CalAIM Resources for Providers

• Claims/Invoice Submission Process
• Payor ID/Clearing House/EDI

• CS Reference Guide – Health Net – English (PDF)
• CS Reference Guide – CalViva Health – English (PDF)
• CS Reference Guide – Community Health Plan of Imperial Valley – English (PDF)
• Refer Members to CS Services Quick Reference – Health Net – English (PDF)
• Refer Members to CS Services Quick Reference – CalViva Health – English (PDF)

• Enhanced Care Management (ECM) Provider Guide – Health Net – English (PDF)
• Enhanced Care Management (ECM) Provider Guide – CalViva Health – English (PDF)
• Enhanced Care Management (ECM) Provider Guide – Community Health Plan of Imperial Valley – English (PDF)

Coming soon

• Gain Additional Revenue for Services You May Already Offer – Health Net – English (PDF)
• Gain Additional Revenue for Services You May Already Offer – Community Health Plan of Imperial Valley – English (PDF)

Coming soon

• Get Help and Support for Your Healthcare Needs – Health Net – English (PDF)
• Get Help and Support for Your Healthcare Needs – CalViva Health – English (PDF)
• CS Member Brochure – Health Net – English (PDF)
• ECM Member Guide – Health Net – English (PDF)
• ECM Member Guide – CalViva Health – English (PDF)

These member resources are available in other languages on the member Enhanced Care Management, Community Supports and Community Health Worker pages.

Federal, state and local disaster assistance are available to Californians and undocumented immigrants impacted by disasters. Refer to the Guide to Disaster Assistance Services for Immigrant Californians (PDF) for services to help with housing, food, basic needs, health care and counseling, insurance, replacing documents, and employment.

Data Sharing

• CS sFTP Details Request Form (Excel)
• CS Member Info Sharing Data Dictionaries (Excel)

Referral Forms

Complete and submit a referral form when requesting prior authorization for Community Supports (CS) services.

Health Net

• Asthma Remediation Referral Form – English (PDF)
• Environmental Accessibility Adaptations (Home Modifications) Referral Form – English (PDF)
• Housing Deposit Referral Form – English (PDF)
• Housing Navigation and Tenancy Referral Form – English (PDF)
• Medically Tailored Meals/Medically Supportive Food Referral Form – English (PDF)
• Nursing Facility Transition/Diversion to Assisted Living Facility Referral Form – English (PDF)
• Personal Care and Homemaker Services Referral Form – English (PDF)
• Recuperative Care Referral Form – English (PDF)
• Respite Services (for Caregivers) Referral Form – English (PDF)
• Short-term Post-Hospitalization Housing Referral Form – English (PDF)

CalViva Health

• Asthma Remediation Referral Form – English (PDF)
• Environmental Accessibility Adaptations (Home Modifications) Referral Form – English (PDF)
• Housing Deposit Referral Form – English (PDF)
• Housing Navigation and Tenancy Referral Form – English (PDF)
• Medically Tailored Meals/Medically Supportive Food Referral Form – English (PDF)
• Nursing Facility Transition/Diversion to Assisted Living Facility Referral Form – English (PDF)
• Personal Care and Homemaker Services Referral Form – English (PDF)
• Recuperative Care Referral Form – English (PDF)
• Respite Services (for Caregivers) Referral Form – English (PDF)
• Short-term Post-Hospitalization Housing Referral Form – English (PDF)

Community Health Plan of Imperial Valley

• Asthma Remediation Referral Form – English (PDF)
• Environmental Accessibility Adaptations (Home Modifications) Referral Form – English (PDF)
• Housing Deposit Referral Form – English (PDF)
• Housing Navigation and Tenancy Referral Form – English (PDF)
• Medically Tailored Meals/Medically Supportive Food Referral Form – English (PDF)
• Nursing Facility Transition/Diversion to Assisted Living Facility Referral Form – English (PDF)
• Personal Care and Homemaker Services Referral Form (PDF)
• Recuperative Care Referral Form – English (PDF)
• Respite Services (for Caregivers) Referral Form (PDF)
• Short-term Post-Hospitalization Housing Referral Form – English (PDF)

Authorization Guides

Community Supports (CS) authorization guides were developed to provide guidance to CS providers based on the Department of Health Care Services (DHCS) eligibility criteria. We encourage all CS providers to use the guides to help determine member eligibility for DHCS pre-approved CS services.

Health Net

• Asthma Remediation – English (PDF)
• Community Transition Services/Nursing Facility Transition Services to a Home – English (PDF)
• Day Habilitation Programs – English (PDF)
• Home Modifications – English (PDF)
• Housing Deposit – English (PDF)
• Housing Deposit Item List Example – English (PDF)
• Housing Tenancy and Sustaining Services – English (PDF)
• Housing Transition Navigation – English (PDF)
• Medically Tailored Meals/Medically Supportive Food – English (PDF)
• Nursing Facility Transition/Diversion to Assisted Living Facilities – English (PDF)
• Personal Care Services and Homemaker Services – English (PDF)
• Recuperative Care – English (PDF)
• Respite Services – English (PDF)
• Short-Term Post-Hospitalization Housing – English (PDF)
• Sobering Centers – English (PDF)

CalViva Health

• Asthma Remediation – English (PDF)
• Community Transition Services/Nursing Facility Transition Services to a Home – English (PDF)
• Day Habilitation Programs – English (PDF)
• Home Modifications – English (PDF)
• Housing Deposit – English (PDF)
• Housing Deposit Item List Example – English (PDF)
• Housing Tenancy and Sustaining Services – English (PDF)
• Housing Transition Navigation – English (PDF)
• Medically Tailored Meals/Medically Supportive Food – English (PDF)
• Nursing Facility Transition/Diversion to Assisted Living Facilities – English (PDF)
• Personal Care Services and Homemaker Services – English (PDF)
• Recuperative Care – English (PDF)
• Respite Services – English (PDF)
• Short-Term Post-Hospitalization Housing – English (PDF)
• Sobering Centers – English (PDF)

Community Health Plan of Imperial Valley

• Asthma Remediation – English (PDF)
• Community Transition Services/Nursing Facility Transition Services to a Home – English (PDF)
• Day Habilitation Programs – English (PDF)
• Home Modifications – English (PDF)
• Housing Deposit – English (PDF)
• Housing Deposit Item List Example – English (PDF)
• Housing Tenancy and Sustaining Services – English (PDF)
• Housing Transition Navigation – English (PDF)
• Medically Tailored Meals/Medically Supportive Food – English (PDF)
• Nursing Facility Transition/Diversion to Assisted Living Facilities – English (PDF)
• Personal Care Services and Homemaker Services – English (PDF)
• Recuperative Care – English (PDF)
• Respite Services – English (PDF)
• Short-Term Post-Hospitalization Housing – English (PDF)
• Sobering Centers – English (PDF)

Findhelp is used to identify local resources, supports staff and community partners when searching for local services. The platform will create an efficiency for staff and Enhance Care Management (ECM) providers to search for Community Supports (CS) programs and/or free or low cost, direct services to support members with social determinants of health (SDOH) needs. The platform increases visibility to CS programs for ECMs, providers and community partners, making it easy to use when referring members to CS providers and closing the loop on referrals.

• Findhelp for Health Net
• Findhelp for CalViva Health

The Findhelp How-To Guide is a step-by-step tool to help CS and ECM providers navigate the findhelp platform. Use the guide to help you with account setup, find CS providers and services, make referrals, connect with the members to provide services, view and update referral status, invoice and billing and more.

• Use findhelp to Connect Members to Community Supports Services – Health Net – English (PDF)
• Use findhelp to Connect Members to Community Supports Services – CalViva Health – English (PDF)
• Use findhelp to Connect Members to Community Supports Services – Community Health Plan of Imperial Valley – English (PDF)
• Findhelp How-To Guide – Health Net – English (PDF)
• Findhelp How-To Guide – CalViva Health – English (PDF)

Complete the following form to add or remove ECM user accounts on findhelp. Submit the completed form to the email address on the form.

• Findhelp ECM Provider Request Form – Health Net – English (PDF)
• Findhelp ECM Provider Request Form – CalViva Health – English (PDF)
• Findhelp ECM Provider Request Form – Community Health Plan of Imperial Valley – English (PDF)

Refer to the flyer for information on how to make Enhanced Care Management (ECM) referrals.

• Use findhelp to Submit ECM Referrals – Health Net – English (PDF)
• Use findhelp to Submit ECM Referrals – CalViva Health – English (PDF)
• Use findhelp to Submit ECM Referrals – Community Health Plan of Imperial Valley – English (PDF)

ECM Referral

• Enhanced Care Management (ECM) Benefit Member Eligibility Checklists/Referral Forms – Health Net – English (PDF)
• Enhanced Care Management (ECM) Benefit Member Eligibility Checklists/Referral Forms – CalViva Health – English (PDF)
• Enhanced Care Management (ECM) Benefit Member Eligibility Checklists/Referral Forms – Community Health Plan of Imperial Valley – English (PDF)

ECM Assessments

Children and Youth Assessment

• Children and Youth (C/Y) Enhanced Care Management Comprehensive Assessment – Health Net – English (PDF)
• Children and Youth (C/Y) Enhanced Care Management Comprehensive Assessment – CalViva Health – English (PDF)
• Children and Youth (C/Y) Enhanced Care Management Comprehensive Assessment – Community Health Plan of Imperial Valley – English (PDF)

Adult Assessment

• Adult Enhanced Care Management (ECM) Comprehensive Assessment – Health Net – English (PDF)
• Evaluación Integral de la Administración Mejorada de la Atención – Health Net – En Español (Spanish) (PDF)
• Adult Enhanced Care Management (ECM) Comprehensive Assessment – CalViva Health – English (PDF)
• Evaluación Integral de la Administración Mejorada de la Atención – CalViva Health – En Español (Spanish) (PDF)
• Adult Enhanced Care Management (ECM) Comprehensive Assessment – Community Health Plan of Imperial Valley – English (PDF)
• Evaluación Integral de la Administración Mejorada de la Atención – Community Health Plan of Imperial Valley – En Español (Spanish) (PDF)

ECM Program Completion Assessment

Health Net

• Enhanced Care Management Program Completion Questionnaire – Health Net – English (PDF)
• Enhanced Care Management Program Completion Questionnaire – Health Net – En Español (Spanish) (PDF)

CalViva Health

• Enhanced Care Management Program Completion Questionnaire – CalViva Health – English (PDF)
• Enhanced Care Management Program Completion Questionnaire – CalViva Health – En Español (Spanish) (PDF)

Community Health Plan of Imperial Valley

• Enhanced Care Management Program Completion Questionnaire – Community Health Plan of Imperial Valley – English (PDF)

Data Sharing

• ECM sFTP Details Request Form (Excel)
• ECM Member Info Sharing Data Dictionaries (Excel)

Doctors, Hospitals and Other Providers

• Health Net Provider Directory
• CalViva Health Provider Directory
• Community Health Plan of Imperial Valley Provider Directory

• Doula Services Benefit flyer – English (PDF)
• Medi-Cal Doula Services Documentation of Doula Visit – Health Net – English (PDF)
• Medi-Cal Doula Services Documentation of Doula Visit – CalViva Health – English (PDF)
• Medi-Cal Doula Services Documentation of Doula Visit – Community Health Plan of Imperial Valley – English (PDF)
• Medi-Cal Member Recommendation for Postpartum Doula Services – Health Net – English (PDF)
• Medi-Cal Member Recommendation for Postpartum Doula Services – CalViva Health – English (PDF)
• Medi-Cal Member Recommendation for Postpartum Doula Services – Community Health Plan of Imperial Valley – English (PDF)

• Medi-Cal Member Recommendation for Community Health Worker Services – Health Net – English (PDF)
• Medi-Cal Member Recommendation for Community Health Worker Services – CalViva Health – English (PDF)
• Medi-Cal Member Recommendation for Community Health Worker Services – Community Health Plan of Imperial Valley – English (PDF)

Coming soon

Q: How do I request a secure file transfer protocol (sFTP) account?
A: Request an sFTP account by filling out the ECM sFTP Details Request Form. You can find the form at CalAIM Resources for Providers, under Forms & Tools > Enhanced Care Management (ECM).

Q: Where do we submit the Return Transmission File (RTF)?
A: RTFs are submitted via the sFTP site. If your sFTP connection is not yet set up, you can send in the RTFs via secure email to ECM_sFTP_Request@healthnet.com.

Q: For those with an sFTP account, will files be delivered via secured email as well?
A: No. Files will be transmitted via sFTP on the 15th of each month.

Q: What do we do if our Member Information File (MIF) includes patients who are not enrolled in our program?
A: In addition to your enrolled members, members/patients labeled with status code 1 – Pending Outreach are included in the MIF. Providers can reach out and enroll them in the program if they qualify based on provider assessment.

Q: Will we receive cobranded letters or packets to use as part of our outreach efforts?
A: Member facing ECM materials are available on the provider resource page for download in English and all Medi-Cal threshold languages on the CalAIM Resources for Providers page, under CalAIM General Information > Member Resources.

Q: Who can I contact for information regarding an outreach list or an ECM guide?
A: Each ECM provider is assigned an operational point of contact. You can find your operational point of contact in the Delegation Oversight Interactive Tool (DOIT) profile for your organization or by emailing CALAIM_Providers@healthnet.com.

Q: Do I enter one row on the Outreach Tracker File (OTF)

per outreach attempt?
A: Yes.

Q: Can I round up the outreach time spent or does it need to be the exact number?
A: Yes. You can round it up to the nearest minute in the OTF.

Q: How do we count the total number of encounter in the RFT?
A: You can count total number of in-person encounters via the data element labeled In-Person. You can count total number of telephonic encounters via the data element labeled Telephonic. The values in each RTF should include the number of each outreach types for that file reporting period.

Q: Is the RTF due by the 5th regardless of when the MIF was received?
A: Yes. The MIF is sent no later than the 15th of the month and the RTF is due by the 5th of the following month. If for some reason the RTF is not submitted on time, the updates can be included in following month's RTF.

Q: What is the phone number for the Community Supports (CS) team?
A: Health Net Provider Services Center: 800-675-6110.
CalViva Health Provider Services Center: 888-893-1569.
Community Health Plan of Imperial Valley: 833-236-4141.

Q: If outreach is performed for a patient already in a board and care home/assisted living facility or skilled nursing facility, is that considered a successful outreach?
A: Yes.

Q: Are ECM providers responsible for adding all previously enrolled patients to the RTF?
A: Yes. The RTF should include all new and past enrollments present in the most recent MIF.

Q: If a member enrolls and then decides to not participate in the program, what would the code be?
A: The member can be marked with status code 4 – Declined. The date of enrollment should be populated under ECM Enrollment Start Date. The date the member decided not to participate in the program should be populated under ECM Enrollment End Date.

Q: If the outreach attempt is by mail, which code should be used?
A: This can be captured under Telephonic/Electronic and Time Spent. This should be defaulted to 1 minute.

Q: Will the Plan keep and provide historical data submitted by providers on the monthly RTF? Or will we need to re-enter details every month?
A: Yes. Provider updates sent on the monthly RTF will be included in the next month's MIF.

Q: Will there be ongoing office hours for questions?
A: Yes. ECM office hours are scheduled to occur at least once a month. Please visit the CalAIM Provider Trainings and Webinars page for upcoming training opportunities.

Q: Is there training for the ECM data exchange files?
A: Yes. ECM data exchange training is available on on the CalAIM Provider Trainings and Webinars page.

Q: What if I get a blocked content message when uploading my file?
A: This is most likely due to your organization's firewall settings. Contact your IT department for help to whitelist the website or webpage.

Q: Due to limited capacity, our provider group elected only to serve members assigned to our group's primary care physicians (PCPs). Can you confirm this will be the case under ECM?
A: Special requests for member assignment preference should be communicated to your ECM operational point of contact at the Plan.

Q: Will we get an email notification notifying us of new files uploaded to sFTP?
A: Yes. You should receive an email when a new file is uploaded to sFTP.

Q: There are occasions where enrolled members are not showing up on the MIF, but we are the CBO by confirming in the Health Net member portal. What are the impacts if enrolled members do not show up on the MIF?
A: Here are two possible scenarios:

1. If you encounter a member that is not on your MIF and check the portal to find that the member is enrolled with another ECM provider, that member would have to call to request a switch to your organization as their ECM provider.
2. If you encounter a member that is not on your MIF and check the portal to find that the member is enrolled with your organization, you should add the member to your next RTF when submitting. This member should show up on your next MIF.

Q: I have received a file response for the RTF submission that it was declined due to being uploaded after the 10th. How can we submit after the 10th if the deadline is indeed the 15th?
A: New MIF files are posted by the Plan to your sFTP site on the 15th of each month. The deadline to submit your data to the Plan is the 5th of each month. If there are errors in your file, we will work with you to fix them and can only accept resubmissions up to the 10th of each month at the latest. After the 10th, files are not accepted.

Q: What file type should the RTF and OTF be submitted as (i.e., macro enabled, etc.)?
A: You can enable macros or not in your final submitted file, but the file extension must be xlsx or xlsm.

Q: For acuity level, is there a definition of low, medium or high with examples?
A: We do not prescribe acuity level. We ask that our providers evaluate this based on their interactions with the member. Guidelines are available in the ECM provider guide.

Q: For acuity, is it a required field? We also submit to Anthem and it is not required, so we have some gaps in having that data entered.
A: The acuity field, while not officially required in the data dictionary, will give you an error message if you try to submit. Please default blank cells to "low" for acuity.

Q: For the most recent encounters with members, including telehealth and in person encounters, are those specifically for successful encounters with the members (not including outreach attempts with members)?
A: The "date of most recent encounter with member" column should list the date of the most recent successful encounter with the member. You can include the count of both successful and unsuccessful encounters in the "In Person" and "Telephonic/Video" columns.

Q: Can we can do outreach for 90 days, not 60?
A: Yes. Outreach should be completed for 90 calendar days (60 business days) at least 5 times using a minimum of 3 outreach modalities before a member is excluded for inability to contact.

Q: Are we referring patients (patients not in MIF) into the ECM program through the RTF?
A: For patients identified in the community (not on your MIF), you will want to submit a referral through the provider portal or fax and then add the member to your monthly RTF when submitting to the Plan.

Q: What's the difference between ECM Enrollment End date and Discontinuation date?
A: The Discontinuation date column and Enrollment End date column are populated based on whether the member was enrolled in the program or not prior to their exclusion. An enrolled member that is being excluded from ECM should have the date listed in the Enrollment End date column. A member that was never enrolled in ECM should have the date listed in the Discontinuation date.

Q: Another managed care plan (MCP) says ECM status code 4 should be used for enrolled cases. So, start and end dates should be listed, but the discontinuation date should be left blank. Does each MCP have their own data dictionary and definition?
A: This is technically correct. If the member was enrolled in ECM and leaving the program for status code 4, the enrollment end date should be populated. The discontinuation date would have no impact on this scenario since it was an enrolled member being excluded.

Q: Is the Validation Function given when we retrieve the MIF?
A: There is no validate functionality in the MIF file. Validations are completed on the RTF and OTF when submitted to the Plan.

Q: What happens if our RTF and OTF data is not submitted by the 5th of the month?
A: There are many implications for failing to submit timely data. Without this data, we are unable to update our records.

• Claims can be denied due to incorrect member status in our system.
• Incentive payments are unable to be calculated.
• Member assignments for the next month may be turned off due to inaccurate capacity assumptions and lack of member information.
• MIF file for the following month will contain outdated member information.

To avoid any of these scenarios, please submit your data as soon as possible following the first of the month and send an email to your Plan contacts to validate the file was received successfully.

Q: When will CS providers receive the Community Supports Authorization Status File (CSASF)?
A: Providers will receive the CSASF bi-weekly on the 15^th and 29^th of every month. The CSASF will contain both members with and without authorization. Members without authorization has been identified as "new potential members" for outreach. Members with authorization that you’ve submitted, will also be contained in this file.

Q: How do I request a secure file transfer protocol (sFTP) account?
A: Request an sFTP account by filling out the CS sFTP Details Request Form. You can find the form on this page under Forms & Tools > Community Supports (CS) or reach out to your point of contact.

Q: If I’m a contracted CS provider and also an ECM provider with an existing sFTP set-up, do I have to complete the CS sFTP Detail Request Form?
A: Yes, ECM providers who are also CS providers will be required to complete the request form, column A-H, leaving columns I-L blank since we will be hosting your sFTP. However, we will be modifying your existing set-up to receive two separate files (one for ECM and one for CS).

Q: Will specs and sample files be shared with CS providers?
A: Yes, you can find the CS Data Sharing Layout on this page under Forms & Tools > Community Supports (CS).

Q: Is DHCS requiring the Community Supports Provider Return Transmission File (CSPRTF)? Where do we submit the CSPRTF?
A: Yes, DHCS requires MCPs to collect the CSPRTF from all contracted CS Providers. Providers will be required to submit the CSPRTF by the 5^th and 10^th of every month via the sFTP site. If your sFTP connection is not yet set up, you can send the CSPRTF via secure email to ECM_sFTP_Request@healthnet.com.

Q: Can we call the patients and/or send them texts? I am concerned about following HIPAA Compliant rules.
A: You may call the member for initial engagement. Texting can be done once you receive approval from the member.

Q: How are you identifying the members that are on the CSASF?
A: Members are identified based on your capacity report, the members zip code, and the CS service your organization provides will determine which members make it onto your CSASF.

Q: Are CS providers required to submit authorization for services?
A: Yes, approved authorizations may be required before rendering services. To submit an authorization, you will use the provider portal. Please refer to the CS authorization guides under Forms and Tools > Community Supports or the most current prior authorization list for additional information.

Q: Will there always be members within the file?
A: The file will include any members that are currently authorized for CS under your entity. We will aim at assigning "new potential CS members" based on your capacity and members available in your service area that meet CS criteria.

Q: How long does it take to determine eligibility?
A: Members assigned to your organization are new potential members who meet the eligibility for the CS service. Providers should use the CS Authorization Guides to confirm member eligibility and interest before submitting an authorization.

Q: Will referrals received be specific to our organization, or will multiple entities be calling the same member lists?
A: Referrals will be specific to the organization. If the member potentially qualifies for more than one CS services then they may appear on more than one CS providers referral list, but each unique member + CS service combination will only be appeared to one provider.

Q: Will there be payments for CS outreach like ECM outreach?
A: No, at this time, outreach is not billable. CS services will require authorizations before you can bill for services.

Q: Is there a distinction between obtaining authorization for day rehab services, versus, as an example, Post-Hospital Stay services?
A: Yes, all 14 community supports (CS) services have distinct authorization requirement. You can find our CS-service specific authorization guide on this page under Forms & Tools > Community Supports (CS), and scroll down on "Authorization Guides".

Q: When it comes to Data exchange this is pertaining to only communication between MCP and Service providing agency?
A:   Correct, it does not go further into data exchange between provider agencies to another provider agency that share a mutual client.

Q: Where do I get the authorization form to fill out for a client?
A: You can find instructions on CS authorization submission at step 6 on the Community Supports End-to-End Process page.

Q: For providers that manage a large number of members, do we need to manually check eligibility of all of these members one at a time regularly thru the provider portal?
A: We highly encourage you to always verify eligibility prior to rendering the service to the member.

Q: Will CS providers, contracted for several CS service receive multiple lists? Does this include the housing trifecta being separated?
A: If your entity is contracted to serve multiple community supports, you will receive a single list of all members currently authorized or assigned to your entity.

Q: Will the CSPRTF be in the same format as all other MCP's?
A: CSPRTF was designed based on the guidelines provided by DHCS, so all MCP CSPRTFs should be aligned for the most part.

Q: Is there a turnaround time for CS referral to be approved and/or denied?

A: CS referrals that are sent directly to contracted CS providers should be timely assessed by the CS provider for eligibility and submitted as an authorization to the health plan. Authorization turnaround is within 5 business days, assuming no additional info is needed it will be approved within that time frame. Some authorizations have quicker response time.

Q: Is the CSASF a rolling list of members, for the ones that we pend will stay on the file month over month until resolved?
A: Yes. The members will remain on the CSASF until they have been resolved.

Q: Do we need an authorization form for ECM?
A: You do not need authorization for ECM, but if the member is currently not assigned to an ECM provider for outreach or service, please complete the ECM referrals form to confirm member's qualification and submit a referral through the fax or through the authorization tab in the provider portal. The member will be added to an assigned ECM provider's next member information file. Note: Members who were listed on your MIF do not need a referral submitted to the plan. You will need to report the member as enrolled status on your next RTF, but you can begin billing following enrollment.

Q: Do we have an authorization form for Community Supports (CS)?
A: Authorization may be required for CS services. For specific details on what needs to be submitted for authorization for each CS, please refer to the authorization guides under Forms and Tools > Community Supports. There are recommended CS referral forms that can be used when submitting an authorization request, or you can use the Outpatient Medi-Cal Prior Authorization Form (PDF). The recommended method to submit authorization is through the provider portal. Requests may also be submitted via fax.

Q: If a member is listed on our MIF provided by the Plan, have they been authorized for ECM services?
A: Yes. Members listed on your MIF have been authorized for ECM services, but you still must reach out to the member to get their consent to enroll in the program. You will then update their status to enrolled on your next RTF file.

Q: Is the member's signature needed on the claim form every time, even if we provide services telephonically?
A: If you have the member's signature on file, you don't need to provide it on each claim/invoice. You can indicate "signature on file/SOF" on the claim or invoice when submitting. Signatures can be collected through various methods, such as electronic signatures, telephonic audio recording or documentation in case notes. For reference, please see the Department of Health Care Services (DHCS) letter that gives general guidance on capturing telephonic signatures (PDF).

Q: Should we use point of service (POS) 02 for telehealth visit/over the phone?
A: There is no requirement on POS. Please ensure you follow the billing guidance and add modifier GQ when billing for telehealth.

Q: Can we submit a claim for mailers sent to members as a part of outreach attempts or reaching out to grandfathered members?
A: Providers can bill for a one-time outreach for new members regardless of outreach outcome.

Q: Can we submit one claim for all members or are individual claims needed?
A: You will need to submit one claim per member.

Q: If we are making phone calls to access services for the member, can these be billed as ECM phone services or can we only bill for phone calls with the member?
A: Yes. You can bill for any time you are doing activities with the member or on behalf of the member to meet their care plan goals and complete interventions.

Q: Do you have to use the provider portal to submit authorization?
A: No, you can submit authorization requests by fax to 800-743-1655.

Q: How will authorization approvals and denials be sent back to providers?
A: You can see determinations on the secure portal in real time, otherwise providers will receive a letter/fax with the determination. ECM does not require prior authorization so there will be no approval or denial status or letters. Member will be added to the assigned ECM's MIF file.

Q: What's the turnaround time for authorization decisions?
A: The turnaround time is dependent on the receipt of all clinical information necessary to render a decision.

Q: Is an authorization needed to submit claims?
A: You do not need to add the authorization number on the claim/invoice. For CS, authorization approval is required before you can provide services and bill.

If you're an ECM provider and if the member is in your MIF, once you enroll the member you can start billing – no authorization is required. If the member is not on the MIF, you will need to first submit a referral by fax or the provider portal (confirm eligibility and confirm member is not already assigned to another ECM provider in the portal before making the referral). The member will be added to your next MIF, but you will not need to wait for the member to appear in your MIF to enroll, provide service and bill.

Important note: Before providing services, always make sure the member is currently eligible with the Plan.

Q: How do I know the member is already assigned to another ECM provider?
A: On the provider portal, after checking for the member eligibility, you can click on the member's name to open their eligibility information on the left-hand side. There will be an ECM section that you can reference if the member is currently enrolled or pending outreach by another ECM provider.

Q: Who is allowed to make a referral to CS?
A: All providers are able to refer a member to our contracted CS providers if they have deemed that the member qualifies for CS services. We highly encourage providers to use the CS authorization guides to determine if the member qualifies for CS services. Providers can refer members to CS by referring them through findhelp or sending the member information to contracted CS providers in our ECM/CS provider directory. For findhelp, if you have an existing account with findhelp, we highly encourage you log in before making a referral. If you do not have an account, you can simply "Sign Up" to create an account at the top right corner to track your member referrals.

Members can also self-refer to CS services by calling the Member Services Department at Health Net: 800-675-6110, CalViva Health: 888-893-1569, or Community Health Plan of Imperial Valley: 833-236-4141.

Q: What findhelp links should we use to make referrals to CS services?
A: You can easily search for and make a referral to CS services through two unique sites for Health Net and Community Health Plan of Imperial Valley members, and CalViva Health members.

Q: Will CS providers get referrals from medical providers or ECM providers through this system?
A: There is a "no wrong door" approach with the referral process. Referrals can come from ECM providers; other providers; other entities serving members, family member(s), guardians and caregivers; and/or other authorized support persons. Referrals are not limited to members engaged with an ECM provider.

Q: Is there additional training for claims and billing through findhelp?
A: Recorded billing trainings are available on the CalAIM Provider Training & Webinars page.

Q: What is the preferred way to make a referral through findhelp?
A: All referring individuals should first complete the CalAIM Assessment. Once the assessment is completed and submitted, a list of CS services will appear based on the results of the assessment. If there is more than one CS provider, work with your member to select the provider that will meet their needs.

Q: Is there any particular order in which the ECM provider will see the list of available partners?
A: There is currently no specific order. All of the program cards will be categorized by CS services specific to county and ZIP Code.

Q: Are ECM providers the only entity that can start a referral?
A: No, the link to the findhelp platform is made available on our website and other providers can also access findhelp to start a referral.

Q: Are Medi-Cal members able to self-refer?
A: Yes, members can self-refer to a CS provider through findhelp..

Q: Is there a suggested timeframe to accept a referral as a provider offering CS service?
A: It depends on the CS services. For example, for recuperative care and sobering center, there is a higher sense of urgency to respond. We will rely on our experienced CS providers to follow the best practice for turnaround time.

Q: Who is the best person to contact to get set-up as a CS provider?
A:  Contact your Plan liaison or email the Systems of Care team to help you get set up on findhelp.

CalAIM findhelp function: As a CS provider, you will be added to the CalAIM function and categorized in specific CS services after you contract with our Plan.

Q: Can we refer to all CS services through findhelp?
A: Our Plan opted into providing all 14 CS services on January 1, 2022. We are phasing in additional services every six months, which may vary by county.

Q: We already signed up through Health Net to provide support services. How do we get linked to findhelp to track referrals?
A: If you have finalized your contract, please contact Systems of Care to be connected directly to and set up with findhelp. If your contract has not been finalized yet, please be patient and wait until that has happened before contacting the Plan.

Q: Can I refer a member to ECM through findhelp?
A: For providers with access to the provider portal, that is the preferred way to make a referral for ECM. For providers or partners without access to the provider portal, you can make a referral through findhelp for ECM. Complete the findhelp referral and the required screening questions.

Q: What will be the data requirement as a care manager referring to ECM in the system?
A: Data requirements are different for ECM and CS. We are following DHCS guidance in terms of minimum data required. We will be working with our providers to identify additional data that will be helpful for program expansion.

Our contracted ECM providers will receive a monthly potential MIF from us and are expected to provide us back with a monthly outreach RTF.

Q: Who can use CalAIM findhelp website?
A: The CalAIM findhelp website is available to all providers. If you have an existing account with findhelp, we encourage you log in before making a referral. If you do not have an account, you can "Sign Up" to create an account at the top right corner to track your member's referrals.

Q: Will the Plan be monitoring the number of referrals to each provider to ensure there are no capacity issues or should each provider turn off access to their program once capacity has been met?
A: CS providers will have the ability to update their capacity in the findhelp platform.

Q: Can I submit claims through the provider portal?
A: Claims cannot be submitted through the provider portal at this time. For information on how to bill for ECM and CS services, please refer to our billing guidance page.

Q: What is the difference between the provider portal, Conduent and findhelp?
A:

• The Provider Portal currently allows you to verify member eligibility, review authorization status and submit authorization for ECM and CS.
• Conduent is for billing by invoice; if you are set up with a clearinghouse (recommended) or submitting paper claims, you do not need to bill by invoice through Conduent.
• Findhelp is a closed-loop referral system to help providers identify CS providers contracted with the Plan and refer members to them. See the findhelp FAQs section above for more information.

Q: We have registered and created an account for the provider portal, but are unable to access certain sections (e.g. authorization, medical information)?
A: Each organization can have at least one user with Account Management access to the provider portal that will allow them to control access for other members in the organization. Contact the Provider Services Center at Health Net: 800-675-6110, CalViva Health: 888-893-1569 or Community Health Plan of Imperial Valley: 833-236-4141 to identify the user with Account Management access in your organization if you do not know who it is or need to assign a user with that access. In addition, you can contact your Plan liaison for assistance.

Q: Is a member able to request a specific ECM or CS provider they want to be assigned to?
A: Yes, members can call the Member Services Department to switch provider assignment. If the member is new to ECM or CS at the point of the referral, it is the member's choice to select the provider they want to be referred to based on our contracted provider directory.

Q: How can we update the contact information listed for our organization in the provider directory?
A: You can contact your assigned point of contact or the Provider Services Center at
Health Net: 800-675-6110, CalViva Health: 888-893-1569 or Community Health Plan of Imperial Valley: 833-236-4141.

Q: How are ECM member assignments made?
A: ECM members are assigned based on:

• PCP: If the member's PCP is an ECM provider, that is the first choice.
• Qualified Provider: If the PCP is not an ECM provider, the member is assigned to the closest ECM provider to the member that serves their population of focus and has capacity.
• Member Request: At any time, the member can call Member Services and request assignment to a specific provider.

Q: How many ECM members can a provider have?
A: Ratios for Lead Care Managers to members cannot exceed 1:50. Each ECM provider must submit an updated capacity report quarterly, at a minimum, to ensure the Plan has the most current numbers. Assignments are given based on reported capacity numbers.

Q: How long do we have to complete the members initial assessment?
A: Every enrolled ECM member must meet the following:

• ECM assessment must be started within 30 days of enrollment.
• ECM assessment must be completed within 60 days of enrollment.
• ECM care plan must be created within 90 days of enrollment.

Note:  Be sure to report these dates on your Return Transmission File (RTF) file each month. The RTF file provides the data for program oversight and calculation of incentive program measures.

Q: What do we do if our Clinical Consultant or Lead Care Managers leave the organization?
A: All ECM programs must have at least one qualified Clinical Consultant (see ECM provider guide for qualifications). If your organization finds itself without a clinical consultant, please contact your operational point of contact and ECM auditor as timely as possible to discuss the path forward.

If you have significant turnover in Lead Care Managers that puts your organization over capacity, please contact your operational point of contact and ECM auditor as timely as possible.

Q: Can CS providers submit multiple Housing Deposit claims for member reimbursement?
A: Providers can submit multiple claims for various Housing Deposit supports for one individual over a lengthy period of time. However, our preference is for providers to submit a single (or few) claims for all the Housing Deposit needs of an individual during a narrow time period.

Q: What if a member does not use the full $6,000. Does that amount rollover?
A: The Housing Deposit benefit is limited by dollar amount and not by utilization. The Health Plan can approve Housing Deposits supports as requested up to $6,000 maximum for an individual’s lifetime.

Q: Will reimbursements received by the CS provider count as revenue for the agency?
A: Housing Deposit reimbursements will be treated the same as other CS reimbursements and will follow all tax reporting requirements. CS providers are strongly encouraged to consult with a certified public accountant (CPA).

Q: Will CS providers be required to collect a W-9 form from a landlord or other vendors they pay for services on behalf of the member?
A: CS providers may need to collect W-9s from each vendor they provided payments to. CS providers are encouraged to consult with a CPA.

Q: Do Housing Deposits need to follow rent reasonableness requirements?
A: There is no rent reasonableness standard or fair market rent requirement for Housing Deposits. Housing choice should follow the member's tenancy preferences as a primary consideration when selecting a housing unit, to the fullest extent possible. Taking into consideration Housing Choice Voucher requirements, location, size, reasonable accommodations and affordability based on member's budget.

Q: Do CS providers need to conduct a housing quality inspection?
A. CS providers must take reasonable measures to confirm the prospective units are safe and habitable and submit documentation to that effect. However, housing inspections do not have to be completed by a housing and urban development (HUD)-certified inspector.

Q: What happens to the rental or utility security deposit if the member moves out?
A. The landlord/owner must return any security deposit amount collected (less any amounts the landlord may withhold under the terms of the lease and state and local law) directly to the member.

Q: Can a member access Housing Deposits a second time?
A. Housing Deposits can only be approved one additional time with documentation as to what conditions have changed to demonstrate why provided Housing Deposits would be more successful on the second attempt.

Q: What is the definition of Street Medicine?
A. Street medicine is provided to individuals experiencing unsheltered homelessness in their lived environment, places that are not intended for human habitation.

Q: Is health care provided at shelters and mobile units considered Street Medicine?
A. Health care services provided at shelters, mobile units/recreational vehicles (RV), or other sites with a fixed, specified locations does not qualify as Street Medicine. These fixed, specified locations are considered mobile medicine, as they require people experiencing unsheltered homelessness to visit a health care provider at the provider's fixed, specified location.

Please note, mobile units/RVs that go to the individual experiencing unsheltered homelessness in their lived environment ("on the street") is considered Street Medicine.

Q: Who can be a Street Medicine provider?
A. A Street Medicine provider refers to a licensed medical provider (e.g., Doctor of Medicine (MD)/Doctor of Osteopathic Medicine (DO), Physician Assistant (PA), Nurse Practitioner (NP), Certified Nurse Midwife (CNM)) who conducts patient visits outside of the four walls of clinics or hospitals and directly on the street, in environments where unsheltered individuals may be (such as those living in a car, RV, abandoned building, or other outdoor areas).

Q: Can non-physicians provide Street Medicine?
A. For a non-physician medical practitioner (PA, NP, and CNM), MCPs must ensure compliance with state law and contract requirements regarding physician supervision of non-physician medical practitioners. Additionally, given the unique and specialized nature of Street Medicine, a supervising physician must be a practicing Street Medicine provider, with knowledge of and experience in Street Medicine clinical guidelines and protocols.

Q: Who is eligible for Street Medicine services?
A. Street medicine providers are required to verify the Medi-Cal eligibility of individuals they encounter in the provision of health care services. Medi-Cal eligible individuals will be covered by either Medi-Cal Fee-for-Service (FFS) or Medi-Cal managed care (with a corresponding MCP) delivery system. For those individuals without Medi-Cal coverage, the Hospital Presumptive Eligibility (HPE) program is one pathway for qualified HPE providers to determine Medi-Cal eligibility.

Q: How does a member receive Street Medicine services?
A. Street Medicine providers go to where the member is physically located. Members do not have to seek out these providers. They just need to be covered by Medi-Cal or HPE.

Q: Are Street Medicine providers mandated reporters who must report when they suspect child or elder abuse has occurred?
A. All licensed health care professionals, including, but not limited to, physicians, nurses, mental health professionals, EMTs, paramedics, medical examiners, all employees at long-term health facilities, social workers, marriage and family counselors, children care custodians, elder or dependent adult custodians, teachers, clergy, employee of protective service or law enforcement agency are all mandated reporters. If a mandatory reporter fails to report suspected abuse, they could be charged with a criminal offense and/or discipline by their regulatory Board.

Q: Is consent required for minors?
A. Minors ages 12 and older may consent to mental health treatment or counseling on an outpatient basis, or to residential shelter services, if both of the following requirements are satisfied:

1. The minor, in the opinion of the attending professional person, is mature enough to participate intelligently in the outpatient services or residential shelter services.
2. The minor:
   • would present a danger of serious physical or mental harm to self or to others without the mental health treatment or counseling or residential shelter services, or
   • is the alleged victim of incest or child abuse.

The professional person offering residential shelter services should make their best attempt to notify the parent or guardian of the provision of services. For mental health treatment or counseling of a minor, the minor's parent or guardian should be involved unless, in the opinion of the professional person who is treating or counseling the minor, the involvement would be inappropriate. Documentation of attempts or contacts to parents and guardian for services should be documented in the minor's record.

Q: Is there compensation for travel time?
A. No.

Q: What are the billing codes?
A. The Centers for Medicare and Medicaid Services (CMS) recently designated POS code 27 for "Outreach Site/Street," which CMS defined as "a nonpermanent location on the street or found environment, not described by any other POS code, where health professionals provide preventive, screening, diagnostic and/or treatment services to unsheltered homeless individuals."

Medi-Cal providers may use POS code 27 for street medicine in addition to the previously announced POS codes for street medicine: 04 (homeless shelter—A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters), 15 (mobile unit—A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic and/or treatment services), and 16 (temporary lodging—A short-term accommodation, such as a hotel, campground, hostel, cruise ship or resort where the patient receives care, and which is not identified by any other place of service (POS) code). Both street medicine and mobile medicine are reimbursable services in accordance with billing protocols and a provider's scope of practice; however, it remains the expectation that individuals experiencing unsheltered homelessness receive appropriate and applicable services in their lived environment via street medicine.

Any claims for street medicine services provided on or after October 1, 2023, that are denied for using POS code 27 do not need to be resubmitted and will be reprocessed after system changes are updated.

Q: I'm a new provider. How do I bill for Street Medicine services?
A. Submit claims and supporting information via one of the options below:

• Electronic data interchange (EDI) through a clearinghouse or Availity (recommended).
• Submit paper CMS-1500 (version 02/12) form for paper claims. Refer to the Claims Procedures page for more information.

Q: Where can I access provider trainings?
A. Refer to the CalAIM Provider Training and Webinars page.

Q: Can a member get Street Medicine and Community Health Worker services at the same time?
A. Yes.

Q: How do we treat mobile clinics?
A. If you get out of the mobile units/RVs and go to the individual experiencing unsheltered homelessness in their lived environment ("on the street"), that is considered Street Medicine. Health care services provided at shelters, mobile units/RV, or other sites with a fixed, specified location does not qualify as Street Medicine. They are considered mobile medicine, as they require people experiencing unsheltered homelessness to visit a health care provider at the provider's fixed, specified location.

Q: What do we do if multiple Street Medicine providers are seeing the same member?
A. Given the difficult of knowing if there are multiple Street Medicine providers see the same member, Street Medicine providers should provide medically necessary and non-duplicative services to our members whenever possible.

Q: Do Street Medicine providers need to check eligibility?
A. Yes, you can check the patient's name and DOB through DHCS' Automated Eligibility Verification System (AEVS). If a provider is an HPE provider, they can process for HPE using HPE protocols.

Q: Do Street Medicine providers submit referrals/requests for services?
A. Street Medicine providers will work with the assigned PCP to refer the member to the specialty network for the member's PPG/PCP.

Q: How do Street Medicine providers make referrals to CS?
A. Refer to the CalAIM Resources for Providers for information and instructions for making referrals.

Q: Do Street Medicine providers have an office so we can mail care plans and request medical records?
A. Yes, some Street Medicine providers are existing providers in the Plan's network. Everyone should have a contact address where they can be reached.

Q: Can an individual seek treatment from any Street Medicine provider or only one that is in the MCP's network?
A. An individual may seek treatment from any Street Medicine provider serving their location or encampment. It is up to the Street Medicine provider to understand if the individual is enrolled in the MCP that the Street Medicine provider is contracted with and can bill that MCP for services.

Q: Will we know the locations of Street Medicine providers so we can instruct members where to go for care?
A. Usually, Street Medicine providers go out to where people are. If the member is on someone's couch, the member can be referred to ECM and we will let the Street Medicine team know that someone needs their care.

Q: What tools are available to providers in the field to make the appropriate referral to specialty services and how do we coordinate with the PPGs?
A. Street Medicine providers should reach out to the member's PCP for the PCP to coordinate the member's referrals.

Q: If a member moves into a different setting (i.e. recuperative care), can Street Medicine providers still provide services?
A. Yes, Street Medicine provider can follow the member to a more housed location, but it is up to the PCP to provide continuity of care services.

Q: Who is the point of contact for street medicine providers?
A. Contact your designated Plan representative.

Q: Would tiny homes, where individuals and families are temporarily housed for a limited period of time, in a rapid rehousing model, fall under mobile (not Street Medicine) in the scope of health care?
A. Yes. Street Medicine is meant to serve people experiencing unsheltered homelessness in their lived environment. Their lived environment may include places like the street, riverbed, car, abandoned buildings or other places not meant for human habitation. Individuals and families in tiny homes, shelters or other interim housing placements are not unsheltered and would fall under mobile medicine or other categories of health care provision as allowed by DHCS.

Q: Can Street Medicine providers provide case management?
A. ECM allows for a type of case management that focuses on ensuring eligible members are supported in navigating their health care. Street medicine providers may want to explore becoming an ECM provider and can contact the Plan for more details.

Q: How will the CS provider connect with the patient? On site? Phone?
A. Both ECM and CS providers make every effort to connect with the patient including both on site and by phone with multiple attempts. It is understood that these services are often best provided as live, in-person services and phones may regularly be lost or stolen. For this reason, street medicine providers are encouraged to help CS providers when referrals are made and as appropriate by sharing contact information or providing specific information about the location of the patient so that the CS provider can make contact as quickly as possible and to support a soft hand off.

Q: How do we know if someone is already enrolled in ECM and how do we connect with their assigned ECM provider?
A. The Plan's provider portal will show ECM enrollment and the assigned ECM provider.

Q: What address should we use on a claim form for a member who is seen on the street or park?
A. Use the provider's billing address.

Q: If the patient's primary care physician (PCP) is different from the street medicine provider, a specialty referral can only done by the patient's PCP, correct? If so, must we always have to refer the patient back to their PCP for referrals?
A. Currently, the Plan is not contracting Street Medicine providers as PCPs. Street medicine providers should render services, bill the Plan, inform the member's PCP of services rendered, and work with the PCP to get referrals to specialists or institutional services.

Q: Since the street medicine provider has to put referrals through the PCP, is the street medicine contact considered a "one and done" contact? Who is doing follow-up care?
A. The goal is to ensure closed loop referrals so that the street medicine provider can know the status of the referral and services to be provided. Findhelp is especially useful for tracking referrals and will help the street medicine provider continue to build a relationship of trust with the patient and can have confidence that services were provided or provide follow up, as needed. Street medicine providers have a broad scope and opportunity to support access to health care. Street Medicine providers should be working together with the PCP and should continue to render services.

Q: Can the member have a Street Medicine PCP and a clinic-based PCP?
A. A member can only be assigned to one PCP. While members have choice on PCP selection, the Plan is not currently contracting with street medicine providers to become PCPs.

Q: The DHCS All Plan Letter 22-023 allows Street Medicine to be direct access providers through direct contracting. In other words, are Street Medicine providers able to make referrals, such as specialty referrals, without going through the assigned PCP?
A. The Plan's interpretation of the APL is that it establishes the expectation that the street medicine provider will refer members to medically necessary covered services within the proper MCP network, and must coordinate care with the MCP, subcontractor and/or PPG as appropriate. The entree to the PPG and its network of specialists would be the PCP and the Plan expects that the Street Medicine provider and PCP collaborate. Alternatively, there should be no issue directly contacting the PPG/Management Services Organization (MSO) for a referral, although there may need to be some exchange needed between the PPG/MSO with the street medicine provider to establish the relationship of the street medicine provider as a treating provider.

Health Net is planning to train and communicate with PPGs and other contracted providers to support building the positive relationships between Street Medicine providers and other contracted providers that are needed for this patient group and other Populations of Focus to be successful.

Q: What are CHWs?
A: CHWs provide health education and navigation services to help members get the care they need. CHWs are members of the community, such as community health representatives and non-licensed public health workers, including violence prevention professionals.

Q: What do CHW do?
A: CHW services may assist with a variety of concerns impacting members, including but not limited to:

• Control and prevention of chronic conditions or infectious diseases.
• Behavioral health conditions.
• Perinatal care, preventive care, sexual and reproductive health.
• Environmental and climate-sensitive health issues.
• Oral health, aging and injury.
• Domestic violence and other violence prevention services.

Q: Who is eligible?
A: CHW services must be recommended by a physician or other licensed practitioner. The physician or licensed practitioner does not need to be enrolled in Medi-Cal or be in-network. The physician or licensed practitioner must ensure that a member meets eligibility criteria below before recommending CHW services:

• Member must be enrolled in Medi-Cal.
• Members with one or more chronic health conditions (including behavioral health) or exposure to violence and trauma:
  • Who are at risk for a chronic health condition or environmental health exposure,
  • Who face barriers in meeting their health or health-related social needs, and/or
  • Who would benefit from preventive services.
• Includes members asking for help and members at risk for not getting preventive services, neither of these categories of eligibility are dependent on have one or more chronic conditions.
• A written recommendation must be submitted to Health Net* for CHW services to be administered.

ECM benefit is a care coordination benefit that has is available to members meeting eligibility requirements and who elect to have receive the benefit. Some of the services in the ECM benefit may be provided by a CHW. The CHW benefit cannot be provided to a member enrolled in ECM.

Q: Who can submit a recommendation for the member?
A: A physician or other licensed practitioner of the healing arts within their scope of practice under state law. Other licensed practitioners who can recommend CHW services within their scope of practice include physician assistants, nurse practitioners, clinical nurse specialists, podiatrists, nurse midwives, licensed midwives, registered nurses, public health nurses, psychologists, licensed marriage and family therapists, licensed clinical social workers, licensed professional clinical counselors, dentists, registered dental hygienists, licensed educational psychologists, licensed vocational nurses, and pharmacists.

Q: How does a member get a recommendation to receive CHW services?
A: A licensed practioner of the healing arts can input a recommendation through the provider portal on the referral landing page.

Q: What are the covered services?
A:

1. Health education - Services that promote health or address barriers to physical and mental health care. This includes providing information on health topics.
2. Health navigation – Services providing information, training, referrals or assistance to help members access health care. Examples include increasing member knowledge of the health care delivery system, or how members can engage in their own care.
3. Screening and assessment – Providing screening and assessment services that do not require a license, and assisting a Member with connecting to appropriate services to improve their health.
4. Individual support or advocacy – Assisting a Member in preventing the onset or exacerbation of a health condition, or preventing injury or violence. This includes peer support as well if not duplicative of other covered benefits.

Q: What does the Supervising Provider do?
A: Supervising providers are organizations employing or otherwise overseeing the CHWs contracted with Health Net. The supervising provider must:

• Ensures that CHWs meet the qualifications listed in APL 24-006.
• Oversee CHW services delivered to members.
• Submit claims for services provided by CHWs with allowable current procedural terminology (CPT) codes as outlined in the Medi-Cal Provider Manual.

CHW supervising providers are reimbursed for CHW services in accordance with the provider contract.

Q: What are the minimum requirements to be a Supervising Provider?
A:

• Be a licensed provider, hospital, outpatient clinic, local health jurisdiction (LHJ) or community-based organization (CBO).
• Have a National Provider Identifier (NPI).
• Ability to receive referrals from licensed practitioners for CHW benefits.
• Ability to submit claims or encounters to Health Net using standardized protocols.
• Ensure your business license meets industry standards.
• Ability to comply with all reporting and oversight requirements.
• Ensure CHWs have sufficient experience to provide services.

Q: How can a CHW help a member?
A:

• Get active in your own healthcare.
• Resolve issues with getting healthcare.
• Schedule office visits, get referrals, secure transportation to medical services and other healthcare needs.
• Manage or know more about your condition.
• Access mental health services.
• Get information on health topics important to you.
• Know what resources are available for domestic violence and other violence prevention services.

Q: Compensation for travel time? ECM providers include this as part of their outreach? So if NOT ECM provider, will we compensate for travel time?
A: No compensation for travel.

Q: How to attest to a care plan on provider portal?
A: To be determined. The Provider portal will have a section to attest to having a care plan once the member receives 12 units of service.

Q: Are we going to have a template for providers for plan of care?
A: We do not have a template care plan but the APL requires it:

• Specify the condition that the service is being ordered for and be relevant to the condition;
• Include a list of other health care professionals providing treatment for the condition or barrier;
• Contain written objectives that specifically address the recipient's condition or barrier affecting their health;
• List the specific services required for meeting the written objectives; and
• Include the frequency and duration of CHW services (not to exceed the Provider's order) to be provided to meet the plan's objectives.

Q: How to bill (for new providers)
A: Workflow: Bill for Community Health Worker services using claims/invoice form

Q: What will you see after you submit the recommendation for CHW services in the provider portal?
A: Once you submit the recommendation, you will neither see or receive a confirmation.

Q: How do I find a CHW?
A: Contact Member Services toll free at 1-800-675-6110 (TTY: 711), 24 hours a day, 7 days a week.

Q: How do I bill for multiple participants in a session?
A:

• Scenario 1: The CHW provides health education services for 1 patient for 2 hours (4 units). The provider is reimbursed for this service at a rate of $26.66/unit t x 4 units. The provider is reimbursed at $106.64 ($26.66 x 4 units)
• Scenario 2: The CHW provides health education services for 3 patients in a group setting for 2 hours (4 units). The provider is reimbursed foreach patient at a rate of $50.64 ($12.66 x 4 units) The total reimbursement for 3 patients in that group comes out to $151.92 ($50.64 x 3 patients)
• Scenario 3: The CHW provides health education services for 8 patients in a group setting for 1.5 hours (3 units). The provider is reimbursed for each patient at a rate of $50.64 ($9.46 x 3 units) The total reimbursement for 8 patients in that group comes out to $227.04 ($28.38 x 8 patients)

Q: What do you do after you reach 12 units?
A: For Members who need multiple ongoing CHW services or continued CHW services after 12 units of services as defined in the Medi-Cal Provider Manual, a written care plan must be written by one or more individual licensed Providers, with the exception of services provided in the emergency department, which may include the recommending Provider and other licensed Providers affiliated with the CHW Supervising Provider. The Supervising Provider must attest to having a Care Plan for a member in the provider portal. Care Plan does not need to be submitted to the plan.

Q: Where can I get the provider training?
A: CalAIM Training & Webinars

Q: Are CHW Supervising Providers required to have a licensed provider on staff?
A: MCPs must not require Supervising Providers to have a licensed Provider on staff in order to contract with the MCP to bill for CHW services.

Q: What is not a covered CHW service?
A:

• Clinical case management/care management that requires a license
• Child care
• Chore services, including shopping and cooking meals
• Companion services
• Employment services
• Helping a Member enroll in government or other assistance programs that are not related to improving their health as part of a plan of care
• Delivery of medication, medical equipment, or medical supply
• Personal Care services/homemaker services
• Respite care
• Services that duplicate another covered Medi-Cal service already being provided to a Member
• Socialization
• Transporting Members
• Services provided to individuals not enrolled in Medi-Cal, except as noted above
• Services that require a license

Q: Does the Supervising Provider need to submit evidence of CHW training?
A: No, but CHWs must complete a minimum of six hours of additional relevant training annually. The Supervising Provider must maintain evidence of this training. Supervising Providers may provide and/or require additional training, as identified by the Supervising Provider.

Q: Does the Supervising Provider need to submit evidence of CHW training?
A: No, but CHWs must complete a minimum of six hours of additional relevant training annually. The Supervising Provider must maintain evidence of this training. Supervising Providers may provide and/or require additional training, as identified by the Supervising Provider.

Q: Can a member get a doula and CHW services at the same time?
A: Yes.

Q: What are the billing codes and modifers and services
A:
98960 – Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient [could include caregiver/family] each 30 minutes, individual patient
U2 To denote services rendered by Community Health Workers
U3 To denote services rendered by Asthma Preventive Services providers

98961 – Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient [could include caregiver/family] each 30 minutes; 2-4 patients
U2 To denote services rendered by Community Health Workers
U3 To denote services rendered by Asthma Preventive Services providers

98962 – Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient [could include caregiver/family] each 30 minutes; 5-8 patients
U2 To denote services rendered by Community Health Workers
U3 To denote services rendered by Asthma Preventive Services providers.

Q: What is the daily limits on services?
A: Maximum frequency is four units (two hours) daily per beneficiary, any provider. Additional units may be provided with medical necessity. TARs may be submitted after the service was provided.

Q: Is this benefit available for DSNP members?
A: Yes, based on Medi-Cal benefit.

Q: What are doulas?
A: Doulas are birth workers who provide health education, advocacy, and physical, emotional, and non-medical support for pregnant and postpartum persons before, during, and after childbirth, including support during miscarriage, stillbirth, and abortion. Doulas are not licensed and they do not require supervision.

Q: What does a doula do?
A: Doulas offer various types of support, including health navigation; lactation support; development of a birth plan; and linkages to community-based resources.

Q: Who is eligible for doula services?
A: The member must be active and enrolled in the Medi-Cal Plan.

• Doulas must verify eligibility for the month of service by contacting the Plan.
• The member must be pregnant or have been pregnant within the past year and would benefit from doula services or requested doula services.

Q: How does a member meet the criteria for this benefit?
A: A Member would meet the criteria for doula services if they are pregnant, or were pregnant within the past year, and would either benefit from doula services or they request doula services. Doula services can only be provided during pregnancy; labor and delivery, including stillbirth; miscarriage; abortion; and within one year of the end of a Member’s pregnancy.

Q: What does first set of services covered?
A: The first set of services cover:

• One initial visit.
• Additional visits – up to eight given in any combination of prenatal and postpartum visits.
• Labor and delivery support – including miscarriage, stillbirth and abortion.
• Postpartum – up to two extended three-hour visits.

Q: What are the requirements to refer a member to additional doula services (beyond the first set of services described above)?
A: Additional visits during the postpartum period require a recommendation:

• Up to nine postpartum visits can be added.
• Cannot be established by a standing order for doula services.

Q: How does a member receive a recommendation?
A: You can download the recommendation form from our website under Forms and Tools | Doulas. Keep the recommendation form in the member's record.

Q: How does a member receive services?
A: Members can receive doula services virtually or in-person in any setting, such as home, office, hospital, or an alternative birthing center. All visits are limited to one per day, per member.

Q: How can a doula help a member?
A: Doulas should work with the member's primary care physician (PCP) or contact the Plan to refer a member to a network provider for the following services:

• Behavioral health services.
• Belly binding after cesarean section by clinical personnel.
• Clinical case coordination.
• Health care services related to pregnancy, birth, and the postpartum period.
• Childbirth education group classes.
• Comprehensive health education including orientation, assessment, and planning (Comprehensive Perinatal Services Program services).
• Hypnotherapy (non-specialty mental health service).
• Lactation consulting, group classes, and supplies.
• Nutrition services (assessment, counseling, and development of care plan).
• Transportation.
• Medically appropriate Community Supports services.

Q: What are the documentation requirements for a doula to complete for services?
A: MCPs must ensure doulas document the dates, time, and duration of services provided to Members. Documentation must also reflect information on the service provided and the length of time spent with the Member that day. For example, documentation might state, "Discussed childbirth education with the Member and discussed and developed a birth plan for one hour." Documentation should be integrated into the Member's medical record and available for encounter data reporting. The doula's National Provider Identifier (NPI) number should be included in the documentation. Documentation must be accessible to the MCP and DHCS upon request. You can download a template for this documentation from our website under Forms and Tools | Doulas.

Q: Are doulas mandated reporters?
A: Doulas are not "mandatory reporters." However, if the doula has another profession where they are mandatory reporters, that requirement supersedes the doula's standards of practice. It is the doula's responsibility to make clear that they have these dual roles when the client engages their services.

Q: What are the requirements to be a doula?
A: All doulas must be at least 18 years old, possess an adult/infant Cardiopulmonary Resuscitation (i.e., CPR) certification, and have completed Health Insurance Portability and Accountability Act training. Additionally, a doula must qualify by meeting either the training or experience pathway, as described below:

Training Pathway:

• Complete a minimum of 16 hours of training in the following areas:
  • Lactation support
  • Childbirth education
  • Foundations on anatomy of pregnancy and childbirth
  • Nonmedical comfort measures, prenatal support, and labor support techniques
  • Developing a community resource list
• Provide support at a minimum of three births

Experience Pathway:

• All of the following:
  • At least five years of active doula experience in either a paid or volunteer capacity within the previous seven years.
  • Attestation to skills in prenatal, labor, and postpartum care as demonstrated by the following: Three written client testimonial letters, or professional letters of recommendation from any of the following: a physician, licensed behavioral health provider, nurse practitioner, nurse midwife, licensed midwife, enrolled doula, or community-based organization. Letters must be written within the last seven years. One letter must be from either a licensed Provider, a community-based organization, or an enrolled doula. "Enrolled doula" means a doula enrolled either through DHCS or through a MCP.

Q: What are the continuing education requirements
A: Doulas must complete three hours of continuing education in maternal, perinatal, and/or infant care every three years. Doulas must maintain evidence of completed training to be made available to DHCS upon request.

Q: What is not covered by doulas?
A: The following services are not covered under Medi-Cal or as doula services:

• Belly binding (traditional/ceremonial)
• Birthing ceremonies (i.e., sealing, closing the bones, etc.)
• Group classes on babywearing
• Massage (maternal or infant)
• Photography
• Placenta encapsulation
• Shopping
• Vaginal steams
• Yoga

Q: Compensation for travel time? ECM providers include this as part of their outreach? So if NOT ECM provider, will we compensate for travel time?
A: No.

Q: What are the billing codes and modifers and services?
A: Doula services can be billed with these CPT codes and modifiers:

Code or Code Ranges: 59409, 59612, 59620, 59840, T1032, T1033, Z1032, Z1034, Z1038
Required Modifier: XP
Allowable Modifiers: SA, SB, U7, 93, 95

Q: How to bill (for new providers)
A: CalAIM Training & Webinars

Q: How do I find a doula?
A: Searchable in provider directories.

Q: Where can I get the provider training?
A: CalAIM Training & Webinars

Q: Can a member get a doula and Community Health Worker services at the same time?
A: Yes.

Q: If a member calls and has a doula they want to work with but they are not contracted, what do I tell them?
A: We would establish a Single Case Agreement until a contracted is executed.

Q: Will we pay a doula retro?
A: Not usually, but depending on the case review.

Q: Can doula services be provided virtually?
A: Yes, Doula services can be provided virtually or in-person with locations in any setting including, but not limited to, homes, office visits, hospitals, or alternative birth centers.

Q: Will there be a doula directory?
A: Yes, the Department of Health Care Services is looking into different ways to create a public-facing directory of enrolled doulas.

Q: Will successful PAVE enrollment be sufficient for a doula to join the plans as a network provider without requiring a doula to undergo additional vetting by the plan?
A: Yes. Successful PAVE enrollment is sufficient for a doula to join the plan as a network provider without requiring the doula to undergo additional vetting by the plan. Enrollment though PAVE meets all federal and state enrollment requirements.

Please complete a form below as it pertains to the service and county(ies) you would like to provide service. Submit the completed form to the email address on the form. If you are interested in providing service in multiple counties, select all applicable counties on the form (only one form is needed).

Health Net

• Community Supports Provider Information Form – Health Net – English (PDF)
• Enhanced Care Management Provider Information Form – Health Net – English (PDF)

CalViva Health

• Community Supports Provider Information Form – CalViva Health – English (PDF)
• Enhanced Care Management Provider Information Form – CalViva Health – English (PDF)

Community Health Plan of Imperial Valley

• Community Supports Provider Information Form – Community Health Plan of Imperial Valley – English (PDF)
• Enhanced Care Management Provider Information Form – Community Health Plan of Imperial Valley – English (PDF)

Our team member will send a certification application after you complete the Provider Interest Form (PIF). The applications below are only examples of what you will receive. Please do not complete the forms below. Rather, wait for our team member to send you the certification application after you submit the PIF.

Health Net

• Community Supports Provider Certification Tool – Health Net – English (PDF)
• Enhanced Care Management (ECM) Provider Certification Application – Health Net – English (PDF)
• Enhanced Care Management (ECM) Provider Certification Application Addendum – Health Net – English (PDF)

CalViva Health

• Community Supports Provider Certification Tool – CalViva Health – English (PDF)
• Enhanced Care Management (ECM) Provider Certification Application – CalViva Health – English (PDF)
• Enhanced Care Management (ECM) Provider Certification Application Addendum – CalViva Health – English (PDF)

Community Health Plan of Imperial Valley

• Community Supports Provider Certification Tool – Community Health Plan of Imperial Valley – English (PDF)
• Enhanced Care Management (ECM) Provider Certification Application – Community Health Plan of Imperial Valley – English (PDF)
• Enhanced Care Management (ECM) Provider Certification Application Addendum – Community Health Plan of Imperial Valley – English (PDF)

Providers are required to submit staffing and capacity reports at minimum on a quarterly basis or as update is needed.

• CS Staffing and Capacity Report (XLXS)
• ECM Staffing and Capacity Report (XLXS)

• Community Health Worker Provider Participation Application – Health Net – English (PDF)
• Community Health Worker Provider Participation Application – CalViva Health – English (PDF)
• Community Health Worker Provider Participation Application – Community Health Plan of Imperial Valley – English (PDF)

On January 1, 2022, the California Department of Health Care Services (DHCS) implemented the California Advancing and Innovating Medi-Cal (CalAIM) Incentive Payment Program to support CalAIM initiatives. The California state budget allocated $300 million for incentive payments to Medi-Cal managed care plans (MCPs) for state fiscal year (SFY) 2021-2022, $600 million for SFY 2022-2023 and $600 million for SFY 2023-2024.

Incentive program payments are intended to:

• Build appropriate and sustainable Enhanced Care Management (ECM) benefit and Community Support capacity;
• Drive MCP investment in necessary delivery system infrastructure;
• Incentivize MCP take-up of Community Support;
• Bridge current silos across physical and behavioral health delivery;
• Reduce health disparities and promote health equity; and
• Achieve improvements in quality performance.

The incentive program period is January 1, 2022, to June 30, 2024. The program period will be split between three distinct program years (PYs):

• PY 1 (January 1, 2022, to December 31, 2022)
• PY 2 (January 1, 2023, to December 31, 2023)
• PY 3 (January 1, 2024, to June 30, 2024)

Incentive Payment Documents

Per incentive program requirements, in January 2022, the Plan submitted Incentive Payment Program Needs Assessment and Gap Filling Plans to DHCS for each of the counties we serve. The Needs Assessment and Gap Filling Plans were developed based on information from the Plan meeting with county and MCP partners, and fielding surveys of contracted ECM and Community Supports providers to identify ECM and Community Supports gaps and needs.

DHCS will use the CalAIM Incentive Payment Program Needs Assessment and Gap Filling Plans, publicly available on the DHCS website, as the basis to determine the allocated incentive dollar proportion that will be paid to the Plan to invest in infrastructure and capacity to support CalAIM objectives.

Going forward, the Plan will solicit feedback from stakeholders on ECM and Community Supports gaps and needs through local level California Department of Health Care Services (DHCS) PATH Collaborative Planning and Implementation (CPI) Initiatives. The DHCS PATH CPI Initiatives will serve as a vehicle for the Plan to engage stakeholders in each county to inform Incentive Payment Program community-wide investments to optimize Incentive Payment Program funding and ensure non-duplicate investments. To learn more about how to participate in a DHCS PATH CPI Initiative, visit the DHCS PATH CPI website.

Eligible ECM providers can earn incentives through the Plan’s ECM Provider Incentive program when timely outreach and reporting is demonstrated. To learn more, refer to the following communications:

• 23-1317 – 2023: ECM Provider Incentive Amendment Letter – Health Net – English (PDF)
• 23-1316 – 2023: ECM Provider Incentive Amendment Letter – CalViva Health – English (PDF)

• 24-230 – 2024: ECM Provider Incentive letter – Health Net – English (PDF)
• 24-229 – 2024: ECM Provider Incentive letter – CalViva Health – English (PDF)
• 24-231 – 2024: ECM Provider Incentive letter – Community Health Plan of Imperial Valley – English (PDF)

• 23-288 – 2023: ECM Provider Incentive letter – Health Net – English (PDF)
• 23-289 – 2023: ECM Provider Incentive letter – CalViva Health – English (PDF)
  
  
• 22-492 – 2022: ECM Provider Incentive letter – Health Net – English (PDF)
• 22-491 – 2022: ECM Provider Incentive letter – CalViva Health – English (PDF)

Eligible Community Health Worker (CHW) providers can earn incentives through the Plan's provider incentive program by demonstrating effective and timely outreach to provide services to eligible members. To learn more, refer to the following communications:

• 24-747 – 2024: CHW Provider Incentive letter – Health Net – English (PDF)
• 24-748 – 2024: CHW Provider Incentive letter – CalViva Health – English (PDF)
• 24-749 – 2024: CHW Provider Incentive letter – Community Health Plan of Imperial Valley – English (PDF)