Gold Coast Health Plan (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 state Department of Health Care Services (DHCS).
Beacon Health Options partners with Gold Coast Health Plan (GCHP) to manage the mental health benefit of Medi-Cal beneficiaries. The Primary Care Provider (PCP) referral form allows PCPs access to the services available through Beacon.
In compliance with CAQH CORE Operating Rules, Gold Coast Health Plan (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 10 p.m. to midnight PST Sunday. 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 prediabetes. The goal of the program is to work with Primary Care Providers (PCP), 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 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:
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.
Click here to watch a provider training video on how to fill out this form properly.
Submit your completed forms to:
Gold Coast Health Plan
Attn: Provider Disputes & Grievances
P.O. Box 9176
Oxnard, CA 93031
Clinical Practice Guidelines
Gold Coast Health Plan's (GCHP) Medical Advisory Committee 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 Guideline
- Immunization Guideline
- Preventive Services Guideline
Utilization Management Guidelines
The goal of Gold Coast Health Plan's (GCHP) Utilization Management (UM) Program is to provide continuity of care, coordination of services and improved health outcomes, while increasing the effectiveness and efficiency of services provided to members.
Licensed nurses may authorize services under the direction of the medical director, but they do not make medical-necessity denial decisions. They apply UM criteria to make decisions and use their clinical knowledge while considering the individual needs of the members. GCHP's medical director is available to the nurses for consultation and to make medical-necessity denials.
The Health Services Department is committed to ensuring medically necessary quality care in appropriate settings. UM nurses and providers—working closely with hospital staff and attending providers—perform pre-service, concurrent and post-service reviews using nationally recognized, evidence-based criteria adopted by GCHP's network of providers, ensuring that the services being performed and the medical equipment being ordered are appropriate.
- Botox Supplemental Clinical Guideline
- Chiropractic Services Guideline
- Custodial Care Guideline
- Genetic Testing Guideline
- Home Enteral Nutrition Guideline
- Intravenous Sedation and General Anesthesia for Dental Services Guideline
- Nusinersen / Spinraza Guideline
- Physical, Occupational, and Speech Therapies for Children under the Age of 21 Years Guideline
- Transgender Services Guideline
Gold Coast Health Plan (GCHP) supports the efforts of its providers to protect patients of all ages against vaccine-preventable diseases.
The Centers for Disease Control and Prevention (CDC) and the California Department of Public Health (CDPH) have immunization resources available for healthcare professionals.
- The #HowIRecommend vaccination videos explain how to make effective vaccine recommendations, address common questions and take a team-based approach to vaccinations.
- "How to Increase Flu Vaccination Coverage in Your Clinic" is a free, on-demand webinar that highlights the importance of protecting patients against influenza, the efforts of Vaccines for Children Program to improve vaccine uptakes, and strategies for increasing overall immunization coverage.
- "Afternoon TEAch with CDPH" is a webinar series that covers a variety of immunization topics.
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:
Managed Care Accountability Set Quality Measures
Gold Coast Health Plan (GCHP) monitors and reports the Managed Care Accountability Set (MCAS) performance measures to assess and improve clinical quality of care. MCAS is based on the Centers for Medicare and Medicaid Services Child and Adult Core Set Measures, which includes NCQA HEDIS® measures. All state Medi-Cal Managed Care Plans are required to annually report these measures to the state Department of Health Care Services (DHCS).
MCAS Reference Materials
To help providers understand the MCAS performance measure requirements, GCHP’s Quality Improvement Department has developed a reference guide and tip sheets to share key information on individual MCAS measures. These tip sheets are not intended to direct clinical judgment, but to serve as resources in understanding measure specifications while providing guidance for measure compliance.
MCAS Tip Sheets
- Follow-up Care for Children Prescribed Attention-Deficit / Hyperactivity Disorder (ADHD) Medication (ADD)
- Antidepressant Medication Management (AMM)
- Asthma Medication Ratio (AMR)
- Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)
- Breast Cancer Screening (BCS)
- Children and Adolescents' Access to Primary Care Practitioners (CAP)
- Controlling High Blood Pressure (CBP)
- Contraceptive Care Postpartum Women Ages 15-44 (CCP)
- Cervical Cancer Screening (CCS)
- Comprehensive Diabetes Care HbA1c Poor Control > 9% (CDC-H9)
- Contraceptive Care – All Women Ages 15-44 (CCW)
- Screening for Depression and Follow-Up Plan (CDF)
- Chlamydia Screening in Women Ages 16-24 (CHL)
- Childhood Immunization Status – Combo 10 (CIS-10)
- Concurrent Use of Opioids and Benzodiazepines (COB)
- Developmental Screening in the First Three Years of Life (DEV)
- Immunizations for Adolescents (IMA)
- Lead Screening in Children (LSC)
- Annual Monitoring for Patients on Persistent Medications (MPM)
- Use of Opioids at Higher Dosage in Persons Without Cancer (OHD)
- Prenatal and Postpartum Care (PPC)
- Diabetic Screening for People with Schizophrenia or Bipolar Disorder Who are Using Antipsychotic Medication (SSD)
- Well-Child Visits in the First 30 Months of Life (W30)
- Weight Assessment and Counseling for Nutrition and Physical Activity for Children / Adolescents (WCC)
- Child and Adolescent Well-Care Visits (WCV)
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 the state Department of Health Care Services (DHCS) to monitor Gold Coast Health Plan's (GCHP) provider network.
Non-emergency medical transportation (NEMT) is a ride for medical care that is not an emergency. NEMT is provided for Gold Coast Health Plan (GCHP) members who cannot sit in a regular vehicle due to a medical condition and who need to be transported in a specialized vehicle, such as a gurney van. NEMT is covered by GCHP.
Providers must complete the NEMT 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 state regulation Title 22.
Once GCHP notifies its contracted transportation provider, Ventura Transit System (VTS), that the member is eligible, VTS will contact the member to arrange transportation.
Non-medical transportation (NMT) is a ride to get to medical care when the member does not have any way to get to that care for services such as scheduled appointments at any medical clinic or provider, dentist, eye doctor or vision center, pharmacy, equipment provider, behavioral therapy visit or approved health education program.
GCHP members who require NMT services should contact the Plan's contracted provider, Ventura Transit System (VTS), directly at 1.855.628.7433/1.800.855.7100 (California Relay Service) to arrange for transportation. Prior to receiving services for the first time, members must attest to VTS that they have no other means of transportation. Members should contact VTS at least 48 hours in advance of the transportation need and be prepared to show their GCHP member ID card.
GCHP reviews and coordinates both NEMT and NMT eligibility with VTS.
GCHP offers NEMT and NMT for eligible members who need a ride to their dialysis appointments. Download some helpful tips for members when scheduling dialysis transportation.
If you have any questions, email GCHP's Provider Relations Department at ProviderRelations@goldchp.org.
Gold Coast Health Plan (GCHP) works with the Ventura County Perinatal Substance Use Task Force, a multi-hospital and multi-disciplinary group. The goals of the Task Force are to ensure that all pregnant women are screened for the risk of substance use, depression, and domestic violence during pregnancy, and to provide comprehensive, caring support, education, and resources to women identified as being at-risk. Data shows that early intervention leads to improved sobriety, less recidivism, improved mother-baby bonding, and lowers other risk factors for the developing fetus. The California Maternal Quality Care Collaborative (CMQCC) has developed a toolkit describing best practices to improve outcomes for substance-exposed mothers and newborns.
The Task Force has an easy-to-follow decision tree for obstetrics providers, which uses best practices of the CMQCC toolkit for the Screening Assessment and Level of Care Determination. This tree includes contact information, including direct links, to numerous resources throughout the county.
Questions about where / how / whom to refer? Contact Ventura County Public Health (VCPH) nursing:
The Task Force offers education, training, and technical assistance for prenatal care providers on the impact of substance use during pregnancy and the importance of screening all pregnant women with the 4Ps Plus Screening Tool to identify those at risk for substance use, depression, and domestic violence. VCPH provides comprehensive nursing assessments, education and linkage to community resources for pregnant women identified as being at-risk for substance use, depression, and domestic violence.
The Provider Manual describes operational policies and procedures relative to the provision of healthcare services to Gold Coast Health Plan (GCHP) members. Revisions and updates are made frequently.
- 2019/20 Provider Manual (updated July 27, 2020)
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 1.888.301.1228.
The Direct Referral Authorization Form is for use by Primary Care Providers when referring members to an in-network, in-area specialist.
The Home Health Prior Authorization Checklist is for use by providers to facilitate the prior authorization process for home health requests.
The MyGoldCare™ palliative care program is available for any member who qualifies. This does not result in a reduction in benefits for members. Providers must complete the MyGoldCare Palliative Care Preauthorization Request Form. This ensures that qualifying members receive care in appropriate settings based on their needs in a timely manner.
The Preauthorization Treatment Request Form is for use by providers when referring members for services found on the Authorizations Required List.
The 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.
- Fax: 1.855.883.1552
Gold Coast Health Plan
P.O. Box 9152
Oxnard, CA 93031-9152
For more information concerning authorizations, Providers can call GCHP at 1.888.301.1228.
Tri-Counties Regional Center (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 think is eligible for TCRC services, please contact TCRC at 1.805.485.3177 or 1.800.664.3177.
GCHP care managers strive to coordinate care with TCRC. If you identify a patient who should be receiving resources from TCRC and who also needs help with coordination of care for a medical problem, please complete a Care Management Provider Referral Form.