January 2026
The Compliance4U newsletter offers insight into the day-to-day functions of the Health Plan’s Compliance Program and serves as a resource to help staff stay informed about key regulatory updates, reporting obligations, audit activities, and policy changes. Its goal is to promote awareness, accountability, and a culture of compliance across all departments within HPSJ/MVHP (“Health Plan”).
Regulatory Affairs (RA)
Regulatory Affairs Launches New Compliance Workflow to Strengthen Oversight
As part of our ongoing commitment to regulatory excellence and risk mitigation, the Regulatory Affairs team is excited to announce the launch of the Regulatory Evidence of Compliance Approval Workflow in 2026. This initiative marks a significant milestone in our corporate objective to enhance processes to identify non-compliance timely and mitigate the risk of repeat audit findings.
A Journey of Continuous Improvement
Over the past three years, we have implemented key enhancements to strengthen compliance oversight:
• 2024: Transitioned from reliance on Business Attestations to requiring collection of evidence of implementation for APL and Contract Amendment reviews.
• 2025: Established a weekly Regulatory Affairs Workgroup to review regulatory analysis against operational functions, ensuring alignment and accountability.
• 2026: Introducing the Regulatory Evidence of Compliance Approval
Workflow, a formalized process that verifies evidence before project closure, ensuring accuracy, completeness, and audit readiness.
Why This Matters
This new workflow ensures:
• Verified compliance evidence for all regulatory changes.
• Clear accountability for implementation and ongoing monitoring.
• Improved risk mitigation through timely identification of gaps.
Thank you for your continued partnership in driving compliance excellence and supporting our corporate objectives.
What’s going on at the State and Federal levels? To support you in your role and ensure timely awareness of changes to regulatory and contractual requirements, Regulatory Affairs staff attend regulatory calls (e.g., DHCS Managed Care Plan Call - MCPC) and other regulatory meetings/calls where key regulatory information is shared
Calls Held by Health Plan’s Regulators
Regulatory Affairs staff maintain materials from regulator calls. Check out previous meetings HERE.
DMHC Fines UnitedHealthcare Benefits Plan of California $475,000 for delaying medical care and payments
The California Department of Managed Health Care (DMHC) has taken enforcement action against UnitedHealthcare Benefit Plan (United), issuing a significant fine for failing to implement Independent Medical Review (IMR) decisions in a timely manner, leading to delays in care This care delay also led to delays in providers being paid. DMHC levied a $475,000 fine. United agreed to pay the fine and implement corrections actions to correct its process.
Important takeaways from this report:
• This situation highlights the critical importance of ensuring that Health Plan complies with the requirements of the Knox-Keene Act and keeps its policies and procedures on file with the Department updated.
• Health Plan must ensure it effectuates IMR decisions timely.
� � � � For more details, read the official press release here.
All Plan Letters (APLs)
DHCS and DMHC issue All Plan Letters (APLs) to formally communicate updates to federal or state policy, regulatory requirements, or operational procedures. These directives are intended to guide Managed Care Plans (MCPs) on how to implement changes and ensure compliance with applicable laws and regulations.
RA reviews and analyzes each APL to interpret its impact, coordinate internal implementation, and ensure timely compliance and required filings.
Draft APLs often identified with placeholder codes such as “XXX” are released by the regulators to solicit feedback from MCPs before finalization. During this comment period, MCPs can raise concerns or seek clarification, which may influence the final version of the policy.
Below is a list of recently released APLs for your awareness:
A. DHCS Regulatory Notices
APL 25-017 2025-2027 Medi-Cal Managed Care Health Plan MEDS/834 Cutoff and Processing Schedule
Issue Date: December 26, 2025
Summary: This APL provides MCPs with the 2025-2027 Medi-Cal Eligibility Data System (MEDS)/834 cutoff and processing schedule.
APL 26-001 Initial Health Appointment (Supersedes APL 22-030)
Issue Date: January 1, 2026
Summary: This APL provides MCPs with guidance regarding the requirements of the Initial Health Appointment (IHA) beginning January 1, 2023.
B. DMHC Regulatory Notices
APL 25-020 Newly Enacted Statutes Impacting Health Plans (2025 Legislative Session)
Issue Date: December 19, 2025
Summary: This APL outlines the newly enacted statutory requirements for plans regulated by DMHC.
APL 25-021 Implementation of Senate Bill 729 (2024) – N/A for Health Plan
Issue Date: December 30, 2025
Summary: This APL informs full-service commercial plans of the requirements enacted under Senate Bill 729. This APL is not applicable for Health Plan.
APL 26-001 National Committee for Quality Assurance (NCQA) Accreditation Compliance Filing
Issue Date: January 2, 2026
Summary: This APL informs plans of the filing requirements for submitting the NCQA Accreditation Compliance Form and documentation of NCQA accreditation to demonstrate compliance with HSC section 1399.871(d).
APL 26-002 Delegation of Risk for COVID-19 Testing or Immunizations.
Applicability of SB 510 (Pan, 2021) to Medi-Cal Managed Care Plans
Issue Date: January 15, 2026
Summary: This APL provides guidance to plans, including Medi-Cal Managed Care Plans, regarding SB 510 (2021) and the delegation of risk for COVID-19 testing or immunizations.
Regulatory Reports
Under the terms of our contract with DHCS and in alignment with our KnoxKeene license requirements regulated by DMHC the Plan is required to routinely submit reports that demonstrate operational performance and regulatory compliance. RA tracks and coordinates these submissions to ensure timeliness and accuracy across all departments.
Below is a list of upcoming regulatory reports due to our regulators this month. The table includes the accountable Director and Executive sponsor for awareness and coordination. Please review the list to determine which reports fall within your area. Reports due for the upcoming month should be saved in this Dropbox Folder.
Accountable
Report Title
Monthly CBAS Waiver File
Monthly Consolidated Billing Supplemental File
Monthly ECM/CS File
Weekly Encounter Data Files
Monthly MCPD/PCPA Files
Monthly Financial Reports
Pamela Lee Lakshmi Dhanvanthari
Clarence Rao Victoria Worthy
Clarence Rao Victoria Worthy
Clarence Rao Victoria Worthy
Clarence Rao Victoria Worthy
Somatra Sourng Michelle Tetreault
Monthly New Member Mailing Attestation Vena Ford Evert Hendrix
Monthly NEMT/NMT Report
Monthly Post-Payment Recovery (PPR) Report
Dale Standfill Liz Le
Christopher Navarro Michelle Tetreault
Monthly Provider Directory File and Use Submission Ana Aranda Liz Le
Monthly Provider Information Network (PIN) Files Ana Aranda Liz Le
Monthly Restricted Provider Site Verification Toni White Betty Clark
Quarterly CBAS Report Pamela Lee Lakshmi Dhanvanthari
Quarterly PHM Key Performance Indicator (KPI) Johnathan Yeh Lakshmi Dhanvanthari
Quarterly MCPAR CI Johnathan Yeh Lakshmi Dhanvanthari
Quarterly Interoperability API Utilization
Quarterly MOU Good Faith Efforts Status Report
Clarence Rao Victoria Worthy
Jeanette Lucht Lakshmi Dhanvanthari
Quarterly Provider Network Impact Report Ana Aranda Liz Le
Quarterly Pending & Unresolved Grievances Report Ramanpreet Kaur Lakshmi Dhanvanthari
Report Title
Semi-Annual Adult Expansion Default
Assignment Report
Semi-Annual Facility Site Review/Medical Record Review (FSR/MRR)
Annual Quality Assurance and Performance Improvement (QAPI) Program Template
Annual CAHPS Results Submission for Health Plan and its Subcontractors
Ana Aranda Liz Le
Ramanpreet Kaur Tracy Hitzeman
Kathleen Dalziel Lakshmi Dhanvanthari
Kathleen Dalziel Tracy Hitzeman
Annual Member Mailing Attestation Vena Ford Evert Hendrix
Annual Medi-Cal for Kids & Teens Materials Attestation
Kathleen Dalziel Lakshmi Dhanvanthari
Annual Claims Settlement and PDR Report Aimee Griffin Michelle Tetreault
Annual High Volume SPD Provider Report Sandeep Mital Lakshmi Dhanvanthari
Annual Delegation Reporting and Compliance Plan
Reshonah Hunte Betty Clark
Annual MOU Annual Report Jeanette Lucht Tracy Hitzeman
Provider Complaints
Provider complaints come to Health Plan in different forms (e.g., direct call to us or dispute submission to DMHC). While our Provider Services and Claims teams address those coming into us, Compliance is the point of contact for those coming through DMHC. In 2026, Health Plan received 1 request (1 new Provider Complaints and 0 additional information requests), disputing 1 claim. In 2025, Health Plan received 70 requests (41 new Provider Complaints and 29 additional information requests), disputing 48 claims. In 2024, we received 67 requests (28 Provider Complaints and 39 additional information requests), disputing 56 claims. In addition, each complaint may contain multiple issues that require a response.
Compliance coordinates a cross-functional group to review each complaint we receive. This group investigates the cases (from the original request to claim processing and dispute resolution) and prepares a comprehensive response to
the DMHC about the provider’s concerns and the actions taken by us. These tables outline the status:
Table 1: Provider Complaints Received from DMHC as of January 16, 2026:
Table 2: Provider Complaint Closures by Decision as of January 16, 2026:
DMHC Consumer Complaints and Independent Medical Review (IMR):
Effective May 2025, RA manages the intake, tracking, and submission of all DMHC consumer complaints and Independent Medical Reviews (IMR) to ensure timely, compliance, and coordinated responses in collaboration with Grievance & Appeals.
DMHC Consumer Complaints
The following reflects the Consumer Complaints received, including analyses by case reason, urgency and outcome.
• Table A displays the Consumer Complaint reasons for Standard Cases, Expedited Cases and Additional Information Requests.
• Table B shows the Consumer Complaint outcomes for Standard Cases, Expedited Cases and Additional Information Requests
DMHC Independent Medical Review
Table C below reflects the number of IMR cases received from the Department since May 30, 2025, and their outcomes.
Table C: DMHC Independent Medical Review (IMR) (May 30, 2025-Dec 11, 2025)
Do you have a question for Compliance? To submit an inquiry, go to Team Sites > Compliance > Requests > Submit an Inquiry on SharePoint or simply use this link: check it out here.
Program Integrity Unit (PIU)
Privacy & Security
Did you know the Health Insurance Portability and Accountability Act (HIPAA) allows healthcare employees to leave voicemails?
What HIPAA Allows
• Permits voicemails: healthcare employees can leave messages, but they should limit the amount of information they state in a voicemail to protect patient privacy and observe the minimum necessary rule.
Best Practices
• Safeguards are required: Avoid sensitive medical details unless the member has given explicit permission.
• Limit content: Use general language like “This is [insert your name] from Health Plan of San Joaquin. Please return my call at your earliest convenience.”
• Avoid sensitive disclosures: Don’t include diagnoses, lab results, or detailed medical information.
• Respect member preferences: Members can tell Health Plan how they want to be contacted (e.g., no voicemail, only cell phone). Member preferences are in QNXT.
• Confirm contact info: Ensure the voicemail is left at the number the member has authorized.
For more information regarding voicemails and HIPAA, click the link https://www.hhs.gov/hipaa/for-professionals/faq/198/may-health-careproviders-leave-messages/index.html
Privacy & Security Incidents
In the month of December, fifty-three (53) HIPAA incidents were reported to PIU. None of these incidents were reportable to DHCS or OCR.
Fraud, Waste, and Abuse (FWA)
Fraud, Waste, and Abuse Cases
In December, the PIU opened two (2) new cases and closed one (1) existing case At month end, our team had 26 open cases
Provider Exclusion Monitoring
PIU regularly monitors vendors and providers we contract with for exclusions, per 42 Code of Federal Regulations (C.F.R.) §438.610, which prohibits Medi-Cal Managed Care Plans (MCPs) from contracting or maintaining a contract with physicians or other health care providers who are excluded, suspended, or terminated from participating in the Medicare or Medi-Cal programs.
Identified Excluded Parties
Zero (0) excluded, restricted, and suspended providers were identified in the month of December through ad hoc and standard monthly screening.
Need to Report a Concern?
You can report FWA concerns anonymously, confidentially and without fear of retaliation to the Program Integrity Unit (PIU):
• Online Reporting Tool: Report Non-Compliance, Privacy or Fraud, Waste & Abuse Issues
• Email: PIU@hpsj.com
Conflict of Interest (COI)
Conflict of Interest Policy Awareness
At Health Plan, maintaining integrity and trust is essential to ensuring our members receive quality care and service. All staff are expected to understand and comply with our Conflict-of-Interest Policy, which ensures that personal interests do not interfere with professional responsibilities.
Key Points to Remember:
• A conflict of interest occurs when decisions or actions are influenced by relationships, financial interests, or other factors outside the best interests of our members and organization.
• Example: If you are involved in selecting vendors and a family member owns a company bidding for a contract, this must be disclosed as a potential conflict.
• Regularly review the policy and disclose any potential conflicts promptly.
• Your commitment to transparency protects our reputation and supports ethical practices across Health Plan.
If you’re unsure about whether you have a COI or need to file Form 700, consult policy CMP23 – Conflict of Interest or contact PIU@hpsj.com for guidance.
Audit & Oversight (A&O)
Transitional Rent Community Support Service Assessments
Introduction
Let’s start with a quiz!
Which of the following is true of the Transitional Rent Community Support Service, per the Department of Health Care Services (DHCS)?
a. It is one of seven Community Support Services that specifically address the needs of Members experiencing or at risk of homelessness.
b. It is the newest addition to the suite of Community Support Services
c. Provides up to six months of rental assistance in interim and permanent settings to Members who are experiencing or at risk of homelessness, have certain clinical risk factors, and have either recently undergone a critical life transition (such as exiting an institutional or carceral setting or foster care).
d. It is covered under Medi-Cal.
e. Is required for the Behavioral Health population of focus as of 1/1/2026.
If you answered a., b., c., d., and e. – or “all of the above” - congratulations –you are correct!
Overview of Community Supports to Support Members Experiencing or at Risk of Homelessness
There are seven Community Support Services to support Members experiencing or at risk of homelessness:
(1) Housing Transition Navigation Services (HTNS)
(2) Housing Deposits
(3) Housing Tenancy and Sustaining Services (HTSS)
(4) Day Habilitation
(5) Recuperative Care (Medical Respite)
(6) Short-Term Post-Hospitalization Housing
(7) Transitional Rent
Coverage of the first six of these Community Support Services is optional - but strongly encouraged – by DHCS, and all Managed Care Plans are required to cover Transitional Rent for Members in the Behavioral Health population of focus as of January 1, 2026. Health Plan provides comprehensive coverage for members by offering all the community supports, including Transitional Rent for members in the Behavioral Health population.
Overview of Transitional Rent
Transitional Rent has three key objectives:
1. Ensure a connection to long-term housing supports, such as rental subsidies, for Members receiving Transitional Rent to provide a pathway to housing stability and prevent a return to homelessness.
2. Use the temporary housing stability afforded by Transitional Rent as an opportunity to help Members connect to needed health care services.
3. Minimize administrative barriers (without compromising program integrity), so that Members experiencing or at risk of homelessness can readily access Transitional Rent.
Compliance
To prepare for the mandatory coverage of Transitional Rent starting 1/1/2026, Audit & Oversight (A&O) has assessed five (5) providers to evaluate their ability to conduct prospective Transitional Rent services in accordance with regulatory standards developed by DHCS. A&O will continue to provide readiness assessments for any additional Transitional Rent providers, as well as annual audits, and ad hoc audits as needed, to ensure adherence to regulatory requirements and ongoing compliance. A&O plays a critical role in ensuring the services provided are effective, adhere to regulatory guidelines, and meet the needs of impacted members.
If you’d like to learn more about the specifics of Transitional Rent, you are encouraged to read the DHCS Community Supports Policy Guide: Volume 2, pages 57-80, which fully outlines the Transitional Rent program.
Compliance Operations
New D-SNP & Medi-Cal Regulatory KPI Reporting Begins January 2026
Beginning in January 2026, all business areas will be required to self-report D-SNP and Medi-Cal Regulatory Key Performance Indicators (KPIs). Each business area is asked to access the Excel spreadsheet and complete self-reporting for all applicable Medi-Cal and D-SNP KPIs for each of their areas. Timely and accurate reporting will support regulatory compliance and consistent performance monitoring across the organization.
Policies and Procedures
Policy & Procedure (P&P) Template
Health Plan’s P&P template has been updated. Going forward, policy owners should utilize the P&P template found here. You’ll see that we’ve incorporated new instructions and minor structural changes to help in developing D-SNP and Medi-Cal/D-SNP related P&Ps.
December 2025 Published Policies
Seventy-seven (77) policies were published in December
BH01 Behavioral Healthcare Services 12/22/2025 Medi-Cal/D-SNP
BH02 Alcohol Misuse 12/26/2025 Medi-Cal/D-SNP
BH09 Behavioral Health Quality Management 12/29/2025 Medi-Cal/D-SNP
CFG01 Maintenance of Provider Data 12/26/2025 Medi-Cal/D-SNP
CL04 Cultural and Linguistic Services 12/22/2025 Medi-Cal/D-SNP
CM75 Care Transition Protocols for DSNP Members 12/26/2025 D-SNP
CM76 Contingency Plan for D-SNP Enrollees 12/26/2025 D-SNP
Policy# and Name
CM77 D-SNP Training Policy Employees 12/26/2025 D-SNP
CM78 D-SNP Training Policy Providers 12/26/2025 D-SNP
CM79 Face to Face Encounters for D-SNP Members 12/26/2025 D-SNP
CM80 Health Risk Assessment for D-SNP 12/31/2025 D-SNP
CM81 Individualized Care Plans (ICPS) 12/26/2025 D-SNP
CM82 Interdisciplinary Care Team 12/26/2025 D-SNP
CMP04 Adherence with Non-Discrimination Laws and Regulations 12/22/2025 Medi-Cal/D-SNP
CMP10 Readiness Assessments (Pre-Contractual & Pre-Delegation Review) 12/22/2025 Medi-Cal/D-SNP
CMP14 Communication and Implementation of Regulatory and Contract Changes 12/22/2025 Medi-Cal/D-SNP
CMP48 First-Tier, Downstream, and Related Entity Identification 12/31/2025 D-SNP
CONT05 Provider Recruitment 12/22/2025 Medi-Cal/D-SNP
CONT13 Contract Terminations 12/22/2025 Medi-Cal/D-SNP
EM01 Emergency Preparedness and Response Plan (EPRP) Policy 12/26/2025 Medi-Cal/D-SNP
FAC01 Health Plan Vehicle Use and Maintenance 12/29/2025 Medi-Cal/D-SNP
FAC04 Office and Cubicle Assignment 12/29/2025 Medi-Cal/D-SNP
FAC05 Community Room Guidelines for French Camp and Modesto 12/29/2025 Medi-Cal/D-SNP
FAC06 Mailroom Operations Policy 12/29/2025 Medi-Cal/D-SNP
FIN28 Budgeting and Forecasting 12/29/2025 Medi-Cal/D-SNP
FIN43 Administration and Management of Risk Corridors 12/31/2025 Medi-Cal/D-SNP
FIN51 Currency Conversion for Payment Requests 12/31/2025 Medi-Cal/D-SNP
FIN57 Risk Adjustment Data Submission 12/30/2025 D-SNP
FIN58 Identify Suspected Diagnosis 12/30/2025 D-SNP
FIN59 Risk Adjustment Data Validation Audits 12/30/2025 D-SNP
FIN60 Risk Adjustment Program Compliance 12/31/2025 D-SNP
GRV06 Independent Medical Review 12/29/2025 Medi-Cal/D-SNP
GRV07 Response Time to DMHC Regarding Urgent Grievances 12/31/2025 Medi-Cal/D-SNP
GRV08 Complaints Tracking Module CTM 12/30/2025 D-SNP
HE05 Community Advisory Committee 12/23/2025 Medi-Cal/D-SNP
HEQ01 Health Equity: Diversity, Equity, and Inclusion (DEI) Training / Transgender, Gender Diverse, and Intersex (TGI) Training 12/30/2025 Medi-Cal/D-SNP
IT201 Information Security Management 12/31/2025 Medi-Cal/D-SNP
IT203 Safeguarding Electronic Confidential Information 12/23/2025 Medi-Cal/D-SNP
IT205 Vulnerability Management Policy 12/30/2025 Medi-Cal/D-SNP
IT206 Patch Management Policy 12/30/2025 Medi-Cal/D-SNP
IT208 Application Security Policy 12/23/2025 Medi-Cal/D-SNP
IT250 Security Incident Management Policy 12/30/2025 Medi-Cal/D-SNP
IT271 Contingency Plan Policy 12/30/2025 Medi-Cal/D-SNP
IT301 Physical and Environmental Protection 12/30/2025 Medi-Cal/D-SNP
IT35 Data Sharing Intake Process 12/30/2025 Medi-Cal/D-SNP
IT401 Acceptable Use of Information Resources 12/30/2025 Medi-Cal/D-SNP
IT402 Information Systems Access Management 12/30/2025 Medi-Cal/D-SNP
IT403 Equipment Policy 12/23/2025 Medi-Cal/D-SNP
IT500 Incident Management Policy 12/30/2025 Medi-Cal/D-SNP
IT501 Change Management Policy 12/30/2025 Medi-Cal/D-SNP
PH04 Pharmacy & Therapeutics Committee 12/23/2025 Medi-Cal/D-SNP
PRO03 Provider Information and Directory Maintenance 12/12/2025 Medi-Cal
PRO03 Provider Information and Directory Maintenance 12/12/2025 Medi-Cal/D-SNP
PRO20 Provider Training and Education 12/08/2025 Medi-Cal/D-SNP
PRO23 Web-based Provider Directory Usability Testing 12/08/2025 Medi-Cal/D-SNP
PRO28 Access and Availability Standards and Monitoring 12/08/2025 Medi-Cal
PRO28 Access and Availability Standards and Monitoring 12/08/2025 Medi-Cal/D-SNP
PRO32 Provider Satisfaction Survey 12/29/2025 Medi-Cal/D-SNP
QM13 Chief Medical Officer/Medical Directors/ Role and Responsibility to the Quality Improvement Program 12/29/2025 Medi-Cal/D-SNP
QM15 Member Experience Surveys 12/08/2025 Medi-Cal/D-SNP
QM20 Supplemental Data Collection – EMR Systems 12/29/2025 Medi-Cal/D-SNP
QM22 Initial Health Appointments 12/29/2025 Medi-Cal/D-SNP
QM33 Provider Appeal Rights 12/29/2025 Medi-Cal/D-SNP
QM38 Quality Improvement and Health Equity Committee (QIHEC) 12/08/2025 Medi-Cal/D-SNP
QM45 Communication with Stakeholders 12/31/2025 Medi-Cal/D-SNP
QM70 Credentialing Information Integrity 12/08/2025 Medi-Cal/D-SNP
SS01 Social Services Supports 12/30/2025 Medi-Cal/D-SNP
UM94 Pre-Service Medical Necessity and Benefit Determination Adverse Decision-Making Process 12/31/2025 D-SNP
UM95 Changing Review Priority of Pre-Service Organization Determinations 12/08/2025 D-SNP
UM96 Clinical Decision-Making and Criteria Hierarchy for Organization Determinations 12/08/2025 D-SNP
UM99 Pre-Service Organization Determinations 12/31/2025 D-SNP
UM100 Prior Authorization for Elective Inpatient Hospital Admissions 12/31/2025 D-SNP
UM102 Reopening of Organization Determinations 12/30/2025 D-SNP
UM103 Requesting Additional Information for Organization Determinations 12/30/2025 D-SNP
UM104 Timeliness of Organization Determinations 12/30/2025 D-SNP
UM105 Utilization Management Committee 12/30/2025 D-SNP
UM106 Withdrawal and Dismissal of Organization Determination Requests 12/30/2025 D-SNP
Did you know?
You can access all published policies directly via the Policies link on our Intranet. If you have any policy-related questions, please get in touch with the Policy Review Team at Policies@hpsj.com
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