Thank you for caring for our members during this difficult time. The purpose of this page is to provide you with the most up-to-date information and guidance we have regarding COVID-19. We understand that there has been much information disseminated over the last week regarding COVID-19. Our goal is to consolidate relevant information for you regarding Medi-Cal guidance during the COVID-19 pandemic.
Latest COVID-19 Memos
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
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:
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.
Contact OptumRx at 1.855.297.2870; TTY 711
Pharmacy Newsletters and DUR Bulletins
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.
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 email@example.com. 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.
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.
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.
- March 31, 2020: COVID-19 Pandemic Emergency Telehealth Guidance
- March 27, 2020: Enterprise Transformation Projects
- March 26, 2020: Shield HealthCare Incontinence Supplies
- March 26, 2020: Beacon Health Options Telehealth Update
- March 25, 2020: 24-Hour Advice Nurse Line for Members
- March 20, 2020: Access to the Preauthorization Treatment Request Form
- March 20, 2020: Issues Affecting Access to Pharmacy Services During the COVID-19
- March 19, 2020: COVID-19 Information and Resources
- March 19, 2020: New Provider Dispute Resolution Process
- March 13, 2020: COVID-19 Testing by Quest Diagnostics
- March 12, 2020: Postponed: Mental Health Issues in the Deaf and Hard of Hearing Community Cultural Competency Training
- March 2, 2020: Cultural Competency Training: Mental Health Issues in the Deaf and Hard of Hearing Community
- February 3, 2020: Preferred Laboratory Provider
- January 31, 2020: Encounter Data Validation Study
- January 31, 2020: Cultural Competency Training – Understanding Gender Identity and Health Disparities in the LGBTQ+ Community
- January 15, 2020: Issue with Claim Check Run of December 30, 2019
- January 9, 2020: MCAS Measurement Year 2019 – Data Collection Effort
- January 3, 2020: Preferred Laboratory Provider
- December 11, 2019: Basic Tobacco Intervention Skills
- December 5, 2019: Gold Coast Health Plan Receives Two Managed Care Quality Awards
- November 19, 2019: Great American Smokeout
- November 14, 2019: New Member Incentive Programs – Cervical Cancer Screening and Child / Adolescent Well-Care Visit
- November 7, 2019: Gold Coast Health Plan Announces Resignation of CEO
- November 5, 2019: New Benefit: Diabetes Prevention Program
- October 23, 2019: National Lead Poisoning Prevention Week
- October 15, 2019: Addressing Health Disparities in the LGBTQ+ Community - Free Webinar
- October 10, 2019: Members Affected by Public Safety Power Shutoffs in Ventura County
- October 9, 2019: Notice: Changes to Pharmacy Prior Authorization Request Process
- October 2, 2019: Member Outreach Campaigns
- September 24, 2019: Annual Well-Care Visits for Adolescents
- September 3, 2019: California Department of Public Health - Food Recall
- August 28, 2019: National Immunization Awareness Month (NIAM) – Provider Resources
- August 27, 2019: Chlamydia Screening for Women 16-24 Years of Age
- August 6, 2019: Prescribing Opioids for Chronic Pain: MCAS Performance Measures
- July 30, 2019: Duplicate Check Printing
- July 25, 2019: Bank Change and Electronic Funds Transfer (EFT) Payments
- June 20, 2019: DHCS Changes in Monitoring Quality in Managed Care
- June 18, 2019: 30-Month Well-Child Visit / Health Assessment – Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Medi-Cal Benefit
- June 14, 2019: Warning: Extortion Scam Targeting DEA Registrants
- June 3, 2019: Prior Authorization Requirement Update
- May 21, 2019: Care Management for Gold Coast Health Plan Members
- May 15, 2019: Asthma Medication Ratio (AMR) – OptumRX Provider Outreach Campaign
- May 14, 2019: “Improving End of Life Conversations with Patients” Workshop
- April 9, 2019: Use of Imaging Studies for Low Back Pain (LBP)
- March 8, 2019: National Nutrition Month
- February 21, 2019: American Heart Month
- February 13, 2019: DHCS is Offering “PAVE 101” Training on February 21; Webinar Supports Shift to Paperless Enrollment for Medi-Cal Providers
- February 4, 2019: Encounter Data Validation Study
- January 22, 2019: MyGoldCare Palliative Care Program Changes – Effective January 1
- January 15, 2019: HEDIS® Measurement Year 2018
- December 13, 2018: Appropriate Testing for Children with Pharyngitis (CWP) Healthcare Effectiveness Data and Information Set (HEDIS®) Measure
- November 28, 2018: Provider Communication Survey
- November 15, 2018: World Prematurity Awareness Month
- November 8, 2018: Crisis Response Protocol for Members
- November 5, 2018: Member Outreach Campaign
- October 11, 2018: Initial Health Assessment (IHA) and Staying Healthy Assessment (SHA)
- September 11, 2018: Prior Authorization Requirement Update Physical Therapy and Occupational Therapy
- August 28, 2018: FINAL REMINDER: CME Palliative Care Training Opportunity
- August 21, 2018: REMINDER: CME Palliative Care Training Opportunity
- August 14, 2018: CME Palliative Care Training Opportunity
- August 9, 2018: National Immunization Awareness Month (NIAM)
- July 31, 2018: Controlling Blood Pressure Measure
- June 29, 2018: Proposition 56 - Supplemental Payment for Physician Services
- June 14, 2018: Decline in the Annual Diabetic Nephropathy Screenings
- May 25, 2018: Behavioral Health Treatment PCP Notification
- May 24, 2018: Department of Health Care Services (DHCS) Medical Audit
- April 27, 2018: World Immunization Week – “Protected Together”
- April 4, 2018: Medi-Cal Program Provider Enrollment
- March 19, 2018: Network Certification Sampling
- February 21, 2018: Assessing Wait Time Standards
- February 20, 2018: Revised Credentialing Requirements for the MyGoldCare Program
- February 15, 2018: Physician Advisory: Oseltamivir/Tamiflu® Availability During Flu Season
- February 15, 2018: Gold Coast Health Plan Asthma Resources and the Thomas Fire
- January 16, 2018: Introduction to Healthcare Effectiveness Data Information Set (HEDIS®) 2018
- January 9, 2018: Release of Information Request for HEDIS® Quality Reviews
- December 27, 2017: MyGoldCare - Palliative Care Program
- December 21, 2017: Health Information Form (HIF)
- December 5, 2017: Prescription Refills and Oxygen Supply for Medi-Cal Members during Thomas Fire
- October 10, 2017: Human Papillomavirus (HPV) Vaccine and the Immunizations for Adolescents (IMA) HEDIS® Measure
- September 7, 2017: Appropriate Strep Testing for Children with Pharyngitis
- August 29, 2107: Depression Screening and Follow-Up for Adolescents and Adults
- August 8, 2017: Member Rewards to Increase Preventive Care
- July 11, 2017: Child Immunization Rate Trends
- June 8, 2017: Annual Monitoring of Patients on ACE inhibitors, ARBs, digoxin, and diuretics
- May 16, 2017: National High Blood Pressure Education Month
- May 10, 2017: Transition of Pharmacy Benefit Manager to OptumRx
- March 30, 2017: Member Rewards to Increase Preventive Care
- March 23, 2017: CMS Core Measure - Screening for Clinical Depression and Follow-up Plan
- March 21, 2017: Tobacco Intervention Skills Training
- January 19, 2017: ROI Request for HEDIS® Quality Reviews
- January 10, 2017: Introduction to HEDIS® 2017
- December 15, 2016: Reminder: Gender Identity and Transgender Health Care
- December 6, 2016: Gender Identity and Transgender Health Care
- November 15, 2016: HEDIS® Asthma Medication Ratio Measure
- November 15, 2016: Community Health Fair and Forum
- November 8, 2016: Prenatal and Postpartum Care (PPC) HEDIS® Measure
- October 27, 2016: HEDIS® Breast Cancer Screening Measure
- October 13, 2016: Changes to the “Immunization for Adolescents” HEDIS® Measure
- September 29, 2016: Appropriate Strep Testing for Children with Pharyngitis
- September 28, 2016: Screening for Alcohol, Tobacco and Illegal Substance Use During Pregnancy
- September 27, 2016: Screening for Clinical Depression and Follow-up Plan
- August 23, 2016: Decline in Women’s Health HEDIS® Measures
- August 16, 2016: Meningococcal Outbreak Health Advisories
- July 25, 2016: Member Rewards to Increase Preventive Care
- May 19, 2016: CHDP Program Well-Child Exam Schedule
- May 17, 2016: Member Rewards
- May 9, 2016: 5th Annual Community Resource Fair
- April 21, 2016: World Immunization Week
- March 23, 2016: Disease Management Program for Diabetes
- February 24, 2016: Managed Care Provider Data Improvement Project
- February 3, 2016: Zika Virus Health Advisory
- January 19, 2016: ROI Request for HEDIS® Quality Reviews
- January 5, 2016: Introduction to HEDIS® 2016
- November 12, 2015: VCMC Event on Marijuana & Pregnancy
- November 3, 2015: RSV and the use of Palivizumab (Synagis®)
- July 31, 2015: Provider Portal System Upgrade
- July 23, 2015: Retinal Eye Exam
- July 22, 2015: Well Child Annual Visit
- July 21, 2015: Postpartum Letter
- July 20, 2015: Provider Training for ICD-10
- April 28, 2015: Provider Town Hall Meeting/ICD-10 Transition
- March 31, 2015: SBIRT Training
- March 26, 2015: Crossover Claims Reminder
- March 4, 2015: Crossover Claims for Dual Eligible Members
- February 9, 2015: Important Information Regarding Measles Outbreak
- February 3, 2015: Provider Town Hall Meeting/NEMT Reminder
- January 28, 2015: Provider Town Hall Meeting/NEMT
- January 6, 2015: ROI Request for HEDIS® Quality Reviews
- December 8, 2014: Quest Diagnostics Patient Service Centers
- November 4, 2014: Measures for Children & Adolescent Wellness Exams
- October 28, 2014: Introduction to HEDIS®
- October 22, 2014: CORRECTION - ACA 1202 PCP RATE INCREASE
- October 9, 2104: Retinal Eye Exam Promotion
- April 15, 2014: New Reporting Requirements by DHCS
- April 4, 2014: Change of Address
- February 10, 2014: Provider Town Hall Meetings
- February 10, 2014: ROI Request for HEDIS® Quality Reviews
- January 2, 2014: LIHP Open Authorizations
- URGENT - Fax Issues December 18, 2013
- ZS Modifier November 27, 2013
- Provider Town Hall Meeting Notice November 5, 2013
- PCP Rate Increases August 27, 2013
- Provider Town Hall Meeting Notice August 13, 2013
- Provider Portal Notice August 2, 2013
- New Member Orientation Meetings July 31, 2013
- Provider Town Hall Meeting Notice July 22, 2013
- Provider Town Hall Meeting Notice April 3, 2013
- HEDIS Report February 19, 2013
- Check Run January 31, 2013
- New Health Services Fax Number, January 28, 2013
- Overpayment Report, January 8, 2013
- New Fax Number/Updated/New Forms, December 31, 2012
- Duplicate Check Memo, December 20, 2012
- Clinicas Specialty Contract, October 12, 2012
- Positive Pay Provider Letter, October 3, 2012
- Prior Authorization List, July 31, 2012
- Drug Formulary, July 28, 2011
- Vision Benefits, July 28, 2011
- Prospective Doctor Letter, October 8, 2010
Provider Operations Bulletin
The GCHP Provider Operations Bulletin is a quarterly newsletter geared towards our medical providers.
- October 2014 (revised)
- July 2014 (1st quarterly edition)
- April 2014
- March 2014
- February 2014
- January 2014
- December 2013
- November 2013
- October 2013
- September 2013
- August 2013
- July 2013
- June 2013
- May 2013
- April 2013
- March 2013
- February 2013
- January 2013
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 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).
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.
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.
The CCS office in Ventura County is located at:
2240 East Gonzales Road, Suite 260
Oxnard, CA 93036
Community-Based Adult Services (CBAS) Program
The Community-Based Adult Services (CBAS) Program replaced the state’s Adult Day Health Care (ADHC) program and is managed by Gold Coast Health Plan (GCHP). CBAS requires prior authorization.
Click here to learn more about CBAS.
In compliance with CAQH CORE Operating Rules, GCHP now offers Providers the following options;
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.
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:
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 firstname.lastname@example.org. For information about EDI please visit: https://www.conduent.com/edi/.
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.
If you have any other questions about transitioning to 5010, please do not hesitate to contact us.
EDI Commercial Support Team
Government Healthcare Solutions
Conduent EDI Solutions, Inc.
2073 Summit Lake Drive
Tallahassee, FL 32317
Phone: 800-952-0495 Option 2 (for GCHP)
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.
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
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.
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.
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.
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).
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.
May 2015 Town Hall Presentation (YouTube Video)
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.
The #HowIRecommend vaccination videos explain how to make effective vaccine recommendations, address common questions, and take a team-based approach to vaccinations.
“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.
“Afternoon TEAch with CDPH” is a webinar series that covers a variety of immunization topics.
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
P.O. Box 9152
Oxnard, CA 93031-9152
Direct authorization questions to:
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 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 Tip Sheets
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.
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.
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.
The Pharmacy Newsletter is designed to educate and inform providers with updates to the Plan's list of covered drugs.
Archived newsletters can be viewed above.
Provider Advisory Committee
- 2020 Provider Advisory Committee Meetings Calendar
- April 7, 2020, Meeting Agenda
- March 10, 2020, Notice of Cancellation
- December 2, 2013, Cancellation Notice
- November 19, 2013, Cancellation Notice
- August 20, 2013, Meeting Agenda
- May 21, 2013, Cancellation Notice
- February 12, 2013, Meeting Agenda
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 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.
Request for Authorization
The CPT Codes© and Descriptors Form is to be used by Podiatrists for Expanded Podiatry Services.
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.
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.
Preauthorization Treatment Request Form is for use by Providers when referring Members for services found on the Authorizations Required List.
Radiology Request Form is for use by Providers when referring Members for CT/MRI/MRA/PET and Clinical Pre-Authorization imaging services.
Services Requiring Prior Authorization provides the list of services requiring prior authorization by our Health Services Department.
The Transplant Preauthorization Request Form is used by providers and transplant centers when referring members for transplant services.
- By fax: 855.883.1552
- By mail:
Gold Coast Health Plan
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.
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.
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.
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