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Member Services Phone Number 888.301.1228

Resources

Choose a link below to quickly navigate to the desired resource.

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.

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). Access the provider attestation form here.

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Beacon (Referral Forms)

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.

Click here to 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
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. Go here to learn more about CBAS.

CORE Channel

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

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.

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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 asthma, diabetes and pre-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, when available, near the member’s home or work.
  • An individualized care plan and access to work with a Nurse Health Coach.

For more information, here are some helpful links:

Click here to learn more.

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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@xerox.com. Click here for information about 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

  • The GCHP Companion Document can be downloaded by clicking here.
  • The EDI Direct 5010 Communications Document can be downloaded by clicking here.
  • WinASAP5010 users can download the quick reference guide by clicking here.
  • EDI Direct 835 Transaction Form can be downloaded by clicking here.

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

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

ACS EDI Gateway, Inc., A Xerox Company
2073 Summit Lake Drive
Tallahassee, FL 32317
Phone: 800.952.0495
www.xerox.com/en-us/services/edi/gateway

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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.

Download the 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).

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Forms and Documents

Claims

Health Services

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

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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

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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.

  • Click here to access the Utilization Management Guidelines Page

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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).

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HEDIS®

The Health Effectiveness Data and Information Set (HEDIS®) is a standardized set of performance measures developed by the National Committee on Quality Assurance (NCQA). HEDIS® evaluates the quality of care and services provided by health plans to their members.

To help providers understand the annual HEDIS® measure requirements, GCHP’s Quality Improvement Department has developed provider tip sheets that provide key information on individual HEDIS® measures. These tip sheets are not intended to serve as clinical judgement, but to serve as guides and be used as a resource to assist in understanding specific HEDIS measures while providing guidance for measure compliance.

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.

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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

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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.

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NEMT/NMT Form

NEW NEMT PROCESS EFFECTIVE MARCH 1, 2015

GCHP provides eligible members with Non-Emergency Medical Transportation (NEMT) services.
 
Providers must complete the NEMT/NMT 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 Title 22.

This change impacts new requests for nonemergency transportation rides; previously authorized trips do not require re-authorization even when transportation occurs on or after March 1, 2015.

GCHP reviews and coordinates NEMT eligibility with Ventura Transit System (VTS).  VTS will then contact the member to arrange transportation.

Click here to access a list of Frequently Asked Questions (FAQs).
Click here to access the NEMT/NMT Prescription/Attestation of Medical Necessity Form.

Contact Provider Relations at ProviderRelations@goldchp.org with any questions.

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Pharmacy Newsletter

The  Pharmacy Newsletter is designed to educate and inform providers with updates to the Plan's list of covered drugs. Click here for the current newsletter. To view archived editions, click here.

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Provider Advisory Committee

Provider Directories

Provider Directories

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Provider Manual

The Provider Manual describes operational policies and procedures relative to the provision of health care services to Gold Coast Health Plan members. Revisions and updates are made frequently.

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.

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Provider Orientation

View the schedule for the Provider Orientation Meetings for June 2011.

Provider Training Notice

View the 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.

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.

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.

Urgent Care Treatment Authorization Request Form is for use by Primary Care Providers when directing the urgent care center to treat the patient during usual business hours.

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.

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Request for Proposals

Gold Coast Health Plan offers vendors an opportunity to respond to request for proposals (RFP) for a variety of services.

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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. Click here.

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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.

Click here to access the Tri-Counties Regional Center website.

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.

Click here to access the form.

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