Medical Audits and Corrective Action Plans
The Department of Health Care Services (DHCS) works with the Department of Managed Health Care (DMHC) to conduct routine medical surveys of Medi-Cal Managed Care Health Plans (MCPs) on selected populations on an annual basis. The medical survey is a comprehensive evaluation of the MCP's compliance with managed health care law Period(Knox-Keene Health Care Service Plan Act).
DHCS’ Managed Care Quality and Monitoring Division (MCQMD) is responsible for ensuring overall monitoring and oversight of MCPs. MCQMD designates the Medical Review Branch (MRB) of DHCS’ Audits and Investigations Division (A&I) to perform the mandated audits.
MCQMD and A&I have partnered together to create Technical Assistance Guides (TAG) for each of the following six audit categories of review. The TAGs are designed to identify key elements that will be commonly evaluated to inform MCPs of the audit process and increase transparency.
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Utilization Management
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Case Management and Coordination of Care
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Access and Availability
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Member Rights
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Quality Improvement
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Administrative and Organizational Capacity
- State Supported Services
DHCS makes a finding of fact with respect to the ability of the MCPs to provide quality health care services, the effectiveness of peer review, and utilization control mechanisms, and the overall performance in providing health care benefits to its enrollees. These audits assist DHCS with its overall monitoring effort, and identify areas of non-compliance, which form the basis for corrective actions.
MCPs are required to provide a Corrective Action Plan (CAP) upon the completion of a DHCS Medical Audit or any other monitoring activity where findings are identified. DHCS conducts CAP submission evaluations and provides technical assistance to ensure compliance.
Medical Audit Reports and Corrective Action Plans:
See below for the most recent Audit Reports and Corrective Action Plans
Reports
Aetna Better Health of California
2022 Report
AIDS Healthcare Foundation
2022 Report
Alameda Alliance for Health
2022 Report
Anthem Blue Cross Partnership Plan
2021 Report
Blue Shield of CA Promise Health Plan
2022 Report
2022 Report (Cal MediConnect)
California Health and Wellness
2022 Report
CalOptima
2022 Report
CalViva Health
2022 Report
CenCal Health
2021 Report
Central California Alliance for Health
2019 Report
Community Health Group Partnership Plan
2022 Report
Contra Costa Health Plan
2021 Report
Gold Coast Health Plan
2022 Report
Health Net Community Solutions, Inc.
2022 Report
Health Plan of San Joaquin
2021 Report
Health Plan of San Mateo
2022 Report
Inland Empire Health Plan
2022 Report
Kern Health Systems
2021 Report
Kaiser
2021 Report
L.A. Care Health Plan
2021 Report
2021 Report (Cal MediConnect)
2021 Report (Focused)
Molina Healthcare of California Partner Plan, Inc.
2019 Report
Partnership Health Plan of California
2021 Report
Rady Children's Hospital-San Diego
2021 Report
San Francisco Health Plan
2022 Report
Santa Clara Family Health Plan
2022 Report
Senior Care Action Network Health Plan
2022 Report
United Healthcare Community Plan of California, Inc.
2021 Report
Corrective Action Plans
Aetna Better Health of California
Corrective Action Plan in progress
AIDS Healthcare Foundation
2022 Corrective Action Plan
Alameda Alliance for Health
Corrective Action Plan in progress
Anthem Blue Cross Partnership Plan
Corrective Action Plan in progress
Blue Shield of CA Promise Health Plan
Corrective Action Plan in progress
California Health and Wellness
Corrective Action Plan in progress
CalOptima
2020 Corrective Action Plan
CalViva Health
Corrective Action Plan in progress
Care 1st Partner Plan, LLC
2018 Corrective Action Plan
CenCal Health
2021 Corrective Action Plan
Central California Alliance for Health
2019 Corrective Action Plan
Community Health Group Partnership Plan
Corrective Action Plan in progress
Contra Costa Health Plan
Corrective Action Plan in progress
Gold Coast Health Plan
2021 Corrective Action Plan
Health Net Community Solutions, Inc.
2019 Corrective Action Plan
Health Plan of San Joaquin
2021 Corrective Action Plan
Health Plan of San Mateo
Corrective Action Plan in progress
Inland Empire Health Plan
Corrective Action Plan in progress
Kern Health Systems
Corrective Action Plan in progress
Kaiser
2021 Corrective Action Plan
L.A. Care Health Plan
Corrective Action Plan in progress
Molina Healthcare of California Partner Plan, Inc.
2019 Corrective Action Plan
Partnership Health Plan of California
Corrective Action Not Required
Rady Children's Hospital-San Diego
Corrective Action Not Required
San Francisco Health Plan
Corrective Action Plan in progress
Santa Clara Family Health Plan
Corrective Action Plan in progress
Senior Care Action Network Health Plan
Corrective Action Plan in progress
United Healthcare Community Plan of California, Inc.
Archived Reports and CAPS
