Introduction

The Provider Manual is intended for Network Providers in Valley Health Plan (VHP). The Provider Manual contains policies and procedures that describe how to submit claims and encounter data, to obtain authorizations and referrals, and to understand covered services. All Network Providers should use this Manual as the primary reference for the policies and guidelines of Valley Health Plan. This Manual contains policies, procedures and guidelines for Valley Health Plan's product lines: Valley Health Plan Commercial Santa Clara Family Health Plan–Network 2 o Medi-Cal Managed Care o Healthy Families o Healthy Kids The VHP Provider Manual is divided into the 16 sections: Section 1: Introduction Section 2: Authorization & Referrals Section 3: Claims Section 4: Summary of Benefits Section 5: Primary Care Section 6: Ancillary Services for Chiropractic and Acupuncture Section 7: Mental Health and Substance Abuse Section 8: Urgent and Emergency Care Section 9: Case Management Section 10: Pharmacy Section 11: Health Education Section 12: Provider Relations (Including Dispute Process) Section 13: Quality Management Section 14: HIPAA Section 15: Forms and Attachments Section 16: Glossary of Terms You can access the Provider Manual at our website: www.valleyhealthplan.org or for a hard copy please contact the Provider Relations Department at (408) 885-2221. This Manual provides a summary of the important features of Valley Health Plan. The Member Handbook, Evidence of Coverage and the Summary of Benefits for each product line contain more detailed information on the exact terms and conditions of VHP coverage and on the benefits, limitations and exclusions.

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VHP will have a positive impact on the health of our families, friends, and neighbors.

To support the well-being of our members through a commitment to accessible, high-quality health services and community-focused, local care.

Valley Health Plan, an HMO that is owned and operated by Santa Clara County, is licensed by Knox Keene and has offered healthcare insurance to County employees since 1985. Valley Health Plan offers four distinct products. The Commercial product is available to County Employees and their dependents and selected other non-profit and Santa Clara County related organizations. The Delegated product includes Managed Medi-Cal, Healthy Families and Healthy Kids. Santa Clara Family Health Plan (SCFHP) is the plan of record for these products and is responsible for the Membership. SCFHP delegates to Valley Health Plan the responsibility to provide all covered services except Mental Health, Dental, and Vision Care to assigned SCFHP Members.

VHP operates as an integrated network that provides a comprehensive range of hospital, physician and other health care services for its Members.

The Valley Health Plan Network includes: Santa Clara Valley Medical Center (hospital, practitioners and affiliated health centers) Lucile Packard Children's Hospital and practitioners Stanford Medical Center and practitioners O’Connor Hospital Saint Louise Regional Hospital El Camino Hospital Community Clinics (Mayview Community Health Centers, Planned Parenthood Mar Monte, Gardner Family Health Network, East Valley Community Clinic, Indian Health Center of SCC, School Health Clinics of SCC, North East Medical Services, San Jose Foothill Health Centers, and Asian American Community Involvement). Several Independently contracted primary care physicians Santa Clara County Independent Physician Association (SCCIPA physicians) San Jose Medical Group (SJMG) Palo Alto Medical Foundation (PAMF) Northern Cal Advantage Medical Group California IPA

Valley Health Plan is available to respond quickly to your questions and concerns. Office hours are Monday through Friday, 8:00 a.m. to 5:00 p.m.

Responsible for processing of all claims including electronic claims (EDI). Claims Department is able to provide status on claims received.

Reviews and authorizes referrals to facilities and services. UM Department can provide status on authorizations and referrals.

Offers Member education on access to care; use of preventive services and health maintenance and improvement.

Educate providers about VHP policies and procedures. Provider Relations offers training in all aspects of provider interactions with VHP.

Manages and directs all clinical issues, including final determination of all authorizations.

Assists Members in resolving service issues, questions pertaining to coverage, benefits, and assists in selecting a Primary Care Physician.

Assesses the quality of all services delivered to plan Members. Language Assistance – Valley Health Plan Providers can access telephone language translation assistance for VHP Members. In order to access Language Services the provider will be required to enter a system password. To obtain the password contact Provider Relations at (408) 885-2221.

(408) 278-9927

VHP observes the following holidays: • New Year's Day • Martin L. King Day • Cesar Chavez Day • Memorial Day • Independence Day Labor Day Veteran’s Day Thanksgiving Day Day after Thanksgiving Christmas Day

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