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​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​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 Contract & Enrollment Review Division (CERD) of DHCS’ Audits and Investigations (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.

  1. Utilization Management
  2. Case Management and Coordination of Care
  3. Access and Availability
  4. Member Rights
  5. Quality Improvement
  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:

See below for the most recent Audit Reports and Corrective Action Plans

Reports

Aetna Better Health of California

2023 Focused Audit Report

2023 R​eport

AIDS Healthcare Foundation

2023 Focused Audit Report

2024 Report​

Alameda Alliance for Health

2023 Focused Audit Report

2024 R​eport (Medical Audit)

2024 Report​ (State Supported Services)

Anthem Blue Cross Partnership Plan

2023 Focused Audit Report

2023 Report

Blue S​hield of CA Promise Health Plan

2023 Focused Audit Report

2024 Report

California Health and Wellness

2023 Focused Audit Report

2024 Report

CalOptima

2023 Focused Audit Report

​2024 Report

CalViva Health

2023 Focused Audit Report

2024 Report

CenCal Health

2023 Focused Audit Report​

2024 Report​​​

Central California Alliance for Health

2023 Focused Audit Report

2024 Report​

Commun​​​ity Health Group Partnership Plan

2023 Focused Audit Report

2024 Report

Contra Costa Health Plan

2023 Focused Audit Report

2024 Report

Gold Coast Health Plan

2023 Focused Audit Report

2024 Report

​​​​​Health Net Community Solutions, Inc.

2023 Focused Audit Report

2024 Report​​​​​​​

Health Plan of San Joaquin

2023 Focused Audit Report

2023 Report

2024 Report​

Health Plan of San Mateo

2023 Focused Audit Report

2023 Report

Inland Empire Health Plan

2023 Focused Audit Report​

2024 Report​

Kern Health Systems

2023 Focused Audit Report

2023 R​eport

2024 Report​

Kaiser

2023 Focused Audit Report (Sacramento)

2023 Focused Audit Report (San Diego)

2023 Report

L.A. Care Health Plan

2023 Focused Audit Report

​​2024 ​Report​ (Medical Audit)

2024 Report​ (State Supportive Services)

Molina Healthcare of California Partner Plan, Inc.

2023 Focused Audit Report

2024 Report

Partnership Health Plan of California

2023 Focused Audit Report

2023 Report

2024 Report

Rady Children's Hospital-San Diego

2021 Report

San Francisco Health Plan

2023 Focused Audit Report​

2024 Report​

Santa Clara Family Health Plan

2023 Focused Audit Report

2024 Report​

Senior Care Action Network Health Plan

2023 Focused Audit Report

2024 Report

United Healthcare Community Plan of California, Inc.

2022 R​eport

Corrective Action Plans

Aetna Better Health of California

2023 Corrective Action Plan

AIDS Healthcare Foundation

Corrective Action Plan in progress

Alameda Alliance for Health

C​orrective Action Plan​ in progress

Anthem Blue Cross Partnership Plan

2023 C​orrective Action Plan

Blue Shield of CA Promise Health Plan

Corrective Action Plan​ in progress

California Health and Wellness

Corrective Action Not Required

CalOptima

2023 Corrective Action Plan

CalViva Health

C​orrective Action Plan​ in progress

CenCal Health

Corrective Action Not Required

Central California Alliance for Health

2024 Corrective Action Plan​

Community Health Group Partnership Plan

Corrective Action Plan in progress​

Contra Costa Health Plan

Co​rrective Action Plan​ in progress

Gold Coast Health Plan

2023 C​orrective Action Plan​

Health Net Community Solutions, Inc.

Corrective Action Plan in progress

Health Plan of San Joaquin

2023 ​Co​rrective Action Plan

Health Plan of San Mateo

Corrective Action Plan in progress

Inland Empire Health Plan

2023 Corrective Action Plan

Kern Health Systems

2023 Corrective Action Plan

Kaiser

​Corrective Action Plan in progress

​L.A. Care Health Plan

Corrective Action Plan in progress

Molina Healthcare of California Partner Plan, Inc.

Corrective Action Plan in progress

Partnership Health Plan of California

2023 C​orrective Action Plan​

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.

Corrective Action Not Required

Archived Reports and CAPS​​



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Last modified date: 4/25/2025 1:36 PM