Appropriate Use of “Urgent” Requests for Your Patients How to Enter Referrals/Authorizations
Referral Expectations for HMO Members
Breast
Cervical
Cancer Facts and Figures 2026
Chlamydia
Childhood
Initial Health Appointments (IHAs)
Health Risk Assessments (HRAs)
On January 1, 2026, Valley Health Plan moved office locations. If you are mailing correspondence to VHP, such as provider disputes or other responses, please mail directly to VHP’s new address:
VHP
5845 Hellyer Avenue San Jose, CA 95138
Our office hours will remain the same from 8 a.m. to 5 p.m Monday-Friday. Please update your records to reflect the change if you have not already.
For all claims, please continue to mail them to the appropriate P.O. Box as listed below.
For claims associated with Employer Group, Covered California, and Individual & Family Plan members, please mail to:
VHP Claims Department
P.O. Box 26160
San Jose, CA 95159
For claims associated with Medi-Cal Plan members, please mail to:
VHP Medi-Cal
P.O. Box 28407
San Jose, CA 95159
Please view this tip sheet to learn how to enter referrals/authorizations in VHP Access: https://issuu.com/valleyhealthplan/docs/ vhp_access_-_how_to_enter_referrals
Providers are reminded that urgent requests should only be submitted when a patient has a non-emergency condition requiring prompt medical attention, when treatment cannot safely wait for a routine appointment, but the condition is not life threatening. Requests that do not meet this definition should not be marked as urgent. Misclassification may delay processing for patients with true urgent needs and may impact compliance with regulatory timeframes.
VHP is a Health Maintenance Organization (HMO), and members are expected to receive care from in-network specialists and facilities. Referrals to quaternary providers should be reserved only for services that require a higher level of care. Providers are encouraged to verify network participation and refer members appropriately to support continuity, coordination, and timely access to care.
Cultural responsiveness is not about knowing everything about every culture. It is about recognizing that health decisions do not happen in isolation.
Members bring beliefs about illness, family roles, healing practices, past experiences with healthcare, and social realities into every visit. The CLAS Program promotes culturally responsive care.
You can help by:
● Respecting beliefs and decision-making: Some patients prefer family involvement. Others balance traditional healing practices alongside Western medicine. Asking open questions can turn hesitation into partnership.
● Using culturally appropriate education and follow-up: Standard instructions do not resonate with everyone the same way. Adjusting language, pacing, and framing, along with confirming understanding can help prevent confusion.
● Addressing social and cultural realities: The CDC estimates that social and environmental factors influence up to 80% of health outcomes. Housing stability, food access, transportation, work schedules, and immigration concerns often shape adherence to health advice.
● What feels hardest about this plan right now?
● What has worked for you before?
● Is there anything about your culture or family that I should know?
According to the World Health Organization (WHO), cancer is a leading cause of morbidity and mortality worldwide. Early detection and treatment are key to improving patient outcomes. Colorectal, breast, and cervical cancers are among the most common types of cancer. Regular screening is important for early detection and treatment.
Early detection reduces morbidity and mortality rates, allows for a greater range of treatment options, and lowers healthcare costs. By following the U.S. Preventive Services Task Force (USPSTF) guidelines and tracking performance using Healthcare Effectiveness Data and Information Set (HEDIS) measures, medical professionals can help improve the early detection and treatment of cancer, leading to better health outcomes for their patients. It is important for practitioners to be aware of these recommendations and measures so that they can help identify patients who are due for cancer screening and ensure that they receive the appropriate tests.
Over the past year, VHP has launched a new value-based payment program to improve health outcomes by helping to close gaps in care. Below are some of our strategies to increase the number of VHP members who are screened for colorectal, breast, and cervical cancer.
VHP will continue to collaborate with our providers by:
● Supporting them by incenting and sharing gaps in care data
● Reaching out to members to deliver education and screening reminders
● Tracking and trending areas needed for quality improvement
Colorectal cancer is the third most common cancer among both men and women in the U.S. Early detection through regular screening can significantly improve survival rates, with a 90% five-year survival rate when caught in its earliest stage. Here’s what you need to know about screening recommendations:
● The American Cancer Society (ACS) recommends that adults at average risk start at age 45.
● The USPSTF advises screening for adults between ages 45 to 75 using tests such as colonoscopy, sigmoidoscopy, or a high-sensitivity fecal occult blood test.
● For adults aged 76 to 85, screenings should be based on health, previous screenings, and preferences.
Regular screening is the key to preventing and detecting colorectal cancer early, improving outcomes, and saving lives. Screening may:
● Detect precancerous polyps before they become cancerous
● Identify colorectal cancer early, when treatment is most effective
Stool-Based Colorectal Cancer Screening
Last year, VHP partnered with Exact Sciences to offer Cologuard Test kits to eligible Covered California members age 45+ at average risk and due (or overdue) for their colon cancer screening. Since August 2025, 4,747 members received
free kits to screen for colorectal cancer. Of the 1,441 members who completed the test, 82 members presented with a positive test result who were then notified and recommended to schedule a colonoscopy to rule out cancer.
● American Cancer Society Clinician’s Reference: This resource provides an overview of stool-based colorectal cancer screening options and offers guidance on implementing stool-based screening programs.
Breast cancer is the most common cancer among women in the U.S. regardless of race or ethnicity. Regular screening is essential for early detection and improved outcomes. Here’s what you need to know:
● The USPSTF recommends that women ages 40 to 74 years old at average risk get a mammogram every other year.
● Women with a family history of breast cancer (parent, sibling, or child) are at higher risk and may benefit from earlier screening before age 40.
● Detects breast cancer early, when treatment is most effective
● Improves survival rates and treatment options
Discussing personal risk factors with patients can help determine the best screening plans for individual needs.
The ACS launched a digital Breast Cancer Risk Assessment Toolkit for health professionals. This resource supports identification of individuals at higher breast cancer risk to enable personalized screening, prevention, and early detection strategies. Learn more about the ACS Risk Assessment Toolkit here.
Cervical cancer is the fourth most common cancer in women worldwide. In the past, it was the leading cause of cancer-related death among American women, but effective screening and early detection have significantly reduced mortality rates.
Women ages 21 to 65 should undergo
regular cancer screening using a Pap test or a human papillomavirus (HPV) test, as recommended by USPSTF.
● Ages 21 to 29 years: A Pap test (cervical cytology) every three years
● Ages 30 to 65: A Pap test every three years, high-risk human papillomavirus (hrHPV) testing alone every five years, or co-testing (Pap + hrHPV test) every five years
● Detects cervical pre-cancers early, preventing cancer development
● Improves treatment success rates and reduces mortality
Following these screening guidelines helps ensure early detection and better health outcomes.
The ACS has updated its cervical cancer screening guidelines to include HPV selfcollection and recommendations on when screening may safely stop. See below for more resources:
● ACS Cervical Cancer Screening Guidelines
● Cervical Cancer Screening with the HPV Self-Collection Test
● NRTCC Self-collection Clinician Communication Guide
● Webinar Series on Self-Collection for Health Professionals
References:
● Cancer Screening Rates Missing Targets. (2015, May 26). National Cancer Institute.
● HEDIS Measures and Technical
Resources. NCQA. (2022a, December 15).
● U.S. Preventive Services Task Force. (n.d.)
● U. S. Preventive Services Task Force. (n.d.-b).
● Colorectal Cancer: Screening. (2021, May 18).
● “Cancer.” World Health Organization. (n.d.).
● American Cancer Society | Information and Resources about for Cancer: Breast, Colon, Lung, Prostate, Skin. (n.d.). American Cancer Society.
● Breast Cancer Statistics. (2022, November 29). Centers for Disease Control and Prevention.
2026
The American Cancer Society (ACS) provides up-to-date data, evidence-based screening recommendations, and practical tools to support providers in delivering high-quality cancer prevention and early detection services. Below are key updates and resources to support your work.
ACS has released Cancer Facts & Figures 2026, its annual report summarizing the latest cancer incidence, mortality, and survivorship trends in the U.S. Key highlights include:
● 70% of people diagnosed with cancer from 2015 to 2021 are surviving at least five years. 4.8 million lives have been saved due to a 34% decline in cancer death rates since 1991.
● Incidence rates are increasing for breast, prostate, liver, melanoma (female), oral cavity, pancreas, and uterine cancers.
Resources:
● American Cancer Society
● ACS Cancer Facts & Figures 2026
Chlamydia is the most common sexually transmitted infection (STI) in the United States. In 2024, the Centers for Disease Control and Prevention (CDC) reported 1,515,985 chlamydia cases. In addition, the number of reported cases is lower than the actual number. This is because about 75% of infected people do not have symptoms. They do not seek treatment until they have complications such as pelvic inflammatory disease (PID), infertility, ectopic pregnancy, or chronic pelvic pain.
The USPSTF recommends yearly chlamydia screening for sexually active women, including pregnant persons, even without chlamydia signs and symptoms. Sexually active women 24 years or younger and women 25 years or older with an increased risk should be screened.
Increased risks include women aged 15 to 24 years old or women 25 years or older with:
● A previous or coexisting STI
● A new or more than one sex partner
● A sex partner who has other sex partners
● A sex partner with an STI
● Inconsistent condom use when not in a mutually monogamous relationship
● A history of exchanging sex for money or drugs
● A history of incarceration
Clinicians should consider the communities they serve. They may want to check with local public health authorities for further guidance on who is at increased risk.
For more details on chlamydia trends and screening, visit:
● USPSTF Chlamydia and Gonorrhea Screening
● CDC - Chlamydia
● SCC Public Health Epidemiology Annual Report 2024
● National Committee for Quality Assurance – Chlamydia Screening
Routine health checkups are crucial in monitoring the growth and development of young children. State regulations require health care providers to assess children between six months and six years old for childhood lead poisoning. These regulations apply to all physicians, nurse practitioners, and physician assistants.
● Even low levels of lead exposure have lasting neurodevelopmental effects.
● Children at risk of lead exposure may not receive appropriate treatment or investigation because low levels of lead exposure may not show any symptoms.
● It is a state requirement.
Screen with a blood lead test:
● Children in publicly supported programs* at both 12 months and 24 months.
● Children aged 24 months to 6 years in publicly supported programs* who were not tested at 24 months or later.
* Examples of publicly supported programs include Medi-Cal, Child Health and Disability Prevention, and the Women, Infants, and Children Program.
Assess if the child is not in a publicly supported program:
● Ask “Does your child live in or spend a lot of time in a place built before 1978 that has peeling or chipped paint that has been recently remodeled?”
● If the answer is “yes” or “don’t know,” complete a blood lead test.
Other indications for a blood lead test:
● Suspected lead exposure
● Parental request
● Recent immigration from a country with high levels of environmental lead
● Change in circumstances that has put a child at risk of lead exposure
A finger-prick or heel-prick (capillary) sample is usually the first step to determine if a child has lead in their blood. A finger-prick can provide fast results and produce higher results if the sample captures lead on the skin. A finger-prick that shows a blood lead level at or above the CDC’s blood lead reference value of 3.5 micrograms per deciliter is usually followed by a second test to confirm it.
Health care providers play an important role in preventing lead poisoning. Providers can identify children at higher risk, test their blood lead levels, and connect families with follow-up services. Valley Health Plan covers the cost of lead screening for children for all health plans. For more information visit:
● Standard of Care on Screening for Childhood Lead Poisoning
● 2023 Blood Lead Testing and Anticipatory Guidance.pdf (ca.gov)
Providers play a vital role in assessing and managing their patients’ immediate health needs, chronic conditions, and preventive care. On Jan. 1, 2023, the Initial Health Assessment (IHA) was replaced with the Initial Health Appointment (IHA) by the Department of Health Care Services (DHCS). DHCS documents this change in All Plan Letter APL 22-030 Initial Health Appointment.
The Initial Health Appointment happens when a member visits their primary care provider (PCP). The provider assesses and manages the member’s immediate health needs, chronic conditions, and preventive care. The IHA policy, in line with the Population Health Management Guide and the Medi-Cal Managed Care Health Plan contract, is designed to enhance patient care and outcomes.
All Medi-Cal members must complete an IHA within 120 days of enrollment and periodically redo the assessment according to the requirements above.
● Must be performed by a primary care provider
● It is not needed if the member’s medical records were fully updated within the previous 12 months
● Must be provided in a way that is culturally and linguistically appropriate for the member
● Must be documented in the member’s medical record
The IHA Includes:
● Taking a history of the member’s physical and mental health
● Identifying health risks
● Assessing the need for preventive screenings or services
● Providing health education
● Diagnosing and planning for treatment of any diseases
The DHCS requires PCPs to complete an IHA for all new plan members within 120 calendar days of enrolling in a Medi-Cal managed care health plan (including Santa Clara Family Health Plan).
IHAs are not diagnostic tools or full health histories. Their purpose is to engage patients in their health and promote better long-term choices and behaviors.
● Increase patient connection by using data for discussion
● Help identify and prioritize patient health issues and goals
● Help patients understand their current health status
● Remind patients about habits that affect their health
● Identify issues requiring patient referral to additional resources
More Resources:
● All Plan Letter APL 22-030 Initial Health Appointment
● Population Health Management Guide
● Managed Care Health Plan contract
Every year, VHP asks members to complete a Health Risk Assessment (HRA), which includes a questionnaire about their health needs and recent changes. The assessment helps VHP understand a member’s risks and ensures that the member receives the appropriate VHP services. Once an HRA is
received, a case manager can work closely with the member and their primary care provider to understand and manage their health and to create an individual care plan (ICP).
You may receive copies of these ICPs for some of your patients. If you do, we invite you to participate in any feedback and collaborate in support of your patients meeting their health care needs.
The results also help Valley Health Plan validate and identify programs that are appropriate for the broader population.
Please encourage your Valley Health Plan patients to complete the HRA. The questionnaire is offered in English, Spanish, Vietnamese, and Chinese, and can be translated into other languages upon request. Currently, members may access VHPConnect at www.vhpconnect.org to take their HRA online or receive it via mail.
The VHP Case Management Team is also happy to help members complete their HRAs over the phone. It takes about 10 minutes, and they can call 669.220.5235 for assistance.
Your support and partnership are greatly appreciated. If you, or your patients, have questions about the HRA, please contact us directly.
Valley Health Plan (VHP) offers a comprehensive set of Health and Wellness programs designed to support preventive care, chronic disease management, and population health priorities aligned with HEDIS quality measures. These programs extend care beyond the clinical setting by engaging members, reinforcing provider recommendations, and supporting care gap closure.
● Controlling high blood pressure (CBP) through health education, blood pressure monitoring support, and follow-up engagement
● Diabetes Prevention Program (DPP) and Diabetes Self-Management education to support healthy lifestyle changes
● Asthma education and selfmanagement to improve symptom control and reduce exacerbations for children ages 6-12
● Tobacco cessation education to support those who are ready to quit smoking or reduce tobacco use
● Nutrition, fitness, and healthy living programs, including aquatics and wellness resources, to support behavior change and overall health
● Maternal and family support, including doula benefits and selfmanagement tools
To view a complete list of available programs, visit VHP’s website at www.valleyhealthplan.org.
VHP’s Health Education and Case Management teams work directly with members to assess needs, provide culturally and linguistically appropriate preventative and chronic disease education, and connect them to programs that complement clinical care and support quality outcomes.
Providers are encouraged to remind members of these resources during preventive visits, chronic disease management, and quality improvement efforts related to HEDIS measures.
No referral form is required. Members may self-refer by:
● Calling the VHP Health Education line at 408.970.2299
● Completing an online Health & Wellness Request Form
● Sending a message through their member portal: VHP Connect
VHP recently launched a new Health Education outreach initiative to support improved performance on the Controlling Blood Pressure (CBP) measure, while also strengthening care coordination for members with hypertension.
Beginning in August 2025, VHP’s Health Education Team implemented an outreach campaign targeting members who had a diagnosis of hypertension and did not have a recent blood pressure reading on file within the past 12 months. Using culturally and linguistically tailored scripts, VHP’s Health Education Specialists contacted members to provide education to these members including:
● Ways to monitor and track their blood pressure
● Risks of uncontrolled hypertension
● Building healthy daily habits such as eating well, being active, and managing stress
As of December 31, 2025, the VHP’s Health Education team reached out to 2,452 members, with 38% successfully engaged. Engagement included members who completed the outreach intervention, as well as those who declined participation but still received some health education. When appropriate, members were supported in capturing and reporting updated blood pressure readings.
This effort also strengthened early identification of members with uncontrolled hypertension. Members identified with Stage 2 or higher blood pressure readings were referred to VHP’s Case Management for follow-up care and ongoing support, reinforcing collaboration between VHP’s teams to address clinical needs early.
The outreach also highlighted the importance of culturally responsive care. Approximately 33% of members preferred communication in a language other than English, underscoring the value of bilingual staff and tailored engagement strategies. Many members expressed appreciation for the direct outreach and education provided.
To further encourage provider collaboration, VHP developed provider communications to notify practices when their patients reported high blood pressure readings to encourage timely follow-up. This approach allows VHP to support providers by improving documentation, identifying members who may need additional clinical support, and engaging members proactively in managing their blood pressure. VHP’s Health Education will continue this outreach in measurement year 2026, to further improve outcomes related to hypertension control.
Providers play a critical role in closing care gaps related to blood pressure control. To support this effort, we encourage providers to:
● Review updated blood pressure readings shared by VHP during our Health Education outreach.
● Schedule timely follow-up visits for members with elevated or uncontrolled blood pressure.
● Ensure blood pressure readings are documented during office visits and submitted through standard reporting channels.
● Reinforce hypertension education during visits, including the importance of routine monitoring and medication adherence. Together, through coordinated outreach, documentation, and follow-up care, we can improve blood pressure control and support better outcomes for your VHP patients.
Valley Health Plan offers a certified Tobacco Cessation Program provided by VHP Health Education Specialists to support members who are ready to quit smoking or reduce tobacco use.
This program is designed as a two-session, one-on-one workshop, currently offered virtually and in-person. The program offers personalized education and support tailored to each member’s needs. During the
sessions, VHP’s Health Education Specialists work closely with members to:
● Review quitting strategies
● Identify individual smoking triggers
● Discuss Nicotine Replacement Therapy (NRT) options
Members are also supported in selecting a quit date and developing a plan to manage withdrawal symptoms and prevent relapses.
The program is available at no cost to members and is appropriate for individuals who are considering quitting for the first time, as well as those who have attempted to quit in the past. Members who complete both sessions receive a certificate of completion.
This in-house approach allows VHP to provide culturally responsive, individualized education, while supporting providers’ efforts to address tobacco use as part of preventive care.
Providers are encouraged to promote and refer their VHP patients to VHP’s Tobacco Cessation Program as part of routine care and preventive counseling.
No referral form is required, and providers may inform their VHP patients directly about the program and how to enroll. VHP patients may self-refer using one of the following options:
● Call the VHP Health Education line at 408.970.2299.
● Complete the online Tobacco Cessation Program Form.
● Send a message through their member portal, VHP Connect.
By encouraging participation in this program, providers can connect patients to personalized cessation support that complements clinical care and helps improve long-term health outcomes.
Effective 1/1/2026, Medi-Cal Rx no longer covers glucagon-like peptide-1 receptor agonists (GLP1 drugs) prescribed for weight loss. This change applies to all Santa Clara Family Health Plan (SCFHP) members, both Medi-Cal and DualConnect (HMO D-SNP) and includes the following GLP-1 drugs:
● Dulaglutide (Trulicity)
● Exenatide (Byetta, Bydureon)
● Liraglutide (Victoza, Saxenda)
● Semaglutide (Ozempic, Wegovy, Rybelsus)
● Tirzepatide (Mounjaro, Zepbound)
If your patient has been taking one of these medications for weight loss and has no other condition requiring GLP-1 therapy (e.g., diabetes, obstructive sleep apnea, or metabolic dysfunction-associated steatohepatitis):
● Consider alternatives for weight loss. Refer to the Medi-Cal Rx Contract Drugs List (CDL) at https://medi-calrx.dhcs.ca.gov/home/cdl/.
● Share available resources to support healthy lifestyle choices.
If you have any questions regarding this information, please contact the SCFHP Pharmacy Department at 1.408.874.1796 (TTY: 711). Read the full memo here
The Department of Health Care Services (DHCS) has issued updated requirements for outpatient hospice services under APL 25-008. Key provisions include:
● Hospice services require certification by the attending physician and/or hospice medical director confirming the member has a terminal illness with a life expectancy of six months or less.
● The member must formally elect hospice services in lieu of curative treatment for the terminal condition.
● The hospice provider must submit the MediCal Hospice program election notice to VHP within five (5) calendar days of certification and election.
● If the election form is not submitted timely, VHP is not responsible for covering hospice services from the hospice admission date through the date the form is received and accepted.
● Non-covered days are the hospice provider’s liability, and the provider may not bill the member for these services.
● Hospice services are covered through in-network providers unless medically necessary services are not available in-network.
● Out-of-network hospice providers must:
1. Hold Medicare certification
2. Be licensed by the California Department of Public Health (CDPH)
3. Have a valid National Provider Identifier (NPI) prior to claim payment
● General inpatient hospice care requires prior authorization.
● Routine home care, continuous home care, and respite care do not require prior authorization when provided by an eligible hospice provider.