19-649 Capitated IPAs Pay Public Health Departments for Sensitive Services

Date: 08/21/19

Capitated IPAs Pay Public Health Departments for Sensitive Services

Check the PPA DOFR to determine financial responsibility

Capitated independent practice associations (IPAs) may be required to reimburse for sensitive services given to Medi-Cal members by non-capitated providers. Capitated IPAs must check the Provider Participation Agreement (PPA) Division of Financial Responsibility (DOFR) for financial risk.

·       When the DOFR shows California Health & Wellness Plan (CHWP) is responsible, the claim must be forwarded to CHWP for processing within 10 working days of receipt of the claim.

·       When the DOFR shows the IPA is responsible, the IPA is required to process and pay the claim in a timely manner per the PPA.

No authorization needed for sensitive services

Members can self-refer and see any qualified provider for sensitive services. The services listed below are Medi-Cal covered benefits and do not require prior authorization:

·       Family planning.

·       HIV counseling and testing.

·       Pregnancy testing, including pregnancy termination.

·       Diagnosis and treatment for sexually transmitted infections (STIs).

Key points to remember

Sensitive services are:

·       Protected health information (PHI) and confidential.

·       Covered when performed by qualified in-network or out-of-network providers. Encourage members to access in-network providers, when possible.

·       Available to members (minors) under age 18 without parental consent. Some exceptions apply.

·       Offered timely based on the appointment access standards for the type of medical care needed, and without barriers.

Additional information

If you have questions regarding the information contained in this update, contact CHWP at
1-877-658-0305.