Providers

Welcome Providers

Gold Coast Health Plan and its providers are committed to delivering quality care to their members. We maintain a robust provider network that includes more than 3600 providers, 187 pharmacies and most of the local hospitals and long-term care facilities in Ventura County. This section is designed exclusively for our providers who can access the following:

  • Provider portal.
  • Electronic claims submission.
  • List of covered drugs (formulary).
  • Provider resources (forms and documents).
  • And much more.

Any provider or health care professional who has questions about Medi-Cal or Gold Coast Health Plan can contact our Provider Relations department at providerrelations@goldchp.org or by calling 888.301.1228.

Contact Us

Toll Free Number: 888.301.1228

Gold Coast Health Plan
Attn: Claims
P.O. Box 9152
Oxnard, CA 93031-9152

Gold Coast Health Plan
Attn: Correspondence
P.O. Box 9153
Oxnard, CA 93031-9153

Gold Coast Health Plan
Attn: Grievances
P.O. Box 9176
Oxnard, CA 93031-9176

Credentialing

Gold Coast Health Plan is committed to ensuring access to a high-quality healthcare delivery system. We contract with high-quality institutions, Providers and allied health professionals to ensure that Members receive quality healthcare and services.

The Credentials Committee is responsible for credentialing and recredentialing all healthcare Providers as verification of a Provider's professional qualifications. All credentialing and recredentialing are performed in accordance with National Committee for Quality Assurance (NCQA) standards and guidelines. Credentialing documents are obtained through the Council for Affordable Quality Healthcare (CAQH). Providers who do not have a CAQH file may be required to complete a Practitioner Credentialing Application. Gemini Diversified Services, a credentialing verification organization, conducts primary source verification, data collection and reporting services.

All Providers must be qualified in accordance with current applicable legal, professional and technical standards and appropriately licensed, certified or registered. All Providers must have good standing in the Medicare and Medicaid/Medi-Cal programs. Providers that have been terminated from either Medicare or Medicaid/Medi-Cal cannot participate in Gold Coast Health Plan. The Credentials Committee makes the decision to accept, retain, deny or terminate a practitioner's participation in Gold Coast Health Plan. The Credentials Committee does not make credentialing or recredentialing decisions based on an applicant's age, gender, race, ethnic/national identity, sexual orientation or types of procedures performed by the applicant.

Gold Coast Health Plan may delegate specific credentialing and recredentialing responsibilities to qualified entities. Before delegation is granted, the entity must submit written policies and procedures related to credentialing activities of potential Plan Network Providers. The written policies and procedures must meet Plan requirements for credentialing and recredentialing. Gold Coast Health Plan designated staff, the chief medical officer and the Credentials Committee have responsibility to perform oversight of any delegated entity's credentialing and recredentialing activities to ensure full compliance with Gold Coast Health Plan policies and to make recommendations for improvement as appropriate. If the delegated entity fails to fulfill its obligations, Gold Coast Health Plan will retain the right to revoke delegation.

Credentials/Peer Review Committee Meeting

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Pharmacy

Gold Coast Health Plan contracts with pharmacies in Ventura County and its surrounding counties to enable members to receive their medications in the most convenient location. This page contains important documents and links to information regarding the pharmacy benefit for Gold Coast Health Plan members including the formulary, prior authorization criteria and provider updates.

For any pharmacy wishing to become part of the GCHP Pharmacy Network, please visit the OptumRx provider relations website at https://professionals.optumrx.com/. If you are unable to access the website, please contact OptumRx:

Email: provider.relations@optum.com
Phone: 877.633.4701
Fax: 877.339.0784

Below is a Provider Portal link that enable prescribing providers to verify formulary coverage, prior authorization criteria and initiate a web-based prior authorization request for GCHP members.

OptumRx Provider Website

Contact OptumRx at 1.855.297.2870; TTY 711

Pharmacy Resources

Provider Directory

Formulary

Downloads

Pharmacy Newsletters and DUR Bulletins

Provider Portal

The Gold Coast Health Plan Provider Portal provides online access to member eligibility information, the ability to enter authorization requests and check status of authorizations, and to check the status of claims. Office managers request and maintain user privileges for themselves and for office staff.

Provider Web Portal

Provider Web Portal User Guide

Portal Special Information

Providers will need their IKA provider or professional number to register at the portal. Also:

  • The Reset User function (administrator only) is no longer its own tab but a sub-choice on the Manage Users tab.
  • The authorization search has been expanded by adding the following additional search screens:
    • Service Type
    • Service Location
    • Authorization Status
    • Authorization Type
    • Receive Date Range
    • Primary Diagnosis
  • The maximum number of authorizations returned on a search has been increased to 300.
  • The maximum number of claims returned on a search has been increased to 300.
  • Providers having problems with portal registration or providers who need their IKA provider or professional number can send an email notification to providerrelations@goldchp.org. Please include the name of the provider, the provider type, NPI number and tax ID number.
  • When registering using the tax ID number do not include the hyphen, only include the numbers.
  • When entering the member ID only use the GCHP ID number which is the first nine (9) digits (8 numbers and 1 letter) of their BIC.
  • The following features are NOT currently available through the Provider Portal:
    • Attachments cannot be made to authorizations or claims.
    • Section 1.13. Submission of UBs and HCFAs, has been removed from the Provider Portal User Guide. UBs and HCFAs cannot currently be submitted through the Provider Portal. Until this feature is available, paper claims and electronic claims through EDI Direct will be accepted.

When validating eligibility, Default PCP means the member has not been assigned a primary care provider. Providers can have members complete the PCP Selection Form on the Change Your Primary Care Provider section. Completed forms can be faxed to Gold Coast Health Plan PCP Assignment at 888.310.3660.

Provider Relations

Please contact the Provider Relations Department by emailing us at ProviderRelations@goldchp.org.

Help us keep our records current and accurate by completing and submitting the Provider Information Update Form when changes arise, such as provider status, address, phone number, payment address, NPI and tax ID information.

Interested in becoming a GCHP In-Network Provider? Please contact Provider Relations by email at ProviderRelations@goldchp.org or by calling 888.301.1228.

Provider Updates

Gold Coast Health Plan occasionally sends updates to our providers with important plan information. You can get these updates by contacting Provider Relations at ProviderRelations@goldchp.org or by calling 888.301.1228.

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Provider Operations Bulletin

The GCHP Provider Operations Bulletin is a quarterly newsletter geared towards our medical providers.

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Resources

Affordable Care Act (ACA)—Primary Care Payment Increase

Physicians must self-attest that they are eligible to receive the payment increase by completing the Affordable Care Act (ACA) Self Attestation Form. GCHP cannot make the increased payments to providers until they have completed this and submitted a W9 form.

GCHP ACA FAQ (updated 12/18/2014)

GCHP ACA Provider Information Form

W9 Form

Attestation Form

GCHP has created a convenient online provider attestation form that will allow for the timely acquisition and gathering of network reporting requirements required by the Department of Health Care Services (DHCS).

Provider attestation form

Beacon (PCP Referral Form)

Beacon Health Options partners with Gold Coast Health Plan to manage the mental health benefit of Medi-Cal beneficiaries. The PCP referral form allows primary care providers to access the services available through Beacon.

Beacon Health Options PCP Referral Form

Beacon Health Options Care Management Referral Form

California Children's Services

California Children's Services (CCS) and Gold Coast Health Plan (GCHP) work together for the benefit of children and young adults residing in Ventura County. CCS provides services for children with physical disabilities or conditions that are costly, chronic or catastrophic.

If you have questions about CCS eligibility, GCHP Care Managers may be able to assist you.

Access the CCS website where you can access information about eligibility, benefits, how to apply and all CCS programs.

CCS Website

The CCS office in Ventura County is located at:
2240 East Gonzales Road, Suite 260
Oxnard, CA 93036
Phone: 805.981.5281
Fax: 805.658.4580

Community-Based Adult Services Program (CBAS)

The Community-Based Adult Services Program (CBAS) transitions from a fee-for-service program to a Medi-Cal managed care benefit, on October 1, 2012. CBAS replaces the state's Adult Day Health Care (ADHC) program and will be managed by Gold Coast Health Plan.

Learn more about CBAS

CORE Channel

In compliance with CAQH CORE Operating Rules, GCHP now offers Providers the following options;

Eligibility Benefit Request and Response Transaction (270/271)

Companion Guide: Claim Status Request and Response Transaction (276/277)

Companion Guide: Electronic Remittance Advice – ERA (835)

CORE Channel Enrollment Form

Electronic Remittance Advice – ERA (835) Form

EFT Enrollment Form

The EFT Enrollment Form is intended for CORE EFT enrollments only. For standard EDI EFT requests, please see the documents in the Electronic Funds Transfer section below)

Note: The systems used for the CORE Channel transactions have a standard maintenance schedule of Sunday 10PM to 12AM PST. The systems are unavailable during this time.

Disease Management

Gold Coast Health Plan (GCHP) aims to improve the health of its members and their families by partnering with its network of providers to deliver evidence-based care.

The Disease Management Program is a free service for members that provides them with targeted interventions to help manage chronic conditions like diabetes. The goal of the program is to work with primary care providers, specialists and members to identify the best ways for members to stay as healthy as possible, reduce or delay long-term complications and manage the member's conditions with appropriate care for the best health outcomes. The Program offers members:

  • Educational materials and links to resources in either English or Spanish.
  • Classes taught in English or Spanish near the member's home or work.
  • An individualized action plan and access to work with a Nurse Health Coach.

For more information, here are some helpful links:

Disease Management for Diabetes Referral Form

American Diabetes Association's 2019 Standards of Medical Care in Diabetes

Guidelines for the Diagnosis and Management of Asthma (EPR-3)

Click here to learn more.

Electronic Claims Submission

Providers and clearinghouses are required to enroll as a Trading Partner to submit claims electronically. Please direct questions to EDI Customer Support at 800.952.0495 or by email to edicommercialsupportteam@conduent.com. For information about EDI please visit: https://www.conduent.com/edi/.

Important Deadline

The deadline for conversion to 5010 has been extended to align with the State deadline. Effective July 1, 2012, all GCHP trading partners must submit 837I and 837P Healthcare claims in 5010 X12. If you have not tested or transitioned from 4010 to 5010 please contact our EDI Commercial Support Team at the number or email below.

Helpful Tips 999 and 997 Responses

  • A response file will be produced and posted to your trading partner mailbox for each file you submit to Xerox EDI Direct. It is imperative that you retrieve your response files to determine whether your files were accepted, errored or rejected. If your response file contains any value other than an "A" in the IK5, AK5 or AK9 and you are unsure of the error or rejection, please contact our EDI Commercial Support Team at the number or email below.
  • The most common rejections identified are the subscriber ID and the secondary ID (Legacy IDs).
  • The subscriber ID in loop 2010BA NM109 should be a 9-byte ID (8 numerics + 1 letter).
  • Secondary IDs or Legacy IDs should not be present in the provider loops, with the exception of the tax ID in the 2010AA Billing Loop.

Helpful Guides

GCHP Companion Document

EDI Direct 5010 Communications Document

WinASAP5010 Users: Quick reference guide

EDI Direct 835 Transaction Form

If you have any other questions about transitioning to 5010, please do not hesitate to contact us.

EDI Commercial Support Team
edicommercialsupportteam@conduent.com
Government Healthcare Solutions

Conduent EDI Solutions, Inc.
2073 Summit Lake Drive
Suite 307
Tallahassee, FL 32317
Phone: 800-952-0495 Option 2 (for GCHP)
https://www.conduent.com/edi/

Electronic Funds Transfer

Gold Coast Health Plan supports Electronic Funds Transfer (EFT). Providers who enroll in EFT will have their Medi-Cal payments directly deposited in their checking or savings account. The EFT option is currently being made available to in-network providers located in Ventura County.

Electronic Funds Transfer Form

FAQs for Physicians

This document has been prepared as a quick reference to answer Provider questions about Gold Coast Health Plan. Please click here to view and/or download the document FAQs for Physicians (last updated 2/15/12).

Forms and Documents

Claims

Certification Page

Claim Correction Form

Claims LTC Instructions

Claims Tips

FAQs on Claims Issues

Overpayment Form

Manifestation Codes

Pharmacy Claim Form

Questionable Diagnosis Codes

Unacceptable Principal Diagnosis Codes

Health Services

Staying Healthy Assessment Forms

Synagis Referral Form

Note: Treatment Authorization Requests approved by the Department of Health Services will be honored for 60 days.

Grievance & Appeals (G&A)

Gold Coast Health Plan (GCHP) offers a process for providers to have claim-related issues resolved and/or to express their dissatisfaction with an action that was taken. For complaints concerning refunds or corrected claims, please consult the GCHP Provider Manual.

To better serve its providers, GCHP has streamlined the submission process by offering one submission form that will allow you to indicate whether you are submitting one of the following:

  • Provider Dispute – A request for reconsideration of an original claim that has been previously denied or underpaid.
  • Appeal – A request for reconsideration of an authorization denial or a notice of action.
  • Grievance – A request for reconsideration of a previously-disputed claim in which the provider is not satisfied with the resolution outcome.

Provider Reconsideration Request Form

Submit your completed forms to:

Gold Coast Health Plan
Attn: Provider Disputes & Grievances
P.O. Box 9176
Oxnard, CA 93031

Clinical Practice Guidelines

Gold Coast Health Plan's (GCHP) Medical Advisory Committee (MAC) adopts clinical practice guidelines to educate providers regarding comprehensive, current, evidence-based management practices to improve quality of care. Clinical practice guidelines minimize inter-practitioner variation in an attempt to reduce the use of outdated approaches to care. These guidelines may also be used to define objective clinical criteria for measurement of provider performance, may assist in making utilization management determinations, and will define best practices for Care Management and Disease Management programs.

Asthma Clinical Practices Guideline

Diabetes Clinical Practice Guideline

Immunization Guideline

Preventive Services Guideline

Utilization Management Guidelines

Gold Coast Health Plan (GCHP) has developed utilization management (UM) guidelines that are adopted by the Medical Advisory Committee (MAC) and are used in clinical decision making for review of precertification inpatient, level of care, and retrospective reviews. While the clinical UM guidelines developed by GCHP are available on this website, material from MCG and UpToDate is proprietary and is not published on this site.

Access the Utilization Management Guidelines

Healthy Families Program

The Healthy Families Program (HFP) transitions into Medi-Cal managed care August 1, 2013. Click here to read FAQs targeted for families in preparation for their transition to Medi-Cal and Gold Coast Health Plan from the Department of Health Care Services (DHCS).

Healthy Families Program FAQs for Providers

ICD-10 Transition

Effective October 1, 2015, providers will be required to submit ICD-10 codes on all claims for dates of service on and after October 1st. There are two major reasons for the move to ICD-10: 1). ICD-10 represents a major change in the medical coding system and, 2).There is much greater specificity in ICD-10. This will allow for greater specificity which makes it easier to find codes. In addition, the improved structure of ICD-10-CM will facilitate the development of increasingly sophisticated electronic coding tools that will assist in faster code selection.

GCHP has provided several reference documents & tools that not only address general information about ICD-10, but changes to specific rules around how we, as a plan will handle and process authorizations and claims.

ICD-10 FAQs

May 2015 Town Hall Presentation (YouTube Video)

October 2015 Town Hall ICD-10 Training

August 2015 ICD-10 Quick Reference Guides

Immunizations

Gold Coast Health Plan (GCHP) supports the efforts of its providers to protect patients of all ages against vaccine-preventable diseases.

The Centers for Disease Control and Prevention (CDC) and the California Department of Public Health (CDPH) have immunization resources available for health care professionals.

CDC Resources:

The #HowIRecommend vaccination videos explain how to make effective vaccine recommendations, address common questions, and take a team-based approach to vaccinations.

#HowIRecommend vaccination videos

CDPH Resources:

“How to Increase Flu Vaccination Coverage in Your Clinic” is a free, on-demand webinar that highlights the importance of protecting patients against influenza, the efforts of Vaccines for Children (VFC) Program to improve vaccine uptakes, and strategies for increasing overall immunization coverage.

How to Increase Flu Vaccination Coverage in Your Clinic

“Afternoon TEAch with CDPH” is a webinar series that covers a variety of immunization topics.

Afternoon TEAch with CDPH

For additional resources or information, please email QualityImprovement@goldchp.org or HealthEducation@goldchp.org.

Long-Term Care

The LTC 25-1 Form is preferred. Generating this typed form will help us expedite payment of claims. Please include the diagnosis code for each Member each week.

Mail the 25-1 Form to:
Gold Coast Health Plan
Attention: Claims
P.O. Box 9152
Oxnard, CA 93031-9152

Direct authorization questions to:
Health Services
888.301.1228

Managed Care Accountability Set Quality Measures

Effective in Reporting Year (RY) 2020, Gold Coast Health Plan (GCHP) will monitor and report on the Managed Care Accountability Set (MCAS) performance measures. MCAS is based on the Centers for Medicare and Medicaid Services (CMS) Child and Adult Core Set Measures. All state Medi-Cal Managed Care Plans (MCPs) are required to annually monitor and report these measures to the state Department of Health Care Services (DHCS).

MCAS Frequently Asked Questions

MCAS Reference Materials
To help providers understand the MCAS performance measure requirements, GCHP’s Quality Improvement Department has developed a reference guide and tip sheets to share key information on individual MCAS measures. These tip sheets are not intended to direct clinical judgement, but to serve as resources in understanding measurement specifications while providing guidance for measure compliance.

MCAS Quick Reference Guide

MCAS Tip Sheets

Adult BMI Assessment (ABA)

Follow-up Care for Children Prescribed Attention-Deficit / Hyperactivity Disorder (ADHD) Medication (ADD)

Antidepressant Medication Management (AMM)

Asthma Medication Ratio (AMR)

Adolescent Well-Care Visits (AWC)

Breast Cancer Screening (BCS)

Children and Adolescents’ Access to Primary Care Practitioners (CAP)

Controlling High Blood Pressure (CBP)

Contraceptive Care Postpartum Women Ages 15-44 (CCP)

MCPDIP Provider Form

The Managed Care Provider Data Improvement Project (MCPDIP) is a state issued requirement change for the submission of provider data that replaces the current monthly submission procedure governed by APL-14006. MCPDIP will allow DHCS to monitor GCHP's provider network. Click the link below to access the form.

MCPDIP Provider Form

Non-Emergency Medical Transportation (NEMT) and Non-Medical Transportation (NMT)

Non-Emergency Medical Transportation (NEMT) is a ride for medical care that is not an emergency. NEMT is provided for GCHP members who cannot sit in a regular vehicle due to a medical condition and who need to be transported in a specialized vehicle, such as a gurney van. NEMT is covered by GCHP.

Providers must complete the NEMT Prescription / Attestation of Medical Necessity form and fax it to GCHP at 1-855-883-1552. Completion of the form by providers ensures that a physician has reviewed the requirements for NEMT under state regulation Title 22.

Click here to access the form.

Once GCHP notifies its contracted transportation provider, Ventura Transit System (VTS) that the member is eligible, VTS will contact the member to arrange transportation.

Non-Medical Transportation (NMT) is a ride to get to medical care when the member does not have any way to get to that care for services such as scheduled appointments at any medical clinic or provider, dentist, eye doctor or vision center, pharmacy, equipment provider, behavioral therapy visit, or approved health education program.

GCHP members who require NMT services should contact the Plan’s contracted provider, Ventura Transit System (VTS) directly at 1-855-628-7433/1-800-855-7100 (California Relay Service) to arrange for transportation. Prior to receiving services for the first time, members must attest to VTS that they have no other means of transportation. Members should contact VTS at least 48 hours in advance of the transportation need and be prepared to show their GCHP member ID card.

GCHP reviews and coordinates both NEMT and NMT eligibility with VTS.

Click here for a list of Frequently Asked Questions (FAQs).

GCHP offers NEMT and NMT for eligible members who need a ride to their dialysis appointments. Click the link below for some helpful tips for members when scheduling dialysis transportation.

Click here for the Dialysis Transportation Brochure

If you have any questions, contact GCHP’s Provider Relations Department at ProviderRelations@goldchp.org.

Palliative Care Program

In 2018, Gold Coast Health Plan implemented a palliative care benefit called MyGoldCare™.

GCHP strives to build a strong provider network of qualified, multidisciplinary teams dedicated to providing patient- and family-centered care that addresses the physical, intellectual, emotional, social, and spiritual needs of the Plan’s population in the most compassionate way possible. The MyGoldCare palliative care program will be available for any member who qualifies. This does not result in a reduction in benefits for members.

No prior authorization is required for palliative care services. Referring providers may refer directly to a MyGoldCare palliative care provider to assure timely access. A list of contracted outpatient and in-home palliative care providers can be found in the GCHP Provider Directory.

Click here for Frequently Asked Questions About Palliative Care Services for GCHP Members.

Pharmacy Newsletter

The Pharmacy Newsletter is designed to educate and inform providers with updates to the Plan's list of covered drugs.

Current newsletter

Archived newsletters can be viewed above.

Provider Advisory Committee

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2016

2013

2012

2011

Provider Directory

Access the Provider Directory

Provider Manual

The Provider Manual describes operational policies and procedures relative to the provision of healthcare services to Gold Coast Health Plan Members. Revisions and updates are made frequently. Please note the revision date of the manual.

Provider Manual (last updated January 16, 2019)

We welcome your comments for changes and additional topics to include in this manual. Please email your comments to the Provider Relations Department at ProviderRelations@goldchp.org or through our call center at 888.301.1228.

Provider Orientation

Provider Orientation Meetings

Provider Training Notice

Provider Training Notice

Quality Improvement Committee

The Quality Improvement Committee is responsible for monitoring and evaluation of the overall effectiveness of quality improvement activities at GHCP. The committee oversees the annual review, analysis and evaluation for achievement of goals of the Quality Improvement Program and the Quality Improvement Work Plan. The Committee makes recommendations for implementation of interventions or corrective actions based on results of quality improvement activities. The Quality Improvement Committee provides updates to the Ventura County Medi-Cal Managed Care Commission on a quarterly basis.

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Request for Authorization

The CPT Codes© and Descriptors Form is to be used by Podiatrists for Expanded Podiatry Services.

CPT Codes© and Descriptors Form

Direct Referral Authorization Form (updated July 5, 2016) is for use by Primary Care Providers when referring Members to an in-network, in-area specialist.

Direct Referral Authorization Form

Home Health Prior Authorization Checklist (updated August 3, 2015) is for use by Providers to facilitate the prior authorization process for home health requests.

Home Health Prior Authorization Checklist (updated August 3, 2015)

The MyGoldCare Palliative Care Program is available for any member who qualifies. This does not result in a reduction in benefits for members. Providers must complete the MyGoldCare Palliative Care Preauthorization Request Form. This ensures that qualifying members receive care in appropriate settings based on their needs in a timely manner.

Palliative Care Preauthorization Request Form

Preauthorization Treatment Request Form is for use by Providers when referring Members for services found on the Authorizations Required List.

Preauthorization Treatment Request Form

Radiology Request Form is for use by Providers when referring Members for CT/MRI/MRA/PET and Clinical Pre-Authorization imaging services.

Radiology Request Form

Services Requiring Prior Authorization provides the list of services requiring prior authorization by our Health Services Department.

Services Requiring Prior Authorization

The Transplant Preauthorization Request Form is used by providers and transplant centers when referring members for transplant services.

Transplant Preauthorization Request Form

Submit Authorizations:

  • By fax: 855.883.1552
  • By mail:
    Gold Coast Health Plan
    Attention: Authorizations
    P.O. Box 9152
    Oxnard, CA 93031-9152

For more information concerning authorizations, Providers can contact GCHP at 888.301.1228.

Seniors and Persons with Disabilities Sensitivity Training

The following materials provide an overview and assist health plans in preparation for the mandatory enrollment of seniors and people with disabilities.

Harris Family Center for Disability and Health Policy

Tri-Counties Regional Center (TCRC)

TCRC provides individual and family centered supports for members with developmental disabilities to maximize opportunities and choices for living, working, learning and recreating in the community. To be eligible for services, a person must have a disability that begins before the person's 18th birthday, be expected to continue indefinitely and present a substantial disability as defined in Section 4512 of the California Welfare and Institutions Code. Eligibility is established through diagnosis and assessment performed by regional centers. If you have a patient you feel may be eligible for TCRC services, please contact them at 805.485.3177 or 800.664.3177.

Tri-Counties Regional Center

GCHP Care Managers strive to coordinate care with TCRC. If you identify a patient who should be receiving resources from TCRC who also needs help with coordination of care for a medical problem, please complete a Care Management Provider Referral Form.

Care Management Provider Referral Form

Vision Services

Find a vision services provider near you.

VSP Provider Directory

Behavioral Health Services

View the member materials.

Beacon Member Materials