CurrentPHC CaliforniaPolicy PR 29.0

PHC-CA Provider Contracting and Fee Schedule Disclosure

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This policy governs how PHC California provides fee schedules, payment policies, and coding methodology disclosures to Network Providers during initial contracting, annually, upon written request, and through website postings.

Policy Summary

PayerPHC California

PolicyPHC-CA Provider Contracting and Fee Schedule Disclosure

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionProvide the complete fee schedule and detailed payment policies electronically when each provider contract is first executed, and document the delivery date and method.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ElectronicInitial disclosure

AnnualAnnual disclosure

30 daysWritten-request response

45 daysWebsite-change notice

60 days

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CurrentPHC CaliforniaPolicy PR 29.0

PHC-CA Provider Contracting and Fee Schedule Disclosure

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Policy Summary

PayerPHC California

PolicyPHC-CA Provider Contracting and Fee Schedule Disclosure

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionProvide the complete fee schedule and detailed payment policies electronically when each provider contract is first executed, and document the delivery date and method.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ElectronicInitial disclosure

AnnualAnnual disclosure

30 daysWritten-request response

45 daysWebsite-change notice

60 days

Contract-update lead time

Required Disclosure Elements

Required Fee Schedule and Payment Policy Disclosures

The Health Plan must provide the following fee schedule, payment policy, coding methodology, and reimbursement disclosures to contracted providers.

ALL disclosure requirements

Disclose the complete fee schedule to contracting providers in an electronic format at the time of initial contracting.
Disclose the complete fee schedule annually thereafter, on or before the contract anniversary date, in an electronic format.
Disclose the complete fee schedule upon the contracted provider's written request.
Payment policy and coding methodology disclosures
- Disclose detailed payment policies and rules in an electronic format.
- Disclose any non-standard coding methodologies used to adjudicate claims in an electronic format.
- When available, ensure coding methodologies are consistent with Current Procedural Terminology (CPT) and standards accepted by nationally recognized medical societies and organizations, federal regulatory bodies, and major credentialing organizations.
Global payment provisions
- Clearly and accurately state what is covered under global payment provisions for professional and institutional services.
- Clearly and accurately state what is covered for services provided as part of a course of treatment in an institutional setting.
- Clearly and accurately state what is covered under other global arrangements, including per diem hospital payments.
Required reimbursement policy disclosures
- Clearly and accurately state policies regarding the consolidation of multiple services or charges and any payment adjustments due to coding changes.
- Clearly and accurately state policies regarding reimbursement for multiple procedures.
- Clearly and accurately state policies regarding reimbursement for assistant surgeons.
- Clearly and accurately state policies regarding reimbursement for the administration of immunizations and injectable medications.
- Clearly and accurately state policies regarding recognition of CPT modifiers.
Provide all disclosures in sufficient detail and in a format understandable to a reasonable person with appropriate training, experience, and competence in claims processing.
Disclosures must not include proprietary trade secret information or violate copyright law or patented processes.
The required information may be disclosed through a secure website.
Written notice must be given to the contracted provider at least 45 days before implementing the website transmission format or posting any changes to the information.

Coding and Disclosure Timing Standards

Coding Methodology StandardCPT

CPT	Current Procedural Terminology referenced as a standard with which coding methodologies should be consistent when available

Annual disclosure timing

Disclosure frequencyAnnually after initial contracting

Disclosure deadlineOn or before the contract anniversary date

Delivery formatElectronic format

Annual review lead time

Review and update lead timeAt least 60 days before each contract anniversary date

Responsible departmentsProvider Data Management and Provider Relations Departments

Updated information deadline

Provider Disclosure Responsibilities

Billing Rule

Initial Contracting Disclosure

Include the complete fee schedule and detailed payment policies in the initial contracting package for each Network Provider. At initial contract execution, provide both electronically and document the delivery date and method in Salesforce.

Complete fee schedule and detailed payment policies must be part of the initial contracting package.
Electronic delivery is required at initial contract execution.
Provider Relations must document the delivery date and method in Salesforce.

Billing Rule

Annual Fee Schedule Update

Review the fee schedule and payment policies at least 60 days before each contract anniversary and update them when necessary. Deliver updated information electronically on or before the anniversary date and retain records of all notices sent.

Defined Terms

Network Provider

Covered agreement relationshipsA provider or entity with a Network Provider Agreement with the Health Plan, the Health Plan's Subcontractor, or the Health Plan's Downstream Subcontractor

Covered funding and servicesReceives Medi-Cal funding directly or indirectly to order, refer, or render Covered Services under the contract

ExclusionA Network Provider is not a Subcontractor or Downstream Subcontractor by virtue of the Network Provider Agreement

Policy Summary

PayerPHC California

PolicyPHC-CA Provider Contracting and Fee Schedule Disclosure

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionProvide the complete fee schedule and detailed payment policies electronically when each provider contract is first executed, and document the delivery date and method.

SourceLink

On This Page

Electronically on or before the contract anniversary date

Written-request response deadline

Request eligibilityNetwork Providers may submit written requests at any time

Response deadlineWithin 30 calendar days of receiving the written request

Response formatElectronic delivery

Website notice period

Advance noticeWritten notice at least 45 days before implementing the website transmission format or posting changes

Posting verificationPosted information must be current, accurate, and consistent with policy requirements

Record retentionRetain documentation of website postings and Network Provider notifications

Policy review frequency

Standard review frequencyAt least annually

Earlier review triggerSooner if operational or regulatory changes occur

Review and approval bodyMember Provider Committee (MPC)

Review and update, when necessary, at least 60 days before the contract anniversary.
Provide the updated fee schedule and payment policies electronically on or before the anniversary date.
Provider Data Management must record all notices sent to Network Providers.

Documentation Required

Ad Hoc Provider Requests

Accept written requests from Network Providers for the current fee schedule and payment policies. Provide the requested information electronically within 30 calendar days and document the request, response dates, and delivery method.

Written requests may be submitted at any time.
Electronic response is required within 30 calendar days of receipt.
Document the request date, response date, and delivery method.

Billing Rule

Website Posting Controls

Before implementing website transmission or posting changes to the information, provide Network Providers with written notice at least 45 days in advance. Verify that posted information is current, accurate, and policy-consistent, and retain documentation of postings and notifications.

Give written notice at least 45 days before implementing the website transmission format or posting any information changes.
The Director of Provider Data Management verifies currency, accuracy, and consistency with policy requirements.
Retain documentation of all website postings and Network Provider notifications.

Billing Rule

Payment Policy and Coding Disclosure

Disclose detailed payment policies and rules and any non-standard coding methodologies used to adjudicate claims in an electronic format. Where available, coding methodologies should be consistent with CPT and standards accepted by nationally recognized organizations and applicable regulatory and credentialing bodies.

Clearly state global payment coverage for professional and institutional services, services provided during an institutional course of treatment, and other arrangements such as per diem hospital payments.
State policies for consolidation of services or charges, payment adjustments from coding changes, multiple procedures, assistant surgeons, immunization and injectable medication administration, and CPT modifiers.
Disclose non-standard coding methodologies used to adjudicate claims and align them with accepted CPT and recognized standards when available.

Note

Disclosure Format and Content Limitations

Provide disclosures in sufficient detail and a format understandable to a reasonable person with appropriate training, experience, and competence in claims processing. Do not include proprietary trade secret information or disclose material that would violate copyright law or patented processes.

Disclosures must be clear, accurate, sufficiently detailed, and understandable to qualified claims-processing personnel.
Content limitations prohibit inclusion of proprietary trade secrets and material that violates copyright law or patented processes.