Facey Medical Group has prepared this section to assist our external physicians, and other provider/pracitioners in providing proper care of Facey patients, in keeping with our organizational policies and the standard of excellence that they have come to expect. These resources are organized into the eight focus areas, below.
If you are interested in working with Facey as an contracted, external provider, please send us a letter of interest and a copy of your CV.
- Send your CV and letter by email
- Send by fax: 818-837-5787
Submit paper claims to:
Facey Medical Foundation
PO Box 9605
Mission Hills, CA 91346
Electronic claims may be submitted through office Ally or WebMD.
Inquiries regarding claims, including receipts, status, payment and submission of electronic claims, may be made by contacting Facey's Customer Relations team; call 855-359-6323 or send by mail to the address above.
- Claims must be submitted within 90 days following the date of service, except as otherwise required by federal law or regulation
- Claims payments are made in compliance with state and federal timeliness guidelines
- Claim payment timeliness is measured from the date the claim was received by Facey Medical Foundation
Below are links to helps for completing the CMS claim forms. Make certain that all fields are accurately completed.
A contracted provider dispute is a provider’s written notice to Facey Medical Foundation challenging, appealing or requesting reconsideration of a claim (or a bundled group of substantially-similar multiple claims that are individually numbered) that has been denied, adjusted or contested, or seeking resolution of a billing determination of other contract dispute (or bundled group of substantially-similar multiple billing or other contractual disputes that are individually numbered), or disputing a request for reimbursement of an overpayment of a claim. Each contracted provider dispute must contain, at a minimum, the following information:
- Provider’s name
- Provider’s identification number
- Provider’s contact information
If the contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim, the following must be provided:
- A clear identification of the disputed item, the date of services, and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, request for reimbursement for the overpayment of a claim, contest, denial, adjustment, or other action is incorrect
- If the contracted provider dispute is not about a claim, you must provide a clear explanation of the issue, and the provider’s position on such issue
- If the contracted provider dispute involves an enrollee or group of enrollees, the name and identification number(s) of the enrollee or enrollees, a clear explanation of the disputed item, including the date of service and provider’s position on the dispute, and an enrollee’s written authorization for provider to represent said enrollee(s) must be provided
Substantially-similar multiple claims, billing or contractual disputes may be filed in batches as a single dispute – provided that such disputes are submitted in the following format:
- Sort provider dispute by similar issue
- Provide cover sheet for each batch
- Number each cover sheet
- Provide a cover letter for the entire submission describing each provider dispute with references to the numbered coversheets
Facey Medical Foundation
PO Box 9605
Mission Hills, CA 91346
"A customer is the most important visitor on our premises. He is not dependent on us. We are dependent on him. He is not an interruption in our work. He is the purpose of it.”
Kenneth B Elliott, Vice President of Sales, Studebaker Corporation (1941)
You will find a clinic administrative team at each of the Facey locations, dedicated to assisting our patients with the many issues or questions they may have. You can also contact Facey's central Customer Relations team by phone: 855-359-6323. In addition to general service concerns, they can assist with questions about claims, service authorizations, appointments, eligibility, benefits, resources and more.
To confirm eligibility, contact the health plan directly:
|Anthem Blue Cross||800-677-6669|
|Anthem Blue Cross First Impressions||714-429-2784|
|Blue Shield 65+||800-776-4466|
|Health Net & Health Net Seniority||800-852-5524|
|Humana Gold Plus||800-457-4708|
In 2001, Facey Medical Group implemented its electronic health record (EHR) system, making it one of the earliest adopters of this technology and one of the few physician groups in Southern California to have such a system. It is our responsibility to:
- Promote HIPAA awareness to encourage compliance with all regulations
- Protect patient privacy and provide information security
- Ensure health information is complete and available
- Ensure Coding and Compliance is in place for reimbursement
- Prevent fraud and abuse
As an external provider, you should become familiar with Facey's policies and procedures with regards to medical records. Please review the following:
- MR 100.12 - Medical Record Standards & General Documentation Guidelines
- MR 200.28 - Authorization for Use and Disclosure of PHI
- MR 500.05 - Guidelines for Physician Documentation Audits
Effective June 27, 2010, a new regulation, mandated by Business and Professions Code section 138, went into effect requiring physicians in California to inform their patients that they are licensed by the Medical Board of California, and include the board's contact information. The information must read as follows.
Medical doctors are licensed and regulated by the Medical Board of California
The purpose of this new requirement (Title 16, California Code of Regulations section 1355.4) is to inform consumers where to go for information or with a complaint about California medical doctors.
Physicians may provide this notice by one of three methods:
- Prominently posting a sign in an area of their offices conspicuous to patients, in at least 48-point type in Arial font
- Including the notice in a written statement, signed and dated by the patient or patient's representative, and kept in that patient's file, stating the patient understands the physician is licensed and regulated by the board
- Including the notice in a statement on letterhead, discharge instructions, or other document given to a patient or the patient's representative, where the notice is placed immediately above the signature line for the patient in at least 14-point type
Quality Management is an all encompassing philosophy that supports our organization’s management infrastructure, policies & procedures and practices. Quality Management is driven by five basic principles:
- A focus on patient centered care and patient-provider relationships
- An emphasis on continuously improving performance in all areas
- An emphasis on efficient operational and care systems and patient safety
- The active involvement of leaders and empowerment of employees
- The use of data-driven decision making across the organization
As defined, Quality Management embraces features of both Quality Assurance and Quality Improvement and goes one step further to embody our management philosophy.
Facey Medical Group and Facey Medical Foundation conduct diligent internal processes and audits that review physician and allied health professional provider credentials, medical records, compliance with privacy laws, administration, quality management programs, continuity of care, diagnostic training, medication management, facility and environmental safety and surgical procedures. We place special emphasis on education, guidance and strategic involvement of practicing physicians.
It is the policy of Facey Medical Group and Facey Medical Foundation to provide health services to all patients in a culturally competent and non-discriminatory manner without regard to race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), genetic information, or source of payment or ability to pay.
Further, services will be provided in a non-discriminatory manner to all members, including those with limited English proficiency or reading skills, the sensory impaired, and those with diverse cultural or ethnic backgrounds. Please refer to Language Assistance (LAP) Section under Providers for a LAP Overview and LAP Training. This includes a grid of Health Plan Language Interpreter Services phone numbers to assist with verbal translation and ADA Sign Language translators for patients.
It is the policy of Facey Medical Group and Facey Medical Foundation to adhere to the access standards established by the Industry Collaboration Effort (ICE), the Health Plans and the Department of Managed Health Care (DMHC) Time-elapsed Access Regulations. These regulations establish the minimum compliance standards for enrollee accessibility to primary, specialist, behavioral health, and ancillary care providers. This applies to all DMHC licensed health care service plan contracted practitioners (e.g. HMO, POS, PPO, Medi-Cal, Healthy Families, Healthy Kids and Access for Infants and Mothers). Please refer to the Access Standards Section under Providers for DMHC appointment timeframes and the entire ICE approved policy for your reference.
Patient Complaint/Appeals Process
It is the policy of Facey Medical Group and Facey Medical Foundation to address and resolve all patient concerns in a timely and efficient manner through the involvement of appropriate physicians and management staff. Closure of all complaints/appeals must be reached within the timeframe specified by the health plan. All grievances and appeals will be forwarded to Blue Cross or the appropriate health plan (HMO), but an internal investigation will be initiated upon receipt.
Appeals will be reviewed by the Medical Director of Quality Management and a response to the health plan will be formulated based on chart review, health plan benefit interpretation and criteria as well as any additional information from the provider(s) on an as-needed basis.
All complaints and appeals received from the HMO’s will require a formal written response and medical record request within the time period specified by the HMO, depending on the urgency. All medical records requested by the HMO will be sent out according to the health plan’s specified timeframes for Routine, Urgent and Expedited.
A patient complaint is defined as any concern voiced by a patient that cannot be resolved directly by the physician or staff interacting with the patient. The concern may reach the Medical Group directly from the patient or via the health plan.
An appeal is defined as a request by the patient or provider to reconsider a service request decision.
Patient complaints at Primary Care, OB/GYN, inpatient, residential, ambulatory facilities providing mental health/substance abuse services and new facilities or locations will be monitored continually, investigated and/or referred to the appropriate individual(s) responsible for resolving the issue at all practice sites. These types of complaints will be forwarded as appropriate to the designated health plans as indicated by ICE guidelines.
A Site Visit will be conducted for all new practice and as appropriate to investigate patient complaints. The structured site review evaluates the following:
- Physical accessibility
- Physical appearance
- Adequacy of waiting and exam room space
- Availability of appointments
- Adequacy of medical record keeping
Physician quality of care issues will be forwarded to Quality Management for investigation by the Medical Director of Quality Management or his designee. Such complaints regarding the clinical care of patients by physicians will be shared in a confidential manner with the individual physician involved and the respective Department Chair. The Medical Director of Quality Management, as appropriate, will forward the complaint and the physician response to the Peer Review Committee.
Member Behavioral Warning/Dismissal Process
It is the policy of Facey Medical Group that, based on HMO contractual language, a contracted physician may request that an HMO/PPO patient be removed from his or her care subject to the nature and severity of the event(s). The physician should document that he or she has warned the patient of the consequences of failure to follow medical advice or adhere to recommended treatment plans, including failure to keep appointments. The patient will be verbally counseled by the provider when he/she does not follow medical advice or treatment plans. This discussion should also be documented in the medical record. At the discretion of the provider, a letter may be sent to the patient outlining the expected behaviors and the timeframe to exhibit requested changes in behavior. The Quality Management Department can assist you during this process.
Prior to dismissing the patient from your practice, please contact the Facey Medical Foundation Quality Management Department for assistance with transferring the member to another specialist if continued care is required.
Patient Bill of Rights
Facey Medical Group is a caring and innovative team dedicated to enthusiastically improving the quality of life and health of the people we serve.
We believe that you, as our patient, have certain rights:
- You have the right to receive appropriate access to treatment.
- You have the right to know the names and responsibilities of all health care professionals who are caring for you.
- You have the right to be treated with respect, recognition of your dignity and right to privacy.
- You have the right to receive treatment that is appropriate and consistent with your medical needs.
- You have the right to receive information about Facey Medical Group, its services, practitioners and providers, and members' rights and responsibilities.
- You have the right to participate with practitioners in decision-making regarding your health care.
- You have the right to candid discussion of appropriate or medically necessary treatment options for your condition regardless of cost or benefit coverage.
- You have the right to voice complaints or appeals about Facey Medical Group or the care provided.
- You have the right to receive clear and complete information about your condition and care, including explanations of procedures, tests, treatments and alternatives (including risks and benefits), in order to give informed consent or refuse treatment.
- You have the right to receive a timely response to any reasonable service request.
- You have the right to confidential handling of all communications and medical information maintained at Facey, as provided by law and professional medical ethics.
- You have the right to be represented by parents, guardians, family members or other conservators if you are unable to fully participate in your treatment decisions. These rights will apply to them as well.
- You have the right to make recommendations regarding Facey's member rights and responsibilities policy.
- You have the right to access services & information in an alternative format and in any language that is prevalent among Facey patients.
- You have the right to be free from all forms of abuse or harassment. You have the right to exercise your rights without being subjected to discrimination or reprisal.
We also believe that you, as our patient, have certain responsibilities when receiving care from Facey Medical Group:
- You have the responsibility to provide complete and accurate information to the best of your ability about your health, any medications (including over-the-counter products and dietary supplements), and any allergies or sensitivities which Facey and its practitioners need to know in order to care for you.
- You have the responsibility to ask for clarification about any aspect of your care which you do not fully understand and to participate in developing mutually agreed upon treatment goals.
- You have the responsibility to follow the agreed upon plans and instructions for your care.
- You have the responsibility to notify your health care provider if you notice any change in your health.
- You have the responsibility to extend reasonable courtesy toward all health care providers during the treatment process.
- You have the responsibility to provide a responsible adult to transport you home from the facility and remain with you for 24 hours if required by your provider.
- You have the responsibility to inform your provider about any living will, medical power of attorney or other directive that could affect your care.
- You must accept personal financial responsibility for any charges not covered by your insurance.
This section addresses Facey Utilization Management (UM) processes and the integration of Facey Case Management (CM) services for our Managed Care patients.
UM is a process to assure the delivery of medically necessary, optimally achievable, quality patient care through appropriate utilization of resources in a cost effective and timely manner. UM evaluates medical necessity, medical appropriateness and efficient use of medical services, procedures and facilities, including specialty care, inpatient, outpatient, home care, skilled nursing services, ancillary services and pharmaceutical services. All UM functions are performed under the direction of the UM Department.
Requests for services submitted by providers are reviewed by UM using Facey Medical Group clinical guidelines, Milliman Care Guidelines, Health Plan guidelines, and other criteria as approved by the Facey Medical Guidelines Committee, National Guideline Clearing House, ICSE ICSI, Up-to-date, the Agency for Healthcare Research and Quality, NIH Consensus Statements, authoritative text books and journals, and Medicare Coverage Guidelines. Decision criteria for medical and behavioral health services are reviewed and approved annually by the UM Committee and as necessary additional criteria are adopted by the UM Committee throughout the year. Criteria are utilized on an individual case-by-case basis taking into account patient need and characteristics of the delivery system. Criteria are applied with consideration for the individual patient’s needs, which include but may not be limited to: age, co-morbidity, complications, progress of treatment, psychosocial situation and/or home environment. Facey Medical Foundation uses board certified consultants as necessary to assist in making medical necessity decisions. Requesting providers are notified of the decision via written correspondence. Criteria for appropriateness of medical services are clearly documented and available upon request. They are distributed via provider newsletters. Providers may request copies of the criteria used to make a decision by calling Facey Medical Foundation’s UM Department.
Authorized services may require a co-pay. Co-pays are specific to the patient’s health plan benefits and the services rendered at the time the patient is seen. It is the responsibility of the provider of service to verify and collect the co-pay from the member at the time of service as the co-pay may differ from that stated on the authorization.
Potential quality issues and deviant medical practice identified by UM staff are reported to the Quality Management Department for review and action as necessary. Results of the QM review and any trends identified are reported to the Peer Review Committee and sent to the QM committee on an annual basis.
Facey Utilization Management (UM) processes are maintained by established procedures and policies set by Facey management and provided below.