Choose a link below to quickly navigate to the desired resource.
- Affordable Care Act (ACA) – Primary Care Payment Increase
- Attestation Form
- Beacon (Referral Forms)
- California Children’s Services
- Community-Based Adult Services Program (CBAS)
- CORE Channel
- Disease Management
- Electronic Claims Submission
- Electronic Funds Transfer
- FAQs for Physicians
- Forms and Documents
- Grievance & Appeals (G&A)
- Guidelines (Clinical Practice & Utilization Management)
- Healthy Families Program
- ICD-10 Transition
- Long-Term Care
- MCPDIP Provider Form
- NEMT/NMT Form
- Pharmacy Newsletter
- Provider Advisory Committee
- Provider Directories
- Provider Manual
- Provider Orientation
- Provider Training Notice
- Quality Improvement Committee
- Request for Authorization
- Request for Proposals
- Seniors and Persons with Disabilities Sensitivity Training
- Tri-Counties Regional Center (TCRC)
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). Access the provider attestation form here.
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 (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
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.
In compliance with CAQH CORE Operating Rules, GCHP now offers Providers the following options;
- Companion Guide: 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 (This 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 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:
- Disease Management Referral Form
- American Diabetes Association’s 2017 Standards of Medical Care in Diabetes
- Guidelines for the Diagnosis and Management of Asthma (EPR-3)
Click here to learn more.
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 email@example.com. Click here for information about 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.
- 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
Government Healthcare Solutions
ACS EDI Gateway, Inc., A Xerox Company
2073 Summit Lake Drive
Tallahassee, FL 32317
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.
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).
- 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
Note: Treatment Authorization Requests approved by the Department of Health Services will be honored for 60 days.
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
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 Guidelines
- Immunizations Guidelines
- Preventive Services Guidelines
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
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).
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.
- Required Measure Reporting Provider Reference Guide
- HEDIS® Measure: Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB)
- HEDIS® Measure: Asthma Medication Ratio (AMR)
- HEDIS® Measure: Breast Cancer Screening (BCS)
- HEDIS® Measure: Children and Adolescents’ Access to Primary Care Practitioners (CAP)
- HEDIS® Measure: Controlling Blood Pressure (CBP)
- HEDIS® Measure: Cervical Cancer Screening (CCS)
- HEDIS® Measure: Comprehensive Diabetic Care (CDC)
- HEDIS® Measure: Childhood Immunization Status (CIS)
- HEDIS® Measure: Appropriate Testing for Children with Pharyngitis (CWP)
- HEDIS® Measure: Immunizations for Adolescents (IMA)
- HEDIS® Measure: Use of Imaging Studies for Low Back Pain (LBP)
- HEDIS® Measure: Annual Monitoring for Patients on Persistent Medications (MPM)
- HEDIS® Measure: Prenatal and Postpartum Care (PPC)
- HEDIS® Measure: Upper Respiratory Infection (URI)
- HEDIS® Measure: Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life (W34)
- HEDIS® Measure: Childhood Weight Assessment and Counseling (WCC)
- Coding Tip Sheet: CPT Category II Codes for Quality Measure Reporting
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
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:
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.
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.
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.
- Provider Manual (updated 11/30/16)
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.
View the schedule for the Provider Orientation Meetings for June 2011.
View the Provider Training Notice.
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.
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)
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.
- 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.
Gold Coast Health Plan offers vendors an opportunity to respond to request for proposals (RFP) for a variety of services.
- ICD-10 (International Classification of Diseases) Services RFP
(Deadline: December 27, 2013, 4:00 PM, PST)
- ICD-10 Services RFP FAQs
The following materials provide an overview and assist health plans in preparation for the mandatory enrollment of seniors and people with disabilities. Click here.
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.