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).
Carelon Behavioral Health (formerly 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 Carelon.
- Carelon Behavioral Health PCP Referral Form (coming soon)
- Carelon Behavioral Health Care Management Referral Form (coming soon)
The Community-Based Adult Services (CBAS) Program replaced the state's Adult Day Health Care program and is managed by Gold Coast Health Plan (GCHP). CBAS requires prior authorization.
Visit aging.ca.gov to learn more about CBAS.
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.
Provider Claim Reconsideration Form
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.
Administrative
Medicine
- 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
- Physical, Occupational, and Speech Therapies for Children under the Age of 21 Years Guideline
- Transgender Services Guideline
Rehabilitation Therapy
Gold Coast Health Plan's (GCHP) Health Education Program is committed to helping members stay well. We work with local clinics, providers and hospitals to provide quality health education resources.
To view available member resources, including information on asthma, high blood pressure, our Chronic Disease Self Management Program and more, click here.
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.
CDC Resources:
- The #HowIRecommend vaccination videos explain how to make effective vaccine recommendations, address common questions and take a team-based approach to vaccinations.
CDPH Resources:
- "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.
For additional resources or information, please email QualityImprovement@goldchp.org or HealthEducation@goldchp.org.
Gold Coast Health Plan (GCHP) offers free services to support the linguistic needs of members. They are simple to access and easy to use.
Telephone interpreting services
Telephone interpreting services are available to GCHP providers 24 hours a day, seven days a week.
To access a telephone interpreter:
- Call 1.866.421.3463
- Provide your access code (Contact GCHP’s Cultural and Linguistic Services to obtain an access code)
- Indicate the language needed
- Provide the caller’s name, agency, member’s zip code, and member’s GCHP ID number
- Document the interpreter's name and ID number for reference
Important points to remember when working with a telephone interpreter:
- At the beginning of the call, briefly tell the interpreter the nature of the call.
- Speak directly to the limited English proficient individual and keep the conversation in first person.
- Pause at the end of each complete thought and allow the interpreter to interpret.
- Check for understanding throughout the session.
- Please note, to ensure accuracy, your interpreter may sometimes ask for clarification or repetition.
- End the call when all objectives of the call have been met.
Interpreting and Translation Services
GCHP interpreting and translation services include:
- Written and oral interpretation services from a qualified interpreter.
- Sign Language interpreting for deaf and hearing-impaired members.
- Alternative format requests for Braille, audio format, large print (no less than 20 point Arial font), and accessible electronic formats, as well as requests for other auxiliary aids and services for people with disabilities.
Note: Members are NOT required to provide an interpreter or use a friend, family, including minors to interpret during medical and behavioral appointments.
For easier access when requesting language assistance services for members, GCHP combined the translation and interpreting services request form into one new form. The new form includes all modes of language assistance and auxiliary services.
Language Assistance and Auxiliary Services Request Form
For additional information, contact GCHP’s Cultural and Linguistic Services Department at 1.805.437.5603, or 1.805.437.5624, Monday through Friday from 8 a.m. to 5 p.m., (excluding holidays) or email CulturalLinguistics@goldchp.org.
To learn more, visit the Interpreter and Translation Services page.
As of December 2020, Gold Coast Health Plan no longer accepts the Medi-Cal Long-Term Care (LTC) 25-1 Form for claim submissions. Long-Term Care providers need to submit their claims on the UB-04 Form. The UB-04 Form is the standard claim form that an institutional provider can use for billing medical health claims.
Mail the UB-04 Form to:
Gold Coast Health Plan
Attention: Claims
P.O. Box 9152
Oxnard, CA 93031-9152
Direct authorization questions to:
Health Services
1.888.301.1228
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.
Access the NEMT Prescription / Attestation of Medical Necessity form
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.
Download a list of frequently asked questions (FAQs).
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:
Phone: 1.805.981.5115
Website: www.vchca.org/perinatal-substance-use-services
Services
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.
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 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.
Submit Authorizations:
- Fax: 1.855.883.1552
- Mail:
Gold Coast Health Plan
Attention: Authorizations
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.
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 and who also needs help with coordination of care for a medical problem, please complete a Care Management Provider Referral Form.
Care Management Provider Referral form (English and Spanish).