 The OCFMC / CFMC has been providing employers with quality providers since 1959. The Orange County Preferred Provider Organization (OCPPO) is part of the Orange County Foundation for Medical Care and is one of twenty one Foundations throughout the State of California that together form one of California’s largest statewide PPO/EPO and Workers’ Compensation networks under the California Foundation for Medical Care (CFMC). These networks consist of physicians, hospitals and ancillary providers. OCFMC has over 75,000 members in LA and Orange County and CFMC has over 1.1 million members statewide who utilize our contracted network.
Preferred Provider Organization (PPO)
The Preferred Provider Organization (PPO) is a network of participating hospitals, physicians and ancillary providers who have agreed to accept discounted fees and agreed to physician peer review and utilization management as a means to maintain quality care. The PPO emphasizes patient choice, allowing access to a broad selection of providers who agree to deliver care in a cost-effective manner.
Our network includes some of the most well respected hospitals, specialists, primary care physicians, therapists and ancillary providers available and is one of the largest PPO networks within the State of California. Ancillary providers include ambulance providers, dialysis facilities, chiropractors, durable medical equipment and orthotic & prosthetic providers, home health and home infusion agencies, home cardiac and fetal monitoring, hospice, laboratories and draw stations, outpatient surgery centers, mental health / chemical dependency and eating disorder facilities, physical, speech, occupational, respiratory, registered dietician, imaging centers, sleep study providers, skilled nursing facilities, sub-acute rehabilitation facilities and urgent care centers.
All providers undergo an initial credentialing process prior to being accepted into the network and are re-credentialed every three years.
Exclusive Provider Organization (EPO)
We also offer an Exclusive Provider Organization (EPO) network, which is a subset of the PPO network and is similar to a PPO. The EPO product also allows the employer group to design the benefit plan to meet their needs as well as the needs of their employees. With some of our EPO plans, if a member seeks care from a non-preferred provider he/she will not receive any coverage at all; with other EPO plans, the out-of-network benefits are greatly reduced.
In those EPO plans where the patient is limited to EPO providers, a nurse triage model is utilized to monitor access to services, and providers must obtain approval based on predetermined criteria before services are rendered. The patient does not have to choose a primary care physician to serve as the gatekeeper. Patients are free to select any provider in the EPO for their health care needs.
Worker’s Compensation Network
We also offer a Worker’s Compensation network as well as employer specific MPN network.
Mental Health & Substance Abuse
Our networks include many Mental Health and Substance abuse providers so our clients may customize their medical benefit program to be in compliance with Mental Health Parity.
Non-Network Claims Negotiations (Letters of Agreements)
Letters of Agreements (LOA) are entered into to reduce the financial risk of both the payer and the patient as well as to protect the patient and payer. LOAs state:
The agreed upon reimbursement, normally the lesser of billed charges or the negotiated rate, less any co-payment, co-insurance and/or deductible.
The provider agrees not to balance bill the patient, except for the co-payment, co-insurance and/or deductible.
The provider agrees to coordinate benefits, if applicable.
Upon request, the Contracting Department attempts to negotiate a discounted rate with out-of-network providers throughout the United States, utilizing our standard fee schedules, when possible. If the out-of-network provider will not agree to the standard fee schedule, the best rates possible are negotiated. Upon the completion of the LOA, copies are provided to the requesting party and the Claims Department for loading into the claims system.
CFMC Network Additions and Terminations
At any time a request can be submitted by the group sponsor, the member, or the physician for a specific provider that is not currently in the network. This request can be submitted directly to the OCFMC office or via website where the Provider Nomination Form can be submitted electronically. Upon receipt of such a request, OCFMC will make every effort to bring that provider into the OCFMC network or negotiate a letter of agreement for a specific individual
Upon bankruptcy or any other reason a provider may be terminated from the network, the provider/medical group is immediately removed from the CFMC online directory. Every effort is made to notify clients who utilize those providers. At the client’s request, OCFMC can provide provider termination and provider effective reports that can be run for a given time period or on an ongoing basis.
CFMC Accreditation
For PPO and EPO providers, OCFMC conducts an initial assessment and review of each provider and an ongoing assessment thereafter, at least every three (3) years, of each contracted provider. These assessments are to evaluate and determine whether the providers meet or continue to meet the standards of participation established by OCFMC, including, but not limited to, accreditation, relevant licensure and good standing with appropriate agencies.
OCFMC retains and maintains individual provider files containing credentialing documents that are less than 180 calendar days old at the time the credentialing decisions was made, correspondence, and all documentation utilized to credential and conduct primary source verification of all licensure, certificates, and/or accreditation documentation for all contracted network providers.
The OCFMC Credentialing and Recredentialing Policies and Procedures are reviewed annually, and may be revised at the sole discretion of OCFMC. Providers and health plan clients may review the Credentialing and Recredentialing Policy and Procedures, but do not have the approval rights for revisions and/or changes.
OCFMC will not discriminate against any practitioner based upon age, sex, race, color, creed, religion, disability or any other characteristic protected under state, federal or local laws.
Online Directory
Network providers are most efficiently and accurately found via our web directory which allows an employee to search for specified types of providers by name, location or distance from a specified area. In addition, a mapping function is also available as a search mechanism. Request for specific types of providers are also accommodated as the website lookup allows an employee to search by provider type, gender and language with the ability to print his or her own customized provider directory. The web address for lookup is www.cfmcnet.org and is available 24 hours a day. This site is updated daily as the foundations upload new information. Hard copies are also available upon request.
Average Discount and Network Accessibility Reports
Please contact us at (800) 345-8643 for customized Geo Access / Accessibility Analysis and Average Discount Reports for the CFMC Network. |
