Medi-Cal Encounter Requirements

Provider Monitoring Log

Primary Care Provider: ______

Address: ______

Vendor/Group: ______

Network Manager: ______

Date Placed on Monitoring: ______

Requirement:

  1. Primary Care Providers are required to meet the following minimum encounter thresholds for all Medi-Cal enrollees:
  • Ages 0-2: 4 visit PMPY
  • Ages 3-19: 1.5 visit PMPY
  • Ages 20+: 2 visit PMPY
  • Aged aid code: 6 visit PMPY
  1. Primary Care Providers are required to submit all utilization and encounter data to United Care Medical Group within 90 days after the date of services.

Deficiency

Corrective action shall be taken with providers who have a panel size greater than or equal to 50 members and an average of less than 3 visits per member per year (PMPY < 2).

Action Summary & Timeline

Month 1 / Provider notified of requirement and deficiency and placed on monitoring.
Month 2 / Provider performance monitored and Network Management representative conducts corresponding follow-up visits with Provider office.
Month 3 / If Provider is still not in compliance, Corrective Action Plan shall be issued.
Month 6 / If Provider is still not in compliance, Provider reimbursement may be changed to fee-for-service reimbursement.
Month 12 / If Provider is in compliance, Provider reimbursement may convert back to capitation. If Provider is not in compliance, Provider reimbursement shall remain fee-for-service.

I acknowledge that the above information has been reviewed with me by a United Care Medical Group representative.

Signature: ______

Name: ______

Title: ______

Date: ______

Primary Care Provider: ______

Network Manager: ______

WEEK 1 OF MONITORING: Initial Visit With Provider
Page 1 of this Provider Compliance Monitoring Log shall be reviewed and signed by provider during this visit.
Date of visit:
Provider performance (e.g. 70 members with 0 visits):
Comments from visit (e.g. provider feedback):
WEEK 3 OF MONITORING: 2nd Follow-up With Provider
Date of follow-up:
Improvement since last follow-up? YES / NO
Comments from visit/conversation:
WEEK 5 OF MONITORING: 3rd Follow-up With Provider
Date of follow-up:
Improvement since last follow-up? YES / NO
Comments from visit/conversation:
WEEK 7 OF MONITORING: 4th Follow-Up With Provider
If provider has not corrected deficiency, Corrective Action Plan shall be issued at week 9 visit.
Date of follow-up:
Improvement since last follow-up? YES / NO
Comments from visit/conversation:
WEEK 9 OF MONITORING: 5th Follow-Up With Provider & Corrective Action Plan Issuance
If provider has not corrected deficiency, Corrective Action Plan shall be issued during this visit.
CORRECTIVE ACTION PLAN ISSUED? YES / NO
Date of visit:
Comments from visit:

Last Updated: 03/02/2017Page 1 of 2