Timely Access Report Form Sample PCPs by R7OqsR

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									TIMELY ACCESS REPORT FORM INSTRUCTIONS - PCPs (Sample)
PLEASE first review the GENERAL Timely Access Network Reporting instructions before completing this form. To begin entering data, you must first enter a Record Type. There are four record types: Profile, Address, Specialty and Medical
Group/IPA. For each record type, you must enter the contracted provider’s last name, first name, CA License number, and NPI number. Then, continue to enter other information based on the record type. To view a sample format of this form, please
see the following document: Timely Access Report Form Sample-PCPs.

RECORD TYPE
                                                      Enter Last Name, First Name, CA License number, NPI number, Type of Licensure; enter Y or N under each product line; and enter language (other than English). If the provider speaks more than
Profile
                                                      one language (not English), add second Profile record with same information across the worksheet and enter the second language.
                                                      Enter Last Name, First Name, CA License number, NPI number, language spoken at this facility (other than English, if applicable), address, city, county, state, zip code. Continue adding Address
Address                                               records if provider has more than one facility/office.
                                                      Enter Last Name, First Name, CA License number, NPI number, specialty, specialty (other), subspecialty (if applicable); enter Y or N under Board Certified. Continue adding Specialty records if the
Specialty                                             provider provides multiple specialty services.

                                                      Enter Last Name, First Name, CA License number, NPI number, name of medical group and/or IPA affiliated with your Plan’s contracted provider, if applicable; and medical group/IPA’s Federal Tax
Medical Group/IPA                                     ID, if known. If the provider is associated with multiple medical groups or IPAs, continue to add the affiliated medical group/IPA and their Federal Tax ID numbers, if known.

PCPs Tab
     REQUIRED                                                Required fields MUST be completed or contain a value of "NA" (Except for Health Plan ID for Plan-to-Plan Contract field ).                                                                      Data Type (Length)
     Last Name                                        Last name of provider                                                                                                                                                                                  Text (1 to 50 characters)
     First Name                                       First name of provider                                                                                                                                                                                 Text (1 to 50 characters)
     CA License                                       California License number                                                                                                                                                                              Text (4 to 9 characters)
     NPI                                              NPI number                                                                                                                                                                                             Number (10 digits)

      Health Plan ID for Plan-to-Plan Contract         DMHC issued Plan ID # (933 xxxx) of Health Plan with which provider is contracted. (May leave blank if the provider is not accessed through a Plan-to-Plan contract.)                                 Text (0 or 8 characters)
     Type of Licensure                                M.D, DO, etc.                                                                                                                                                                                          Text (1 to 100 characters)
     Address                                          Physical address of facility. Continue adding Address records if provider has more than one facility/office                                                                                            Text (1 to 100 characters)
     City                                             City in which the facility is located.                                                                                                                                                                 Text (1 to 50 characters)
     County                                           County in which the facility is located. (Please reference the Lookup Code Setup tab for counties. )                                                                                                   Text (1 to 50 characters)
     State                                            State in which the facility is located.                                                                                                                                                                Text (2 to 30 characters)
     Zip Code                                         Zip code in which the facility is located.                                                                                                                                                             Text (5 or 10 characters)
     Specialty                                        Family Practice, General Practice, Internal Medicine, Obstetrics/Gynecology, Pediatrics, or Other. (Please reference the Lookup Code Setup tab for specialties.)                                       Text (1 to 100 characters)
     Specialty (Other)                                Specify specialty if "Other" was selected in previous field or Subspecialty (if applicable).                                                                                                           Text (1 to 100 characters)
     Board Certified                                  Y/N                                                                                                                                                                                                    Text (1 character)
                                                      Name of medical group and/or IPA affiliated with contracted provider (if applicable). Please note that a Medical Group record type must still be completed even if the value of Medical Group/IPA
     Medical Group/IPA                                column is "N/A".                                                                                                                                                                                       Text (1 to 100 characters)

     REQUESTED                                               Requested fields may be completed or left blank.                                                                                                                                                Data Type (Length)
     HMO/POS                                          Y/N if Plan contracts with this Provider for members enrolled in HMO product                                                                                                                           Text (0 to 1 character)
     PPO                                              Y/N if Plan contracts with this Provider for members enrolled in PPO product                                                                                                                           Text (0 to 1 character)
     Medi-Cal                                         Y/N if Plan contracts with this Provider for members enrolled in Medi-Cal product                                                                                                                      Text (0 to 1 character)
     Healthy Families                                 Y/N if Plan contracts with this Provider for members enrolled in Healthy Families product                                                                                                              Text (0 to 1 character)
     Healthy Kids                                     Y/N if Plan contracts with this Provider for members enrolled in Healthy Kids product                                                                                                                  Text (0 to 1 character)
     MRMIB/MRMIP                                      Y/N if Plan contracts with this Provider for members enrolled in MRMIB/MRMIP product                                                                                                                   Text (0 to 1 character)
     AIM                                              Y/N if Plan contracts with this Provider for members enrolled in AIM product                                                                                                                           Text (0 to 1 character)
     Medicare                                         Y/N if Plan contracts with this Provider for members enrolled in Medicare product                                                                                                                      Text (0 to 1 character)
     Other                                            Y/N if Plan contracts with this Provider for members enrolled in other product(s)                                                                                                                      Text (0 to 1 character)
     Language                                         Language spoken by provider or at facility (other than English). (Please reference the Lookup Code Setup tab for languages. )                                                                          Text (0 to 100 characters)
     Language (Other)                                 If more than one language (other than English) is spoken by provider or at facility. (Please reference the Lookup Code Setup tab for languages.)                                                       Text (0 to 100 characters)
     Medical Group/IPA Federal Tax ID                 Medical Group/IPA Federal Tax ID number                                                                                                                                                                Text (0 to 50 characters)

Non-Physician PCPs Tab (if applicable)
     REQUIRED                                                Required fields MUST be completed or contain a value of "NA" (Except for Health Plan ID for Plan-to-Plan Contract field)                                                                        Data Type (Length)
     Last Name                                        Last name of provider                                                                                                                                                                                  Text (1 to 50 characters)
     First Name                                       First name of provider                                                                                                                                                                                 Text (1 to 50 characters)
     CA License                                       California License number                                                                                                                                                                              Text (4 to 9 characters)
     NPI                                              NPI number                                                                                                                                                                                             Number (10 digits)

     Health Plan ID for Plan-to-Plan Contract         DMHC issued Plan ID # (933 xxxx) of Health Plan with which provider is contracted. (May leave blank if the provider is not accessed through a Plan-to-Plan contract.)                                  Text (0 or 8 characters)
     Type of Licensure                                PA, NP, PhD, LCSW, etc.                                                                                                                                                                                Text (1 to 100 characters)
     Address                                          Physical address of facility. Continue adding Address records if provider has more than one facility/office                                                                                            Text (1 to 100 characters)
     City                                             City in which the facility is located.                                                                                                                                                                 Text (1 to 50 characters)
     County                                           County in which the facility is located. (Please reference the Lookup Code Setup tab for counties. )                                                                                                   Text (1 to 50 characters)
     State                                            State in which the facility is located.                                                                                                                                                                Text (2 to 30 characters)
     Zip Code                                         Zip code in which the facility is located.                                                                                                                                                             Text (5 or 10 characters)
     Specialty                                        Family Practice, General Practice, Internal Medicine, Obstetrics/Gynecology, Pediatrics, or Other                                                                                                      Text (1 to 100 characters)
     Specialty (Other)                                Specify specialty if "Other" was selected in previous field or Subspecialty (if applicable).                                                                                                           Text (1 to 100 characters)
     Board Certified                                  Y/N                                                                                                                                                                                                    Text (1 character)
                                                      Name of medical group and/or IPA affiliated with contracted provider (if applicable). Please note that a Medical Group record type must still be completed even if the value of Medical Group/IPA
     Medical Group/IPA                                column is "N/A".                                                                                                                                                                                  Text (1 to 100 characters)

     REQUESTED                                               Requested fields may be completed or left blank.                                                                                                                                           Data Type (Length)
     HMO/POS                                          Y/N if Plan contracts with this Provider for members enrolled in HMO product                                                                                                                      Text (0 to 1 character)
     PPO                                              Y/N if Plan contracts with this Provider for members enrolled in PPO product                                                                                                                      Text (0 to 1 character)
     Medi-Cal                                         Y/N if Plan contracts with this Provider for members enrolled in Medi-Cal product                                                                                                                 Text (0 to 1 character)
     Healthy Families                                 Y/N if Plan contracts with this Provider for members enrolled in Healthy Families product                                                                                                         Text (0 to 1 character)
     Healthy Kids                                     Y/N if Plan contracts with this Provider for members enrolled in Healthy Kids product                                                                                                             Text (0 to 1 character)
     MRMIB/MRMIP                                      Y/N if Plan contracts with this Provider for members enrolled in MRMIB/MRMIP product                                                                                                              Text (0 to 1 character)
     AIM                                              Y/N if Plan contracts with this Provider for members enrolled in AIM product                                                                                                                      Text (0 to 1 character)
     Medicare                                         Y/N if Plan contracts with this Provider for members enrolled in Medicare product                                                                                                                 Text (0 to 1 character)
     Other                                            Y/N if Plan contracts with this Provider for members enrolled in other product(s)                                                                                                                 Text (0 to 1 character)
     Language                                         Language spoken by provider or at facility (other than English). (Please reference the Lookup Code Setup tab for languages. )                                                                     Text (0 to 100 characters)
     Language (Other)                                 If more than one language (other than English) is spoken by provider or at facility. (Please reference the Lookup Code Setup tab for languages.)                                                  Text (0 to 100 characters)
     Medical Group/IPA Federal Tax ID                 Medical Group/IPA Federal Tax ID number                                                                                                                                                           Text (0 to 50 characters)

Lookup Code Setup Tab
When entering County, Specialty, and Language, you must enter the county, type of specialty, and language listed in the tables within the Lookup Code Setup tab. The DMHC web portal system will not accept any other type of specialty and language.
If your database uses a coding system that consists of a number or abbreviation to identify a county, specialty or language, you can enter your code to this table and we can map your specialty code to our system. For instance, if you use DHCS
language codes, you may enter those codes in the highlighted fields under Health Plan Language Code. Then, you can use your language code for the Language column in the PCPs and Non-Physician PCPs Tabs. Please see the "Timely Access Report
Form Sample - PCPs" Excel file for examples.


     OPTIONAL SETUP                                                                                                                                                                                                                                     Data Type (Length)
     Health Plan Specialty Code                       The health plan specialty code must be unique for specialty mapping.                                                                                                                              Text (0 to 100 characters)
     Health Plan Language Code                        The health plan language code must be unique for language mapping.                                                                                                                                Text (0 to 100 characters)
     Health Plan County Code                          The health plan county code must be unique for county mapping.                                                                                                                                    Text (0 to 50 characters)
                             Timely Access Report Sample Form - PCPs                9/16/2012




Row #         Record Type     Last Name     First Name    CA License       NPI
     1   Profile             West         Robert         G1xxx         198712xxxx
     2   Address             West         Robert         G1xxx         198712xxxx
     3   Specialty           West         Robert         G1xxx         198712xxxx
     4   Medical Group/IPA   West         Robert         G1xxx         198712xxxx
     5   Profile             Smith        Joe            G5xxx         112212xxxx
     6   Address             Smith        Joe            G5xxx         112212xxxx
     7   Specialty           Smith        Joe            G5xxx         112212xxxx
     8   Specialty           Smith        Joe            G5xxx         112212xxxx
     9   Medical Group/IPA   Smith        Joe            G5xxx         112212xxxx
    10   Medical Group/IPA   Smith        Joe            G5xxx         112212xxxx
    11   Profile             Chen         John           G9xxx         325414xxxx
    12   Address             Chen         John           G9xxx         325414xxxx
    13   Address             Chen         John           G9xxx         325414xxxx
    14   Specialty           Chen         John           G9xxx         325414xxxx
    15   Medical Group/IPA   Chen         John           G9xxx         325414xxxx
                                   Timely Access Report Sample Form - PCPs                   9/16/2012

Health Plan ID for                                                    Healthy                 MRMIB /
  Plan-to-Plan          Type of      HMO / POS             Medi-Cal   Families   Healthy Kids MRMIP
    Contract           Licensure       (Y/N)   PPO (Y/N)    (Y/N)      (Y/N)        (Y/N)      (Y/N)
                     MD             Y          Y         Y          N            N           N




                     MD             Y            Y          N          Y         N          N




933 xxxx             MD             Y            Y          Y          Y         N          N
933 xxxx
933 xxxx
933 xxxx
933 xxxx
                                 Timely Access Report Sample Form - PCPs                         9/16/2012

              Medicare
     AIM     Advantage   Other
    (Y/N)      (Y/N)     (Y/N)           Language      Language (Other)               Address
N           N          N           ASL
                                   SPN                                     1300 Cesar Chavez Ave 500


N           N          N           French
                                                                           1850 Wilson Terrace 130




N           N          N
                                                                           3600 South St. 101
                                                                           1235 W. Sunset Blvd
                            Timely Access Report Sample Form - PCPs                       9/16/2012




     City          County    State Zip Code          Specialty        Specialty (Other)

Los Angeles   LOS ANGELES   CA      90033
                                              Family Practice


Los Angeles   LOS ANGELES   CA      90033
                                              General Practice
                                              IM




Lakewood      LOS ANGELES   CA      90033
Los Angeles   LOS ANGELES   CA      90026
                                              FP
                                    Timely Access Report Sample Form - PCPs   9/16/2012

     Board
    Certified                                           Medical Group / IPA
     (Y/N)               Medical Group / IPA              Federal Tax ID


Y
                San Bernardino Medical Group, Inc.


Y
N
                Riverside Family Medical Group        1234xxxx
                San Bernardino Medical Group, Inc.    1235xxxx




Y
                Los Angeles Medical Center
                       Timely Access Report Sample Form - Non-Physician PCPs                9/16/2012




Row #          Record Type      Last Name       First Name    CA License            NPI
     1   Profile              Wilson          Thomas         G6xxx             654712xxxx
     2   Address              Wilson          Thomas         G6xxx             654712xxxx
     3   Specialty            Wilson          Thomas         G6xxx             654712xxxx
     4   Medical Group/IPA    Wilson          Thomas         G6xxx             654712xxxx
     5   Profile              Lee             David          G5xxx
     6   Address              Lee             David          G5xxx
     7   Specialty            Lee             David          G5xxx
     8   Specialty            Lee             David          G5xxx
     9   Medical Group/IPA    Lee             David          G5xxx
    10   Medical Group/IPA    Lee             David          G5xxx
    11   Profile              Kim             Marcy          G9xxx
    12   Address              Kim             Marcy          G9xxx
    13   Address              Kim             Marcy          G9xxx
    14   Specialty            Kim             Marcy          G9xxx
    15   Medical Group/IPA    Kim             Marcy          G9xxx
                         Timely Access Report Sample Form - Non-Physician PCPs                   9/16/2012

Health Plan ID for                                                     Healthy
  Plan-to-Plan                        HMO / POS             Medi-Cal   Families   Healthy Kids
    Contract       Type of Licensure    (Y/N)   PPO (Y/N)    (Y/N)      (Y/N)        (Y/N)
                   PA                Y          Y         Y          N            N




933 xxxx         PA                Y            N         N           Y           N
933 xxxx
933 xxxx
933 xxxx
933 xxxx
933 xxxx
933 xxxx         NP                Y            Y         Y           Y           N
933 xxxx
933 xxxx
933 xxxx
933 xxxx
                       Timely Access Report Sample Form - Non-Physician PCPs       9/16/2012

 MRMIB /             Medicare
  MRMIP     AIM     Advantage   Other
   (Y/N)   (Y/N)      (Y/N)     (Y/N)           Language        Language (Other)
N        N         N          N




N        N         N            Y




N        N         N            N          Korean
                            Timely Access Report Sample Form - Non-Physician PCPs          9/16/2012




           Address                    City           County            State    Zip Code

1520 Cesar Chavez Ave 123        Los Angeles   LOS ANGELES        CA           90033




1850 Wilson Terrace 120          Los Angeles   LOS ANGELES        CA           90033




3600 South St. 502               Lakewood      LOS ANGELES        CA           90033
2500 Olympic Blvd                Los Angeles   LOS ANGELES        CA           90023
                        Timely Access Report Sample Form - Non-Physician PCPs                      9/16/2012

                                                   Board
                                                  Certified
        Specialty         Specialty (Other)        (Y/N)               Medical Group / IPA


General Practice                              N
                                                              San Bernardino Medical Group, Inc.


Obstetrics/Gynecology                         N
Internal Medicine                             N
                                                              Riverside Family Medical Group
                                                              San Bernardino Medical Group, Inc.




IM                                            N
                                                              Los Angeles Medical Center
                        Timely Access Report Sample Form - Non-Physician PCPs   9/16/2012



  Medical Group / IPA
    Federal Tax ID




1234xxxx
1235xxxx
                        Timely Access Report Sample Form - PCPs Lookup Code                     9/16/2012



Note: If you would like to use the lookup code from your system, please use this form to set up lookup code mapping for


                                     Health Plan
          Specialty                 Specialty Code                           Language
Family Practice                           FP                        American Sign Language
General Practice                                                    Arabic
Internal Medicine                         IM                        Armenian
Obstetrics/Gynecology                                               Cambodian
Pediatrics                                                          Cantonese
Other                                                               Dutch
                                                                    Farsi
                                                                    French
                                                                    German
                                                                    Greek
                                                                    Hebrew
                                                                    Hindi
                                                                    Hmong
                                                                    Italian
                                                                    Japanese
                                                                    Korean
                                                                    Laotian
                                                                    Mandarin
                                                                    Portuguese
                                                                    Punjabi
                                                                    Romanian
                                                                    Russian
                                                                    Spanish
                                                                    Tagalog
                                                                    Thai
                                                                    Vietnamese
                                                                    Other
Timely Access Report Sample Form - PCPs Lookup Code   9/16/2012
                                         Timely Access Report Sample Form - PCPs Lookup Code   9/16/2012



o set up lookup code mapping for DMHC.


                    Health Plan                                          Health Plan
                  Language Code                           County         County Code
                       ASL                         Alameda
                                                   Alpine
                                                   Amador
                                                   Butte
                                                   Calaveras
                                                   Colusa
                                                   Contra Costa
                                                   Del Norte
                                                   El Dorado
                                                   Fresno
                                                   Glenn
                                                   Humboldt
                                                   Imperial
                                                   Inyo
                                                   Kern
                                                   Kings
                                                   Lake
                                                   Lassen
                                                   Los Angeles
                                                   Madera
                                                   Marin
                                                   Mariposa
                       SPN                         Mendocino
                                                   Merced
                                                   Modoc
                                                   Mono
                                                   Monterey
                                                   Napa
                                                   Nevada
                                                   Orange
                                                   Placer
                                                   Plumas
                                                   Riverside
                                                   Sacramento
                                                   San Benito
                                                   San Bernardino
                                                   San Diego
                                                   San Francisco
                                                   San Joaquin
                                                   San Luis Obispo
Timely Access Report Sample Form - PCPs Lookup Code   9/16/2012

          San Mateo
          Santa Barbara
          Santa Clara
          Santa Cruz
          Shasta
          Sierra
          Siskiyou
          Solano
          Sonoma
          Stanislaus
          Sutter
          Tehama
          Trinity
          Tulare
          Tuolumne
          Ventura
          Yolo
          Yuba

								
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