). CCS covers children with health conditions such as:
Congenital heart disease
Cancers
Tumors
Hemophilia
Sickle cell anemia
Thyroid problems
Diabetes
Serious chronic kidney problems
Liver disease
Intestinal disease
Cleft lip/palate
Spina bifida
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 64
4 | Benefits and services
Hearing loss
Cataracts
Cerebral palsy
Seizures under certain circumstances
Rheumatoid arthritis
Muscular dystrophy
AIDS
Severe head, brain or spinal cord injuries
Severe burns
Severely crooked teeth
Medi-Cal pays for CCS services. If your child is not eligible for CCS program services,
he or she will keep getting medically necessary care from CalViva Health.
To learn more about CCS, you can visit the CCS web page at
www.dhcs.ca.gov/services/ccs. Or call 1-888-893-1569 (TTY/TDD 711).
Institutional long-term care
CalViva Health covers long-term care for the month you enter a facility and the month
after that. CalViva Health does not cover long-term care if you stay longer. FFS Medi-
Cal covers your stay if it lasts longer than the month after you enter a facility. To learn
more, call 1-888-893-1569 (TTY/TDD 711).
Early Start/Early Intervention
The Early Start Program is for infants and toddlers from birth to 3 years who need
early intervention services and have problems that may result in developmental
delays, or who show signs of developmental delay. Some risk conditions are:
Asphyxia
Central nervous system infection
Prematurity
For more information about Early Start/Early Intervention or a referral to the
Regional Center for Early Start/Early Intervention, talk to your doctor or to our plan.
Local Education Agency (LEA) assessment services
The LEA provides certain health care assessment services through school
4 | Benefits and services
programs. The LEA is your local public school. Children age 3 through 21 may get
services without a referral from their PCP. The PCP should coordinate needed
medical services with the LEA. LEA services may include:
Physical and Mental Health evaluations
Education and psychosocial assessments
Health and nutrition education
Developmental assessments
Physical and Occupational Therapy
Speech Therapy and audiology (hearing tests)
Counseling
Nursing services
School health aide services
Medical transportation
Members with developmental disabilities
REGIONAL CENTERS
Regional Centers were created to meet the needs of people who are
developmentally disabled. Regional Centers help their clients and families to find
housing, day programs for adults, transportation, health care and social activities.
Most of their services are free to eligible clients. If you have a family member who
was diagnosed with a disabling condition before the age of 18, your PCP will
connect you with the local Regional Center.
Childhood lead poisoning screening
Our plan covers a blood lead screening test for Members up to age 18 as part of
routine preventive care. Children that test above a certain blood lead level are
referred to the Childhood Lead Poisoning Prevention Program (CLPPP), California
Children’s Services (CCS), and/or the Local Health Department for further evaluation
and treatment.
Direct observed therapy for the treatment of tuberculosis
Our plan will refer members identified with active tuberculosis who are at risk for
non-compliance for the treatment of tuberculosis to the Local Health Department for
direct observed therapy. Members at risk for non-compliance include, but are not
limited to, members with demonstrated multiple drug resistance, Members whose
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
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Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 65
4 | Benefits and services
treatment has failed or who have relapsed after completing a prior regimen, children
and adolescents, and individuals who have demonstrated non-compliance (such as
those who failed to keep office appointments). Our plan will provide all medically
necessary covered services to members with tuberculosis on direct observed
therapy and will ensure joint case management and coordination of care with the
Local Health Department.
Major Organ Transplants
Our plan will refer Members identified as major organ transplant candidates to a
Medi-Cal-approved transplant center and will cover the evaluation performed by the
Medi-Cal-approved transplant center. Examples of major organ transplants are bone
marrow transplants, heart transplants, liver transplants, lung transplants, heart/lung
transplants, combined liver and kidney transplants, and combined liver and small
bowel transplants. If you are accepted as a transplant candidate and Medi-Cal
approves your transplant, you will be disenrolled from CalViva Health and go back to
Fee-for-Service Medi-Cal. CalViva Health will continue to cover all Medically
Necessary services until you are disenrolled. Members who are under 21 are
referred to the California Children’s Services (CCS) program for all transplant
evaluations and Authorization.
CalViva Health does not disenroll Members who need to receive a kidney or cornea
transplant. We will provide all services, including the transplant itself, for Members
who need these medically necessary transplants.
Additional Medi-Cal Benefits not covered by CalViva Health but
available through Fee-For-Service Medi-Cal
:
Blood coagulation factors, such as hemophilia blood coagulation factor.
Pediatric day health care.
State laboratory services under the State Serum Alpha-fetoprotein Testing
program.
Targeted Case Management.
Voluntary Inpatient detoxification services in a general Acute care hospital.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 66
4 | Benefits and services
Services you cannot get through CalViva Health or
Medi-Cal
There are some services that neither CalViva Health nor Medi-Cal will cover, including,
but not limited to:
Experimental or investigational services and drugs
Fertility preservation
In Vitro Fertilization (IVF)
Permanent home modifications
Vehicle modifications
Cosmetic Surgery (surgery to change or reshape normal structures of the
body in order to improve your look)
Mental Health services or counseling for couples or families for relationship
problems.
Custodial Care
Infertility
Vaccines for sports, work or travel
Personal comfort items, (such as phones, television and guest tray) when in
the hospital
Treatment for major alcohol problems. If you need services for major alcohol
problems, you may be referred to the county alcohol and drug program.
Vision Services:
Eyeglasses used for protective, cosmetic, or job-related purposes
Eyeglasses prescribed for other than the correction of refractive errors
or binocular vision problems
Progressive Lenses
Multifocal contact lenses
Vision therapy or visual training
Prescription eyeglasses for a person who has and is able to wear
contact lenses
To learn more call 1-888-893-1569 (TTY/TDD 711).
Evaluation of new and existing technologies
New technologies include procedures, drugs, biological product, or devices that have
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 67
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 68
4 | Benefits and services
been newly developed to treat specific illnesses or conditions, or are new ways of using
current technologies.
Our plan keeps up with the change in technologies and treatments. To help decide if a
new treatment or care should be added to your benefit plan, we review:
The latest medical and scientific writings
Recommendations by practicing doctors or nationally recognized medical
associations
Reports and publications of government agencies.
This work is done to be sure you have access to safe and effective care.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 69
5. Rights and
responsibilities
As a member of CalViva Health, you have certain rights and responsibilities. This
chapter explains these rights and responsibilities. This chapter also includes legal
notices that you have a right to as a member of CalViva Health.
Your rights
CalViva Health members have these rights:
To be treated with respect, giving due consideration to your right to privacy
and the need to maintain confidentiality of your medical information.
To be provided with information about the plan and its services, including
covered services, its practitioners and providers and member rights and
responsibilities.
To be able to choose a primary care provider within CalViva Health’s network.
To have timely access to network providers.
To participate in decision making regarding your own health care, including
the right to refuse treatment.
To make recommendations regarding the plan’s member rights and
responsibilities policy.
To voice grievances, either verbally or in writing, about the organization or the
care you got.
To get care coordination.
To ask for an appeal of decisions to deny, defer or limit services or benefits.
To get free oral interpretation services for your language.
To get free legal help at your local legal aid office or other groups.
To formulate advance directives.
5 | Rights and responsibilities
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 70
To ask for a State Hearing if a service or benefit is denied and you have
already filed an appeal with CalViva Health and are still not happy with the
decision, or if you did not get a decision on your appeal after 30 days,
including information on the circumstances under which an expedited hearing
is possible.
To disenroll from CalViva Health and change to another health plan in the
county upon request.
To access Minor Consent Services.
To get written member-informing materials in alternative formats (such as
braille, large-size print and audio format) upon request and in a timely fashion
appropriate for the format being requested and in accordance with Welfare &
Institutions Code Section 14182 (b)(12).
To be free from any form of restraint or seclusion used as a means of
coercion, discipline, convenience or retaliation.
To truthfully discuss information on available treatment options and
alternatives, presented in a manner appropriate to your condition and ability
to understand, regardless of cost or coverage.
To have access to and get a copy of your medical records, and request that
they be amended or corrected, as specified in 45 Code of Federal
Regulations §164.524 and 164.526.
Freedom to exercise these rights without adversely affecting how you are
treated by CalViva Health, your providers or the State.
To have access to family planning services, Freestanding Birth Centers,
Federally Qualified Health Centers, Indian Health Clinics, midwifery services,
Rural Health Centers, sexually transmitted infection services and emergency
services outside CalViva Health’s network pursuant to the federal law.
Your responsibilities
CalViva Health members have these responsibilities:
Act courteously and respectfully. You are responsible for treating your
doctor and all providers and staff with courtesy and respect. You are
responsible for being on time for your visits or calling your doctor’s office at
least 24 hours before the visit to cancel or reschedule.
Give up-to-date, accurate and complete information. You are responsible
for giving correct information and as much information as you can to all of
5 | Rights and responsibilities
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 71
your providers, and to our plan. You are responsible for getting regular check-
ups and telling your doctor about health problems before they become
serious.
Follow your doctor’s advice and take part in your care. You are
responsible for talking over your health care needs with your doctor,
developing and agreeing on goals, doing your best to understand your health
problems, and following the treatment plans and instructions you both agree
on.
Use the emergency room only in an emergency. You are responsible for
using the emergency room in cases of an emergency or as directed by your
doctor. Emergency care is a service that you reasonably believe is necessary
to stop or relieve sudden serious illnesses or symptoms, and injury or
conditions requiring immediate diagnosis and treatment.
Report wrong-doing. You are responsible for reporting health care fraud or
wrong-doing to CalViva Health. You can do this without giving your name by
calling CalViva Health Fraud and Abuse Hotline toll-free at 1-866-863-2465.
Notice of privacy practices
A statement describing CalViva Health policies and procedures for preserving the
confidentiality of medical records is available and will be furnished to you upon request.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Covered Entities Duties:
CalViva Health provides health care coverage to you and/or your family. We are
required by state and federal law to protect your health information. We must give you
this notice that tells how we may use and share your information and what your rights
are.
Your information is personal and private.
5 | Rights and responsibilities
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 72
We receive information about you after you become eligible and enroll in our health
plan. We also receive medical information from your doctors, clinics, labs and hospitals
in order to pay for your health care. We are prohibited from using or disclosing genetic
information for underwriting purposes.
CHANGES TO NOTICE OF PRIVACY PRACTICES
CalViva Health must obey this notice. We have the right to change these privacy
practices. If we do make changes, we will revise this notice and send it to you.
HOW WE MAY USE AND SHARE INFORMATION ABOUT YOU
Your information may be used or shared by CalViva Health only for a reason directly
connected to your health care.
The information we use and share includes:
Your name,
Address,
Personal information about your circumstances,
Medical care given to you, and
Your medical history.
Some Examples
For treatment: You may need medical treatment that requires us to approve covered
care in advance. We will share information with doctors, hospitals and others in order to
get you the care you need.
For payment: CalViva Health reviews, approves and pays for health care claims sent to
us for your medical care. When we do this, we share information with the doctors,
clinics and others who bill us for your care. And we may forward bills to other health
plans or organizations for payment.
For health care operations: We may use information in your health record to judge the
quality of the health care you receive. We may also use this information in audits, fraud
and abuse programs, planning and general administration. We also provide the names
of members to county immunization reporting registries who report to CalViva Health
whether members have received immunizations to assess their immunization status and
to report related information to the California Department of Health Care Services.
Members may instruct their health care provider that they do not consent to the
provider’s sharing of their immunization information with a county immunization registry.
5 | Rights and responsibilities
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 73
Actions we take when we act as a health care plan include checking your eligibility,
enrollment and amount of medical aid, approving, giving and paying for covered health
care services, and investigating or prosecuting cases (such as fraud).
OTHER USES FOR YOUR HEALTH INFORMATION
We may also send you information about free medical exams and food programs.
We will also send your information when we are required or permitted to do so by law.
Sometimes a court will order us to give out your health information. We will also give out
information when legally required to do so for the operations of the health care program.
This may involve fraud or actions to recover money from others, when another
responsible party has paid your medical claims.
You or your doctor, hospital and other health care providers may appeal decisions
made about claims for your medical care. Your health information may be used to make
these appeal decisions.
WHEN WRITTEN CONSENT IS NEEDED
If we want to use your information for the reasons listed below, we must get your written
consent:
For marketing purposes
For disclosures that constitute the sale of your information
For the use and disclosure of psychotherapy notes
If we want to use your information for a purpose not listed above, we must get your
written consent. If you give us your consent, you may take it back in writing at any time.
WHAT ARE YOUR PRIVACY RIGHTS?
You have the right to ask us not to use or share your personal health care
information in the ways described above. We may not be able to agree to your
request.
You have the right to receive notice whenever a breach of your information
occurs.
You have the right to ask us to contact you only in writing or at a different
address, post office box or phone number. We will accept reasonable requests
when necessary to protect your safety.
5 | Rights and responsibilities
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 74
You and your personal representative have the right to get a copy of your
information. You will be sent a form to fill out and may be charged a fee for the
costs of copying and mailing records. (We may keep you from seeing certain
parts of your records for reasons allowed by law.)
You have the right to ask that information in your records be changed if it is not
correct or complete. We may refuse your request if the information is not created
or kept by CalViva Health, or we believe it is correct and complete. If we don’t
make the changes you ask, you may ask that we review our decision. You may
also send a statement saying why you disagree with our records and your
statement will be kept with your records.
When we share your health information for reasons other than treatment,
payment or CalViva Health operations, you have the right to request a list of
whom we shared the information with, when we shared it, for what reasons, and
what information was shared.
******IMPORTANT******
CALVIVA HEALTH DOES NOT HAVE COMPLETE COPIES OF YOUR MEDICAL
RECORDS. IF YOU WANT TO LOOK AT, GET A COPY OF, OR CHANGE YOUR
MEDICAL RECORDS, PLEASE CONTACT YOUR DOCTOR OR CLINIC.
HOW DO YOU CONTACT US TO USE YOUR RIGHTS?
If you want to use the privacy rights explained in this notice, please call or write us at:
CalViva Health Privacy Office
Attention: Chief Operating Officer
7625 N. Palm Ave., Suite 109
Fresno, CA 93711
Phone: 1-866-863-2465
Fax: (559) 446-1998
COMPLAINTS
If you believe that we have not protected your privacy and wish to complain, you may
file a complaint by calling or writing:
Privacy Officer
c/o Office of Legal Services
California Department of Health Care Services
5 | Rights and responsibilities
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 75
1501 Capitol Avenue
P.O. Box 997413
Sacramento, CA 95899-7413
(916) 255-5259 or 1-877-735-2929 TTY/TDD
E-mail: Privacyofficer@dhcs.ca.gov
OR
Secretary of the U.S. Department of Health and Human Services
Office for Civil Rights
Attention: Regional Manager
50 United Nations Plaza, Room 322
San Francisco, CA 94102
For more information, call 1-800-368-1019
OR
U.S. Office for Civil Rights at 1-866-OCR-PRIV (1-866-627-7748) or 1-866-788-4989
(TTY/TDD 711)
USE YOUR RIGHTS WITHOUT FEAR
CalViva Health cannot take away your health care benefits or do anything to hurt you in
any way if you choose to file a complaint or use the privacy rights in this Notice.
QUESTIONS
If you have questions about this Notice and want further information, please contact us
at the address and phone number provided above.
Notice about laws
Many laws apply to this Member Handbook. These laws may affect your rights and
responsibilities even if the laws are not included or explained in this handbook. The
main laws that apply to this handbook are state and federal laws about the Medi-Cal
program. Other federal and state laws may apply too.
5 | Rights and responsibilities
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 76
Notice about Medi-Cal as a payer of last resort
Sometimes someone else has to pay first for the services CalViva Health provided to
you. For example, if you are in a car accident or if you are injured at work, insurance or
Workers Compensation has to pay first.
DHCS has the right and responsibility to collect for covered Medi-Cal services for which
Medi-Cal is not the first payer. If you are injured, and someone else is liable for your
injury, you or your legal representative must notify DHCS within 30 days of filing a legal
action or a claim. Submit your notification online:
Personal Injury Program at http://dhcs.ca.gov/PI
Workers Compensation Recovery Program at http://dhcs.ca.gov/WC
To learn more, call 1-916-445-9891.
The Medi-Cal program complies with state and federal laws and regulations relating to
the legal liability of third parties for health care services to members. CalViva Health will
take all reasonable measures to ensure that the Medi-Cal program is the payer of last
resort.
Medi-Cal members may also have other health coverage (OHC) provided to them at no
cost. By law, members are required to exhaust all services provided by the OHC before
using services through CalViva Health. If you do not apply for or keep no-cost or state-
paid OHC, your Medi-Cal benefits and/or eligibility will be denied or stopped. Federal
and state laws require Medi-Cal members to report private health insurance. To report
or change private health insurance, go to http://dhcs.ca.gov/mymedi-cal. Or go through
your health plan. Or call 1-800-541-5555 (TTY/TDD 1-800-430-7077 or 711). Outside of
California, call 1-916-636-1980. If you do not report changes to your OHC promptly, and
because of this, get Medi-Cal benefits that you are not eligible for, you may have to
repay DHCS.
Notice about estate recovery
The Medi-Cal program must seek repayment from the estates of certain deceased
Medi-Cal members from payments made, including managed care premiums for nursing
facility services, home and community-based services, and related hospital and
prescription drug services provided to the deceased Medi-Cal member on or after the
member’s 55th birthday. If a deceased member does not leave an estate or owns
nothing when they die, nothing will be owed.
5 | Rights and responsibilities
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 77
To learn more about the estate recovery, go to http://dhcs.ca.gov/er. Or call
1-916-650-0490 or get legal advice.
Notice of Action
CalViva Health will send you a Notice of Action (NOA) letter any time CalViva Health
denies, delays, terminates or modifies a request for health care services. If you disagree
with the plan’s decision, you can always file an appeal with CalViva Health. See the
Appeals section below for important information on filing your Appeal. When
CalViva Health sends you a NOA it will inform you of all rights you have if you disagree
with a decision we made.
Third party liability
CalViva Health will not make any claim for recovery of the value of Covered Services
provided to a Member when such recovery would result from an action involving the tort
liability of a third party or casualty liability insurance, including workers’ compensation
awards and uninsured motorist coverage. However, CalViva Health will notify the DHCS
of such potential cases, and will help the DHCS in pursuing the State’s right to
reimbursement of such recoveries. Members are obligated to assist CalViva Health and
the DHCS in this regard.
Independent contractors
The relationship between CalViva Health and each participating provider is an
independent contractor relationship. Participating providers are not employees or
agents of CalViva Health and neither CalViva Health, nor any employee of CalViva
Health, is an employee or agent of a participating provider. In no case will CalViva
Health be liable for the negligence, wrongful act, or omission of any participating or
other health care provider. Participating providers, and not CalViva Health, maintain the
physician-patient relationship with the member. CalViva Health is not a provider of
health care.
5 | Rights and responsibilities
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 78
Health care plan fraud
Health care plan fraud is defined as a deception or misrepresentation by a provider,
Member, employer or any person acting on their behalf. It is a felony that can be
prosecuted. Any person who willfully and knowingly engages in an activity intended to
defraud the health care plan by filing a claim that contains a false or deceptive
statement is guilty of insurance fraud.
If you are concerned about any of the charges that appear on a bill or Explanation of
Benefits form, or if you know of or suspect any illegal activity, call our plan’s toll-free
Fraud and Abuse Hotline at 1-866-863-2465 (Open 8 a.m. to 4 p.m. Monday through
Friday). All calls are strictly confidential.
Circumstances beyond CalViva Health’s control
To the extent that a natural disaster or emergency circumstances results in CalViva
Health’s facilities or personnel not being available to provide or arrange for services or
benefits under this Member Handbook, CalViva Health's obligation to provide such
services or benefits shall be limited to the requirement that CalViva Health make a
good-faith effort to provide or arrange for the provision of such services or benefits
within the current availability of its facilities or personnel.
6. Reporting and
solving problems
There are two kinds of problems that you may have with CalViva Health:
A complaint (or grievance) is when you have a problem with CalViva Health
or a provider, or with the health care or treatment you got from a provider
An appeal is when you don’t agree with CalViva Health’s decision not to
cover or change your services
You have the right to file grievances and appeals with CalViva Health to let us know
about your problem. This does not take away any of your legal rights and remedies. We
will not discriminate or retaliate against you for complaining to us. Letting us know about
your problem will help us improve care for all members.
You should always contact CalViva Health first to let us know about your problem. Call
us 24 hours a day, 7 days a week at 1-888-893-1569 (TTY/TDD 711). Tell us about your
problem.
If your grievance or appeal is still not resolved, or you are unhappy with the result, you
can call the California Department of Managed Health Care (DMHC) and ask them to
review your complaint or conduct an Independent Medical Review. You can call the
DMHC at 1-888-466-2219 (TTY/TDD 1-877-688-9891 or 711) or visit the DMHC website
for more information: www.dmhc.ca.gov.
The California Department of Health Care Services (DHCS) Medi-Cal Managed Care
Ombudsman can also help. They can help if you have problems joining, changing or
leaving a health plan. They can also help if you moved and are having trouble getting
your Medi-Cal transferred to your new county. You can call the Ombudsman Monday
through Friday, between 8:00 a.m. and 5:00 p.m. at 1-888-452-8609.
You can also file a grievance with your county eligibility office about your Medi-Cal
eligibility. If you are not sure who you can file your grievance with, call 1-888-893-1569
(TTY/TDD 711).
To report incorrect information about your additional health insurance, please call Medi-
Cal Monday through Friday, between 8:00 a.m. and 5:00 p.m. at 1-800-541-5555.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 79
6 | Reporting and solving grievances
Complaints
A complaint (or grievance) is when you have a problem or are unhappy with the
services you are receiving from CalViva Health or a provider. There is no time limit to
file a complaint. You can file a complaint with CalViva Health at any time by phone, in
writing or online.
By phone: Call CalViva Health at 1-888-893-1569 (TTY/TDD 711) 24 hours a
day, 7 days a week. Give your health plan ID number, your name and the reason
for your complaint.
By mail: Call CalViva Health at 1-888-893-1569 (TTY/TDD 711) and ask to have
a form sent to you. When you get the form, fill it out. Be sure to include your
name, health plan ID number and the reason for your complaint. Tell us what
happened and how we can help you.
Mail the form to:
CalViva Health
Grievance and Appeals Department
P.O. Box 10348
Van Nuys, CA 91410-0348
Your doctor’s office will have complaint forms available.
Online: Visit the CalViva Health website. Go to www.CalVivaHealth.org.
If you need help filing your complaint, we can help you. We can give you free language
services. Call 1-888-893-1569 (TTY/TDD 711).
Within 5 days of getting your complaint, we will send you a letter letting you know we
got it. Within 30 days, we will send you another letter that tells you how we resolved
your problem. If you call CalViva Health about a grievance that is not about health care
coverage, medical necessity, or experimental or investigational treatment, and your
grievance is resolved by the end of the next business day, you may not get a letter.
If you want us to make a fast decision because the time it takes to resolve your
complaint would put your life, health or ability to function in danger, you can ask for an
expedited (fast) review. To ask for an expedited review, call us at 1-888-893-1569
(TTY/TDD 711) and we will make a decision within 72 hours of receiving your complaint.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 80
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 81
6 | Reporting and solving grievances
Appeals
An appeal is different from a complaint. An appeal is a request for CalViva Health to
review and change a decision we made about coverage for a requested service. If we
sent you a Notice of Action (NOA) letter telling you that we are denying, delaying,
changing or ending a service, and you do not agree with our decision, you can file an
appeal. Your PCP or other provider can also file an appeal for you with your written
permission.
You must file an appeal within 60 calendar days from the date on the NOA you got from
CalViva Health. If you are currently getting treatment and you want to continue getting
treatment, then you must ask CalViva Health for an appeal within 10 calendar days from
the date the NOA was delivered to you, or before the date CalViva Health says services
will stop. When you request an appeal under these circumstances, treatment will
continue upon your request. We may require you to pay for the cost of services if the
final decision denies or changes a service.
You can file an appeal by phone, in writing or online:
By phone: Call CalViva Health at 1-888-893-1569 (TTY/TDD 711) 24 hours a
day, 7 days a week. Give your name, health plan ID number and the service you
are appealing.
By mail: Call CalViva Health at 1-888-893-1569 (TTY/TDD 711) and ask to have
a form sent to you. When you get the form, fill it out. Be sure to include your
name, health plan ID number and the service you are appealing.
Mail the form to:
CalViva Health
Grievance and Appeals Department
P.O. Box 10348
Van Nuys, CA 91410-0348
Your doctor’s office will have appeal forms available.
Online: Visit the CalViva Health website. Go to www.CalVivaHealth.org.
If you need help filing your appeal, we can help you. We can give you free language
services. Call 1-888-893-1569 (TTY/TDD 711).
Within 5 days of getting your appeal, we will send you a letter letting you know we got it.
Within 30 days, we will tell you our appeal decision. If CalViva Health does not tell you
its appeal decision within 30 days you can request a State Hearing and an Independent
6 | Reporting and solving grievances
Medical Review. But if you ask for a State Hearing first, and the hearing has already
happened, you cannot ask for an IMR. In this case, the State Hearing has final say.
If you or your doctor wants us to make a fast decision because the time it takes to
resolve your appeal would put your life, health or ability to function in danger, you can
ask for an expedited (fast) review. To ask for an expedited review, call 1-888-893-1569
(TTY/TDD 711). We will make a decision within 72 hours of receiving your appeal about
whether we will expedite your appeal.
What to do if you do not agree with an appeal decision
If you filed an appeal and got a letter from CalViva Health telling you we did
not change our decision, or you never got a letter telling you of our decision
and it has been past 30 days, you can:
Ask for a State Hearing from the California Department of Social Services
(CDSS), and a judge will review your case.
File an Independent Medical Review/Complaint form with the Department of
Managed Health Care (DMHC) to have CalViva Health’s decision reviewed or
ask for an Independent Medical Review (IMR) from the DMHC. During DMHC’s
IMR and an outside doctor who is not part of CalViva Health will review your
case. DMHC’s toll-free telephone number is 1-888-466-2219 and the TDD line is
1-877-688-9891. You can find the Independent Medical Review/Complaint form
and instructions online at the DMHC’s website: www.dmhc.ca.gov.
You will not have to pay for a State Hearing or an IMR.
You are entitled to both a State Hearing and an IMR. But if you ask for a State Hearing
first, and the hearing has already happened, you cannot ask for an IMR. In this case,
the State Hearing has the final say.
The sections below have more information on how to ask for a State Hearing and an
IMR.
Complaints and Independent Medical Reviews (IMR)
with the Department of Managed Health Care
An IMR is when an outside doctor who is not related to your health plan reviews your
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
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Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 82
6 | Reporting and solving grievances
case. If you want an IMR, you must first file an appeal with CalViva Health. If you do not
hear from your health plan within 30 calendar days, or if you are unhappy with your
health plan’s decision, then you may request an IMR. You must ask for an IMR within 6
months from the date on the notice telling you of the appeal decision but you only have
120 days to request a State Hearing so if you want an IMR and a State hearing file your
complaint as soon as you can. Remember, if you ask for a State Hearing first, and the
hearing has already happened, you cannot ask for an IMR. In this case, the State
Hearing has the final say.
You may be able to get an IMR right away without filing an appeal first. This is in cases
where your health problem is urgent.
If your complaint to DMHC does not qualify for an IMR, DMHC will still review your
complaint to make sure CalViva Health made the correct decision when you appealed
its denial of services. CalViva Health has to comply with DMHC’s IMR and review
decisions.
Here is how to ask for an IMR. The term “grievance” is for “complaints” and “appeals”:
The California Department of Managed Health Care is responsible for regulating health
care service plans. If you have a grievance against your health plan, you should first
telephone your health plan at 1-888-893-1569 (TTY/TDD 711) and use your health
plan’s grievance process before contacting the department. Utilizing this grievance
procedure does not prohibit any potential legal rights or remedies that may be available
to you. If you need help with a grievance involving an emergency, a grievance that has
not been satisfactorily resolved by your health plan, or a grievance that has remained
unresolved for more than 30 days, you may call the department for assistance. You may
also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the
IMR process will provide an impartial review of medical decisions made by a health plan
related to the medical necessity of a proposed service or treatment, coverage decisions
for treatments that are experimental or investigational in nature and payment disputes
for emergency or urgent medical services. The department also has a toll-free
telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing
and speech impaired. The department’s internet website http://www.dmhc.ca.gov has
complaint forms, IMR application forms and instructions online.
State Hearings
A State Hearing is a meeting with people from the California Department of Social
Services (CDSS). A judge will help to resolve your problem or tell you that
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
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Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 83
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 84
6 | Reporting and solving grievances
CalViva Health made the correct decision. You have the right to ask for a State Hearing
if you have already filed an appeal with CalViva Health and you are still not happy with
the decision or if you did not get a decision on your appeal after 30 days
You must ask for a State Hearing within 120 days from the date on CalViva Health’s
notice telling you of the appeal decision. Your PCP can ask for a State Hearing for you
with your written permission.
You can ask for a State Hearing by phone or mail.
By phone: Call the CDSS Public Response Unit at 1-800-952-5253
(TTY/TDD 1-800-952-8349 or 711).
By mail: Fill out the form provided with your appeals resolution notice. Send it to:
California Department of Social Services
State Hearings Division
P.O. Box 944243, MS 09-17-37
Sacramento, CA 94244-2430
If you need help asking for a State Hearing, we can help you. We can give you free
language services. Call 1-888-893-1569 (TTY/TDD 711).
At the hearing, you will give your side. We will give our side. It could take up to 90 days
for the judge to decide your case. CalViva Health must follow what the judge decides.
If you want the CDSS to make a fast decision because the time it takes to have a State
Hearing would put your life, health or ability to function fully in danger, you or your PCP
can contact the CDSS and ask for an expedited (fast) State Hearing. CDSS must make
a decision no later than 3 business days after it gets your complete case file from
CalViva Health.
Fraud, waste and abuse
If you suspect that a provider or a person who gets Medi-Cal has committed fraud,
waste or abuse, it is your right to report it by calling the confidential toll-free number 1-
800-822-6222 or submitting a complaint online at www.dhcs.ca.gov/.
Provider fraud, waste and abuse includes:
Falsifying medical records
Prescribing more medication than is medically necessary
Giving more health care services than medically necessary
Billing for services that were not given
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
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6 | Reporting and solving grievances
Billing for professional services when the professional did not perform the
service
Offering free or discounted items and services to members in an effort to
influence which provider is selected by the member
Changing member’s primary care physician without the knowledge of the
member
Fraud, waste and abuse by a person who gets benefits includes:
Lending, selling or giving a health plan ID card or Medi-Cal Benefits
Identification Card (BIC) to someone else
Getting similar or the same treatments or medicines from more than one
provider
Going to an emergency room when it is not an emergency
Using someone else’s Social Security number or health plan ID number
To report fraud, waste and abuse, write down the name, address and ID number of the
person who committed the fraud, waste or abuse. Give as much information as you can
about the person, such as the phone number or the specialty if it is a provider. Give the
dates of the events and a summary of exactly what happened.
Send your report to:
CalViva Health
Attention: Chief Compliance Officer
7625 N. Palm Ave, Suite 109
Fresno, CA 93711
Toll-free Phone: 1-866-863-2465 (Open 8 a.m. – 4 p.m. Monday through Friday)
Fax: 559-446-1998
7. Important numbers
and words to know
Important phone numbers
CalViva Health Member Services 1-888-893-1569 (TTY/TDD 711)
CalViva Health community office 1-866-863-2465 (TTY/TDD 711)
Disability Services
Website: https://www.ada.gov/
California Relay Service (CRS): TTY/TDD: 711
AT&T 1-866-421-4288 (Voice)
Americans Disabilities Act (ADA) Information: 1-800-514-0301
(Voice); 1-800-514-0383 (TDD)
California Children’s Services (CCS) program:
Website: https://www.dhcs.ca.gov/services/ccs
Fresno County 1-559-600-3300
Kings County 1-559-852-4693
Madera County 1-559-675-4945
Child Health and Disability Prevention (CHDP) Program:
Website: https://www.dhcs.ca.gov/services/chdp
Fresno County: 1-559-600-3281
Kings County: 1-559- 584-1401
Madera County: 1-559- 675-7608
California State Services
DHCS Ombudsman Office: 1-888-452-8609
(website: https://www.dhcs.ca.gov/services/MH/Pages/MH-
Ombudsman.aspx)
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 86
7 | Important numbers and words to know
Department of Social Services: 1-800-952-5253
(TDD: 1-800-952-8349) (website: https://www.cdss.ca.gov/county-
offices)
Department of Managed Health Care (DMHC): 1-888-466-2219
(1-888-HMO-2219)(website: https://www.dmhc.ca.gov/)
Social Security Administration
Supplemental Security Income (SSI): 1-800-772-1213,
(TTY/TDD: 1-800-325-0778)
Website: https://www.ssa.gov/
County Offices
Mental Health website:
https://www.dhcs.ca.gov/individuals/Pages/MHPContactList.aspx
o Fresno County
Website: https://www.co.fresno.ca.us/departments/social-
services/assistance-programs/medi-cal
Fresno County Department of Social Services: 1-855-832-8082
Fresno County Department of Behavioral health: 1-800-654-3937
o Kings County
Website: https://www.countyofkings.com/services/human-services-
agency/medi-cal-services
Kings County Department of Human Services Agency: 1-877-410-8813
Kings County Department of Behavioral health: 1-800-655-2553
o Madera County
Website: https://www.maderacounty.com/government/social-
services/healthcare
Madera County Department of Social Services: 1-559-675-2300
Madera County Department of Behavioral health: 1-888-275-9779
Words to know
Active labor: The period of time when a woman is in the three stages of giving birth
and either cannot be safely transferred in time to another hospital before delivery or a
transfer may harm the health and safety of the woman or unborn child.
Acute: A medical condition that is sudden, requires fast medical attention and does not
last a long time.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
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Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 87
7 | Important numbers and words to know
American Indian: An individual, defined at title 25 of the U.S.C. sections 1603(c),
1603(f). 1679(b) or who has been determined eligible, as an Indian, pursuant to 42
C.F.R. 136.12 or Title V of the Indian Health Care Improvement Act, to receive health
care services from Indian health care providers (Indian Health Service, an Indian Tribe,
Tribal Organization, or Urban Indian Organization–I/T/U) or through referral under
Contract Health Services.
Appeal: A member’s request for CalViva Health to review and change a decision made
about coverage for a requested service.
Benefits: Health care services and drugs covered under this health plan.
California Children’s Services (CCS): A Medi-Cal program that provides services for
children up to age 21 with certain diseases and health problems.
California Health and Disability Prevention (CHDP): A public health program that
reimburses public and private health care providers for early health assessments to
detect or prevent disease and disabilities in children and youth. The program helps
children and youth access regular health care. Your PCP can provide CHDP services.
Case manager: Registered nurses or social workers who can help y ou understand
major health problems and arrange care with your providers.
Certified Nurse Midwife (CNM): An individual licensed as a Registered Nurse and
certified as a nurse midwife by the California Board of Registered Nursing. A certified
nurse midwife is permitted to attend cases of normal childbirth.
Chiropractor: A provider who treats the spine by means of manual manipulation
Chronic condition: A disease or other medical problem that cannot be completely
cured or that gets worse over time or that must be treated so you do not get worse.
Clinic: A facility that members can select as a primary care provider (PCP). It can be
either a Federally Qualified Health Center (FQHC), community clinic, Rural Health Clinic
(RHC), Indian Health Clinic (IHC) or other primary care facility.
Community-based adult services (CBAS): Outpatient, facility-based services for
skilled nursing care, social services, therapies, personal care, family and caregiver
training and support, nutrition services, transportation, and other services for members
who qualify.
Complaint: A member’s verbal or written expression of dissatisfaction about CalViva
Health, a provider, or quality of services provided. A complaint is the same as a
grievance.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 88
7 | Important numbers and words to know
Continuity of care: The ability of a plan member to keep getting Medi-Cal services
from their existing provider for up to 12 months, if the provider and CalViva Health
agree.
Coordination of Benefits (COB): The process of determining which insurance
coverage (Medi-Cal, Medicare, commercial insurance or other) has primary treatment
and payment responsibilities for members with more than one type of health insurance
coverage.
Copayment: A payment you make, generally at the time of service, in addition to the
insurer's payment.
Coverage (covered services): The health care services provided to members of
CalViva Health, subject to the terms, conditions, limitations and exclusions of the Medi-
Cal contract and as listed in this Evidence of Coverage (EOC) and any amendments.
DHCS: The California Department of Health Care Services. This is the State office that
oversees the Medi-Cal program.
Disenroll: To stop using this health plan because you no longer qualify or change to a
new health plan. You must sign a form that says you no longer want to use this health
plan or call HCO and disenroll by phone.
DMHC: The California Department of Managed Health Care. This is the State office that
oversees managed care health plans.
Durable medical equipment (DME): Equipment that is medically necessary and
ordered by your doctor or other provider. CalViva Health decides whether to rent or buy
DME. Rental costs must not be more than the cost to buy. Repair of medical equipment
is covered.
Early and periodic screening, diagnostic, and treatment (EPSDT): EPSDT services
are a benefit for Medi-Cal members under the age of 21 to help keep them healthy.
Members must get the right health check-ups for their age and appropriate screenings
to find health problems and treat illnesses early.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
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Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 89
7 | Important numbers and words to know
Emergency medical condition: A medical or mental condition with such severe
symptoms, such as active labor (go to definition above) or severe pain, that someone
with a prudent layperson’s knowledge of health and medicine could reasonably believe
that not getting immediate medical care could:
Place your health or the health of your unborn baby in serious danger
Cause impairment to a body function
Cause a body part or organ to not work right
Emergency room care: An exam performed by a doctor (or staff under direction of a
doctor as allowed by law) to find out if an emergency medical condition exists. Medically
necessary services needed to make you clinically stable within the capabilities of the
facility.
Emergency medical transportation: Transportation in an ambulance or emergency
vehicle to an emergency room to get emergency medical care.
Enrollee: A person who is a member of a health plan and gets services through the
plan.
Excluded services: Services that are not covered by the California Medi-Cal Program.
Family planning services: Services to prevent or delay pregnancy.
Federally Qualified Health Center (FQHC): A health center in an area that does not
have many health care providers. You can get primary and preventive care at an FQHC.
Fee-For-Service (FFS): This means you are not enrolled in a managed care health
plan. Under FFS, your doctor must accept “straight” Medi-Cal and bill Medi-Cal directly
for the services you got.
Follow-up care: Regular doctor care to check a patient’s progress after a
hospitalization or during a course of treatment.
Formulary: A list of drugs or items that meet certain criteria and are approved for
members.
Fraud: An intentional act to deceive or misrepresent by a person who knows the
deception could result in some unauthorized benefit for the person or someone else.
Freestanding Birth Centers (FBCs): Health facilities where childbirth is planned to
occur away from the pregnant woman’s residence that are licensed or otherwise
approved by the state to provide prenatal labor and delivery or postpartum care and
other ambulatory services that are included in the plan. These facilities are not
hospitals.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 90
7 | Important numbers and words to know
Grievance: A member’s verbal or written expression of dissatisfaction about
CalViva Health, a provider, or the services provided. A complaint is an example of a
grievance.
Habilitation services and devices: Health care services that help you keep, learn or
improve skills and functioning for daily living.
Health Care Options (HCO): The program that can enroll or disenroll you from the
health plan.
Health care providers: Doctors and specialists such as surgeons, doctors who treat
cancer or doctors who treat special parts of the body, and who work with CalViva Health
or are in the CalViva Health network. CalViva Health network providers must have a
license to practice in California and give you a service CalViva Health covers.
You usually need a referral from your PCP to go to a specialist. Your PCP must get pre-
approval from CalViva Health before you get care from the specialist.
You do not need a referral from your PCP for some types of service, such as family
planning, emergency care, ob/gyn care or sensitive services.
Types of health care providers include, but are not limited to:
Audiologist is a provider who tests hearing.
Certified nurse midwife is a nurse who cares for you during pregnancy and
childbirth.
Family practitioner is a doctor who treats common medical issues for people
of all ages.
General practitioner is a doctor who treats common medical issues.
Internist is a doctor who treats common medical issues in adults.
Licensed vocational nurse is a licensed nurse who works with your doctor.
A counselor is a person who helps you with family problems.
Medical assistant or certified medical assistant is a non-licensed person who
helps your doctors give you medical care.
Mid-level practitioner is a name used for health care providers, such as nurse-
midwives, physician assistants or nurse practitioners.
Nurse anesthetist is a nurse who gives you anesthesia.
Nurse practitioner or physician assistant is a person who works in a clinic or
doctor’s office who diagnoses, treats and cares for you, within limits.
Obstetrician/gynecologist (ob/gyn) is a doctor who takes care of a woman’s
health, including during pregnancy and birth.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 91
7 | Important numbers and words to know
Occupational therapist is a provider who helps you regain daily skills and
activities after an illness or injury.
Pediatrician is a doctor who treats children from birth through the teen years.
Physical therapist is a provider who helps you build your body’s strength after
an illness or injury.
Podiatrist is a doctor who takes care of your feet.
Psychologist is a person who treats mental health issues but does not
prescribe drugs.
Registered nurse is a nurse with more training than a licensed vocational
nurse and who has a license to do certain tasks with your doctor.
Respiratory therapist is a provider who helps you with your breathing.
Speech pathologist is a provider who helps you with your speech.
Health insurance: Insurance coverage that pays for medical and surgical expenses by
repaying the insured for expenses from illness or injury or paying the care provider
directly.
Home health care: Skilled nursing care and other services given at home.
Home health care providers: Providers who give you skilled nursing care and other
services at home.
Hospice: Care to reduce physical, emotional, social and spiritual discomforts for a
member with a terminal illness. Hospice care is available when the member has a life
expectancy of 6 months or less.
Hospital: A place where you get inpatient and outpatient care from doctors and nurses.
Hospitalization: Admission to a hospital for treatment as an inpatient.
Hospital outpatient care: Medical or surgical care performed at a hospital without
admission as an inpatient.
Indian Health Clinic (IHC): A health clinic operated by the Indian Health Service (IHS)
or by an Indian Tribe, Tribal Organization, or Urban Indian Organization.
Inpatient care: When you have to stay the night in a hospital or other place for the
medical care you need.
Long-term care: Care in a facility for longer than the month of admission.
Managed care plan: A Medi-Cal plan that uses only certain doctors, specialists, clinics,
pharmacies and hospitals for Medi-Cal recipients enrolled in that plan. CalViva Health is
a managed care plan.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 92
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 93
7 | Important numbers and words to know
Medical home: A model of care that will provide better health care quality, improve self-
management by members of their own care and reduce avoidable costs over time.
Medically necessary (or medical necessity): Medically necessary care are important
services that are reasonable and protect life. This care is needed to keep patients from
getting seriously ill or disabled. This care reduces severe pain by treating the disease,
illness or injury. For members under the age of 21, Medi-Cal services includes care that
is medically necessary to fix or help a physical or mental illness or condition, including
substance use disorders, as set forth in Section 1396d(r) of Title 42 of the United States
Code.
Medicare: The federal health insurance program for people 65 years of age or older,
certain younger people with disabilities, and people with end-stage renal disease
(permanent kidney failure that requires dialysis or a transplant, sometimes called
ESRD).
Member: Any eligible Medi-Cal member enrolled with CalViva Health who is entitled to
get covered services.
Mental health services provider: Licensed individuals who provide mental health and
behavioral health services to patients.
Midwifery services: Prenatal, intrapartum, and postpartum care, including family
planning care for the mother and immediate care for the newborn, provided by certified
nurse midwives (CNM) and licensed midwives (LM).
Network: A group of doctors, clinics, hospitals and other providers contracted with
CalViva Health to provide care.
Network provider (or in-network provider): Go to “Participating provider.”
Non-covered service: A service that CalViva Health does not cover.
Non-emergency medical transportation (NEMT): Transportation when you cannot get
to a covered medical appointment and/or to pick up prescriptions by car, bus, train or
taxi. CalViva Health pays for the lowest cost NEMT for your medical needs when you
need a ride to your appointment.
Non-formulary drug: A drug not listed in the drug formulary.
Non-medical transportation: Transportation when traveling to and from an
appointment for a Medi-Cal covered service authorized by your provider and when
picking up prescriptions and medical supplies.
Non-participating provider: A provider not in the CalViva Health network.
7 | Important numbers and words to know
Other health coverage (OHC): Other health coverage (OHC) refers to private health
insurance and service payers other than Medi-Cal. Services may include medical,
dental, vision, pharmacy and/or Medicare supplemental plans (Part C & D).
Orthotic device: A device used as a support or brace affixed externally to the body to
support or correct an acutely injured or diseased body part and that is medically
necessary for the medical recovery of the member.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
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Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 94
Out-of-area services: Services while a member is anywhere outside of the service
area.
Out-of-network provider: A provider who is not part of the CalViva Health network.
Outpatient care: When you do not have to stay the night in a hospital or other place for
the medical care you need.
Outpatient mental health services: Outpatient services for members with mild to
moderate mental health conditions including:
Individual or group mental health evaluation and treatment (psychotherapy)
Psychological testing when clinically indicated to evaluate a mental health
condition
Outpatient services for the purposes of monitoring medication therapy
Psychiatric consultation
Outpatient laboratory, supplies and supplements
Palliative care: Care to reduce physical, emotional, social and spiritual discomforts for
a member with a serious illness.
Participating hospital: A licensed hospital that has a contract with CalViva Health to
provide services to members at the time a member gets care. The covered services that
some participating hospitals may offer to members are limited by CalViva Health’s
utilization review and quality assurance policies or CalViva Health’s contract with the
hospital.
Participating provider (or participating doctor): A doctor, hospital or other licensed
health care professional or licensed health facility, including sub-acute facilities that
have a contract with CalViva Health to offer covered services to members at the time a
member gets care.
Physician services: Services given by a person licensed under state law to practice
medicine or osteopathy, not including services offered by doctors while you are
admitted in a hospital that are charged in the hospital bill.
Plan: Go to “Managed care plan.”
7 | Important numbers and words to know
Post-stabilization services: Covered services related to an emergency medical
condition that are provided after a member is stabilized to maintain the stabilized
condition. Post-stabilization care services are covered and paid for.
Pre-approval (or prior authorization): Your PCP or other providers must get approval
from CalViva Health before you get certain services. CalViva Health will only approve
the services you need. CalViva Health will not approve services by non-participating
providers if CalViva Health believes you can get comparable or more appropriate
services through CalViva Health providers. A referral is not an approval. You must get
approval from CalViva Health.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 95
Prescription drug coverage: Coverage for medications prescribed by a provider.
Prescription drugs: A drug that legally requires an order from a licensed provider to be
dispensed, unlike over-the-counter (OTC) drugs that do not require a prescription.
Primary care: Go to “Routine care.”
Primary care provider (PCP): The licensed provider you have for most of your health
care. Your PCP helps you get the care you need. Some care needs to be approved first,
unless:
You have an emergency
You need ob/gyn care
You need sensitive services
You need family planning services/birth control
Your PCP can be a:
General practitioner
Internist
Pediatrician
Family practitioner
Ob/gyn
Indian Health Clinic (IHC)
Federally Qualified Health Center (FQHC)
Rural Health Clinic (RHC)
Nurse practitioner
Physician assistant
Clinic
Prior authorization (pre-approval): A formal process requiring a health care provider
to get approval to provide specific services or procedures.
7 | Important numbers and words to know
Prosthetic device: An artificial device attached to the body to replace a missing body
part.
Provider Directory: A list of providers in the CalViva Health network.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 96
Psychiatric emergency medical condition: A mental disorder in which the symptoms
are serious or severe enough to cause an immediate danger to yourself or others or you
are immediately unable to provide for or use food, shelter or clothing due to the mental
disorder.
Public health services: Health services targeted at the population as a whole. These
include, among others, health situation analysis, health surveillance, health promotion,
prevention services, infectious disease control, environmental protection and sanitation,
disaster preparedness and response, and occupational health.
Qualified provider: Doctor qualified in the area of practice appropriate to treat your
condition.
Reconstructive surgery: Surgery to correct or repair abnormal structures of the body
to improve function or create a normal appearance to the extent possible. Abnormal
structures of the body are those caused by a congenital defect, developmental
abnormalities, trauma, infection, tumors, or disease.
Referral: When your PCP says you can get care from another provider. Some covered
care services require a referral and pre-approval (prior authorization).
Rehabilitative and habilitative therapy services and devices: Services and devices
to help people with injuries, disabilities, or chronic conditions to gain or recover mental
and physical skills.
Routine care: Medically necessary services and preventive care, well child visits, or
care such as routine follow-up care. The goal of routine care is to prevent health
problems.
Rural Health Clinic (RHC): A health center in an area that does not have many health
care providers. You can get primary and preventive care at an RHC.
Sensitive services: Services for family planning, sexually transmitted infections (STIs),
HIV/AIDS, sexual assault and abortions.
Serious illness: A disease or condition that must be treated and could result in death.
Service area: The geographic area CalViva Health serves. This includes the counties
of Fresno, Kings and Madera.
Skilled nursing care: Covered services provided by licensed nurses, technicians
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 97
7 | Important numbers and words to know
and/or therapists during a stay in a Skilled Nursing Facility or in a member’s home.
Skilled nursing facility: A place that gives 24-hour-a-day nursing care that only trained
health professionals may give.
Specialist (or specialty doctor): A doctor who treats certain types of health care
problems. For example, an orthopedic surgeon treats broken bones; an allergist treats
allergies; and a cardiologist treats heart problems. In most cases, you will need a
referral from your PCP to go to a specialist.
Specialty mental health services: Services for members who have mental health
services needs that are a higher level of impairment than mild to moderate.
Terminal illness: A medical condition that cannot be reversed and will most likely
cause death within one year or less if the disease follows its natural course.
Triage (or screening): The evaluation of your health by a doctor or nurse who is
trained to screen for the purpose of determining the urgency of your need for care.
Urgent care (or urgent services): Services provided to treat a non-emergency illness,
injury or condition that requires medical care. You can get urgent care from an out-of-
network provider, if network providers are temporarily not available or accessible.
Call Member Services at 1-888-893-1569 (TTY/TDD 711).
CalViva Health is here 24 hours a day, 7 days a week. The call is toll free.
Or call the California Relay Line at 711. Visit online at www.CalVivaHealth.org. 98
