Community Health Worker Workflow

The member must be active and enrolled in the Medi-Cal Plan. Confirm member eligibility for the month of service through either of the following:

Provider portal (preferred method). Log in to the secure provider portal, then select Eligibility.
Automated Eligibility Verification System: 800-456-2387
The Automated Eligibility Verification System (AEVS) is available from 7:00 a.m. to 8:00 p.m., seven days a week. To access this automated network, providers will need their Medi-Cal Provider Identification Number (PIN).

If you are a provider who currently does not have access to the portal, refer to the below brochure for instructions on how to register:

Check for Enhanced Care Management (ECM) flag in provider portal. If the member is already in ECM, they cannot quality for Community Health Worker services.

The member must have a recommendation on file from a physician or other licensed practitioner of the healing arts.

If you are a supervising provider for Community Health Worker services, complete and submit the recommendation by logging in to the provider portal > Eligibility, enter Member ID or Last name and DOB, then select Check Eligibility to access members record. Select Referral to document the recommendation.

If the provider does not have access to the provider portal, download the Medi-Cal Member Recommendation form below:

The physician can give the completed Medi-Cal Member Recommendation for Community Health Worker Services form to the member who can provide it to the Community Health Worker. The Community Health Worker and/or supervising provider will document the recommendation form in the member’s record and keep recommendation on file.

Community Health Worker will contact members to schedule an appointment.

If the member qualifies for CS services, refer to the CS workflow for referral information.

The supervising provider must complete a care plan for member receiving over 12 units and keep the care plan on file for the member.

Once the care plan is developed, the supervising provider must go to provider portal and attest to a care plan. (Pending).

Member care plan needs to be assessed every six months after initial date of care.

Providers can bill through claims submission or invoice submission. If you submit claims, you won't have to submit an invoice and vice versa.

Submit claims or invoice forms and supporting information to 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 section for more information.
Bill by invoice. (Download the Invoice form)
Note: Payor Primary ID for HNT and CVH is 95567.

Email: CalAIM_CS_invoicesubmission@centene.com

Address: Health Net – CalAIM Invoice, PO Box 10439, Van Nuys, CA 91410-0439

Fax: 833-386-1043

Conduent Web Portal

Billing training

To learn more about how to bill for Community Health Worker services, refer to the Claims and Invoice Guidance training.

Note: The training deck is available after viewing the training video.

Community Health Worker End-to-End Process

Step 1 – Verify member eligibility

Step 2 – Submit written recommendation for Community Health Worker services

Step 3 – Schedule an appointment for Community Health Worker services

Step 4 – Refer Member to Community Supports services (as needed)

Step 5 – Once a member receives 12 units of service, a care plan is required

Step 6 – Bill for Community Health Worker services using claims/invoice form

Billing training