Skip Ribbon Commands
Skip to main content

Medical Audits and Corrective Action Plans 

Under the authority of the California Welfare and Institutions Code §14456, the Department of Health Care Services (DHCS), Audits & Investigations Division, Medical Review Branch, conducts annual medical audits of Medi-Cal Managed Care Health Plans (MCPs). 

The reviews use the standards and criteria established pursuant to the Knox-Keene Health Care Service Plan Act of 1975, or to Chapter 11A (commencing with Section 11491) of Part 2 of Division 2 of the Insurance Code.  The audits verify compliance with contract requirements, state law, and All Plan Policy Letters in the following categories:

  1. Utilization Management
  2. Case Management and Coordination of Care
  3. Access and Availability of Care
  4. Member Rights
  5. Quality Management
  6. Administrative and Organizational Capacity
  7. 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: 

  1. Alameda Alliance for Health
    [Review Period 04/01/14 - 03/31/15]
    Report & Corrective Action Plan   
       
  2. Anthem Blue Cross Partnership Plan
    [Review Period 10/01/15 - 09/30/16]
    Report & Corrective Action Plan
       
  3. CalOptima
    [Review Period 02/01/15 - 01/31/16]
    Report & Corrective Action Plan
       
  4. CalViva Health
    [Review Period 04/01/15 – 03/31/16]
    Report & Corrective Action Plan
       
  5. Care 1st Partner Plan, LLC
    [Review Period 02/01/16 - 01/31/17]
    Report & Corrective Action Plan
       
  6. CenCal Health
    [Review Period 10/01/15 – 09/30/16]
    Report (Corrective Action Plan N/A)
       
  7. Central California Alliance for Health
    [Review Period 11/01/15 – 10/31/16]
    Report (Corrective Action Plan N/A)
       
  8. Community Health Group Partnership Plan
    [Review Period 06/01/15 - 05/31/16]
    Report & Corrective Action Plan
       
  9. Contra Costa Health Plan
    [Review Period 03/01/14 - 02/28/15]
    Report & Corrective Action Plan
       
  10. Gold Coast Health Plan
    [Review Period 04/01/15 – 03/31/16]
    Report & Corrective Action Plan   
       
  11. Health Net Community Solutions, Inc.
    [Review Period 05/01/15 – 04/30/16]
    Report & Corrective Action Plan
       
  12. Health Plan of San Joaquin
    [Review Period 07/01/15 – 06/30/16]
    Report (Corrective Action Plan N/A)
       
  13. Health Plan of San Mateo
    [Review Period 11/01/15 – 10/31/16]
    Report & Corrective Action Plan   
       
  14. Inland Empire Health Plan
    [Review Period 10/01/2015 - 09/30/2016]
    Report & Corrective Action Plan
       
  15. Kern Health Systems
    [Review Period 08/01/2015 - 07/31/2016]
    Report & Corrective Action Plan
       
  16. Kaiser
    [Review Period 09/01/2014 - 08/31/2015]
    Report & Corrective Action Plan
       
  17. L.A. Care Health Plan
    [Review Period 07/01/15 – 06/30/16]
    Report & Corrective Action Plan
       
  18. Molina Healthcare of California Partner Plan, Inc.
    [Review Period 08/01/15 – 07/31/16]
    Report & Corrective Action Plan
       
  19. Partnership Health Plan of California
    [Review Period 01/01/16 - 12/31/16]
    Report & Corrective Action Plan
       
  20. San Francisco Health Plan
    [Review Period 03/01/15 – 02/29/16]
    Report & Corrective Action Plan
       
  21. Santa Clara Family Health Plan
    [Review Period 04/01/2015 – 03/31/2016]
    Report & Corrective Action Plan
       

Archived Reports

  

Last modified on: 10/18/2017 2:00 PM