A newsletter for SCFHP providers
Vol. 4, Issue 9  November 2020 
In this issue

Preventive medicine services via telehealth

Preventive medicine service (PMS) visits are an essential component of pediatric primary care. It is important for children to continue to receive PMS during the current Public Health Emergency. The American Academy of Pediatrics (AAP) strongly recommends a telehealth and a second (in-person) visit to complete all components of the PMS visit. Refer to SCFHP’s guidance on how to conduct and bill for these PMS visits combining telehealth and in-person activities to ensure that services are provided timely.

Youth with diabetes

Did you know that November is National Diabetes Awareness Month? This year’s focus is taking care of youth who have diabetes. Diabetes is one of the most common chronic conditions in school-aged youth in the United States, affecting about 193,000 youth under age 20. Additionally, the Journal of Pediatrics estimates the prevalence of prediabetes among adolescents with obesity is approximately 30%. Regardless of their age, youth who have diabetes may need support with their diabetes care from their caregivers and healthcare team. According to the National Institute of Health (NIH), research has shown that diabetes is best managed by shared responsibility between parents and adolescents with diabetes. As a health care provider, you play an important role in guiding families toward this shared responsibility. Check out NIH’s National Diabetes Month toolkit for additional resources and information on how you can help support your patients with diabetes.
Diabetes self-management and medical nutrition therapy are covered benefits for SCFHP members.

Coverage for patients with gender dysphoria

When determining coverage of treatment and surgery for members with gender dysphoria, SCFHP uses nationally recognized medical and clinical guidelines, and considers the knowledge and expertise of providers qualified to treat gender dysphoria.
In the treatment for gender dysphoria, the core services are:
  • Mental health services;
  • Psychotherapy;
  • Hormone therapy; and
  • Surgical procedures and treatments that bring primary and secondary gender characteristics into conformity with the individual’s identified gender.
Use the Prior Authorization Request Form to propose a treatment plan for your patients with gender dysphoria.

Learn more about coverage determination for members with gender dysphoria in the Department of Health Care Services (DHCS) All Plan Letter 20-018.

Screen your patients for chlamydia

According to the U.S. Preventive Services Task Force, chlamydia is one of the most commonly reported sexually transmitted infections (STIs) in the United States. Chlamydial infections are 10 times more prevalent than gonococcal infections in women aged 18 to 26 years. As a healthcare provider, you are trusted by your patients–you can empower your patients to take charge of their sexual health. We encourage you to talk to your patients, and perform chlamydia screening for your them by collecting urine for analysis or swabbing with ThinPrep (also used for Pap smears) during well-woman exams. 
Learn more on the Centers for Disease Control and Prevention’s (CDC) website #TalkTestTreat.

Order a 90-day supply of maintenance drugs for your patients

SCFHP encourages providers to consider prescribing a 90-day supply of maintenance drugs for patients with chronic medical conditions. A 90-day supply may improve medication adherence and reduce trips to the pharmacy. This benefit is available at participating network retail and mail order pharmacies. The Provider and Pharmacy Search Tool tells you which pharmacies can dispense a 90-day/extended day supply.
For Cal MediConnect members, a 90-day supply has the same copay as a one-month supply.

Stopping healthcare fraud, waste, and abuse (FWA)

Healthcare fraud is a serious issue that contributes to the skyrocketing cost of medical care. The National Health Care Anti-Fraud Association estimates that Medicare and Medicaid fraud costs $70 billion to $200 billion each year.
Anyone can commit fraud. That includes doctors, hospital employees, billing services, medical equipment suppliers, patients, and caregivers. Violators can be prosecuted under civil and criminal laws. Preventing fraud is everyone's job.
Healthcare fraud, waste, and abuse can take many forms. Examples of fraudulent activity by providers include:
  • Billing for services that were not provided. This includes billing for no-shows.
  • Billing for duplicate services or non-covered services as covered items.
  • Billing for a more complex or expensive service than was provided (also called "upcoding").
  • Misrepresenting a patient's diagnosis.
  • Requiring a patient to return for unneeded follow-up services.
  • Using an incorrect or inappropriate provider number to be paid.
  • Signing blank records or certification forms that are used by another entity to obtain payment.
  • Unbundling services from a group to increase medical payment.
  • Misrepresenting dates, descriptions of services, or identities of patients or providers.
  • Falsifying signatures or medical records.
  • Accepting kickbacks or bribes for patient referrals.
Here are some steps you can take to protect your practice:
  • Make copies of each patient's insurance card and driver's license.
  • Maintain a treatment record for each patient and document all services, orders, and prescriptions.
  • Carefully review all documentation before certifying the medical necessity of services or supplies needed/requested by patients.
  • Have internal audits in place to detect billing inaccuracies promptly.
If you suspect fraud, waste, or abuse, contact SCFHP as soon as possible. All calls to the SCFHP Fraud Hotline are anonymous and confidential.
Call: SCFHP 24/7 Fraud Hotline: 1-408-874-1450 (TTY: 711)
Fax: 1-408-874-1970
Attn: Compliance Officer
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158
Learn more about FWA and when and how to report Medicare or Medicaid fraud on the SCFHP website.

Office closures

The SCFHP office will be closed on the following days in November:
  • November 11, in observance of Veteran’s Day
  • November 26-27, in observance of Thanksgiving

Provider Link
Visit to download your member roster, check authorizations and claims status, and check member eligibility.

Interactive Voice Response (IVR)
Call our IVR line at 1-408-874-1473 to verify member eligibility, check claims status based on your TIN, and request confirmation of eligibility verification or claim(s) processed.

Resources on our website Resources from the County Questions? 
Please email Provider Services at

Memo round up

We are dedicated to keeping our providers informed about operational and regulatory changes. Below are important memos that were sent recently:
  • October 8, 2020 – Register for the Medi-Cal Rx web portal
  • October 26, 2020 – Get $100 for completing certified ACE training
  • October 26, 2020 – Preventive medical care via telehealth and in-person visits
  • October 27, 2020 – Blood pressure monitor for SCFHP patients diagnosed with hypertension
  • October 29, 2020 – Billing guide for drugs, medical supplies, and durable medical equipment effective 1/1/2021
  • November 3, 2020 – New video remote interpreting services for American Sign Language
  • November 6, 2020 – Long-term care discharge, hospice notification, and admission date requirements
Provider memo archive

SCFHP by the numbers

Providers (unique NPIs)

Primary care
Medi-Cal: 827
Cal MediConnect: 547
Medi-Cal: 4,277
Cal MediConnect: 2,999
Medi-Cal: 843
Cal MediConnect: 227


Medi-Cal: 256,490
Cal MediConnect: 9,570
Total: 266,060


Medi-Cal: 177
Cal MediConnect: 174

As of October 2020
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