Enhanced Care Management End-to-End Process
Click on the steps to view end-to-end process workflow for referrals to Community Supports services.
If you identify a member who will benefit from ECM, confirm if the member may already be assigned to another ECM provider by either:
- Visiting the provider portal:
- Log in to the secure provider portal at CAHealthWellness.com.
- Select Eligibility and search eligibility for the member.
- Select Enhanced Care Management on the left navigation.
- Calling Provider Services – Providers with no provider portal access can call California Health & Wellness Plan (CHWP) Provider Services at 877-658-0305 to find out if the member is already assigned to an ECM provider.
For members already assigned to an ECM provider, but would like to change to another ECM provider, they will need to call Member Services.
Confirm member eligibility through either of the following:
- The provider portal (preferred method). Log in to the secure provider portal CAHealthWellness.com > Eligibility, then select Enhanced Care Management. Refer to the Referral and Auths Guidance for ECM Providers training on the CalAIM Provider Training page to see the steps to check eligibility through the provider portal.
- The Automated Eligibility Verification System (AEVS) on the Department of Health Care Services Medi-Cal eligibility website. Use AEVS if you do not have access to the provider portal.
Complete ECM screening forms on the CalAIM Resources for Providers page to determine if the member qualifies for ECM. To access the forms, select Enhanced Care Management (ECM) in the Forms & Tools section.
Refer a member to ECM by submitting a referral through the provider portal or fax. Attach ECM screening forms or other documents that will help identify why the member might qualify for ECM. Note: Prior authorization for ECM services is not needed.
- Online (recommended): Go to CAHealthWellness.com and log in.
- Fax: 800-743-1655
Refer to the Referral and Auths Guidance for ECM Providers training on the CalAIM Provider Training page for more information on referrals.
- ECM referral is submitted through the authorization process for new members not on the MIF. The referral is a way to add members to an ECM provider's MIF file for ECM outreach.
- When submitting the referral for ECM, indicate the ECM provider who the member would like to be referred to. To find a contracted ECM provider, please refer to our Provider Directory.
- Go to the Claims Procedures section online to find the HCPC code to use when submitting the ECM authorization for referring a member, use the one for ECM outreach.
- Providers should use diagnosis codes that best describes the member's condition and why they qualify for the service. There are z codes for members who qualify for program due to social determinants; refer to the provider Help Tailor Services and Programs for At-Risk Members with New Social Determinants of Health Codes.
- After the ECM provider receives the MIF, they will contact the member to determine if the member qualifies and wants to enroll in ECM.
- If the member qualifies and consents to enroll, the ECM provider will submit the ECM status on the monthly Return Transmission File (RTF), indicating the member as Enrolled and the Enrollment Date.
- RTF and Outreach Tracker File (OTF) are due back to the Plan by the 5th of each month.
Important Note: If an ECM provider enrolls a member but does not send back the RTF file indicating member as enrolled, we will not be able to flag this member in our systems and report as ECM enrolled. On a monthly cadence, the Plan will process the RTFs and update member’s ECM status based on RTFs.
ECM providers are required to provide person-centered care management by working with the member to assess risk, needs, goals, barriers and preferences, and have a care management plan that coordinates and integrates all of the member's clinical and non-clinical health care related needs.
- ECM providers are required to initiate an assessment within 30 days and complete the essential elements needed to develop plan of care within 60 days after the member opts in.
- ECM providers are encouraged to initiate and complete the assessment as soon as possible.
For more details on risk assessment and care plan, refer to the Enhanced Care Management (ECM) Provider Guide (PDF).
Providers can bill through claims submission or invoice submission. Note, if you submit claims, you won't have to submit invoices and vice versa.
Important note: Authorization number is not a required field for billing.
- One-time ECM outreach: Providers can bill for one outreach for all potential ECM members on their MIF regardless of the outreach outcome.
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
Address: California Health & Wellness Plan – CalAIM Invoice, PO Box 10439, Van Nuys, CA 91410-0439
To learn more about how to bill for ECM, refer to the Claims and Invoice Guidance for ECM Providers training on the CalAIM Provider Training page.
Note: The training deck is available after viewing the training video.
An ECM provider will need to assess within six months of the member's enrollment in ECM to:
- Determine the most appropriate level of services for the member.
- Confirm whether ECM or a lower level of care coordination best meets the member's needs.
Please use the program completion assessment template Enhanced Care Management Program Completion Questionnaire (PDF).
After ECM enrollment, the provider should complete program completion assessment evaluating if member should remain in program (every six months). Program completion assessments do not need to be submitted to the Plan. Validation of completion of these assessments will be done via file review and data monitoring.