Community Health Worker End-to-End Process

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:

• Save Time Navigating the Provider Portal brochure – Health Net (PDF)
• Save Time Navigating the Provider Portal brochure – CalViva Health (PDF)
• Save Time Navigating the Provider Portal brochure – Community Health Plan of Imperial Valley (PDF)

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.

CHW services require a written recommendation by a physician or other licensed practitioner of the healing arts within their scope of practice under state law before services can be provided.

The recommending licensed provider does not need to be enrolled in Medi-Cal or be a network provider within the beneficiary's managed care plan.

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, licensed educational psychologists, licensed vocational nurses, and pharmacists.

Download the Medi-Cal Member Recommendation form:

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

The contracted CHW provider organization must document the recommendation in the provider portal by (see screenshot):

1. Logging in to the provider portal
2. Under Eligibility, enter Member ID or Last name and DOB, then select Check Eligibility to access members record.
3. Select Referral to document the recommendation.
4. Select Community Health Worker from the drop down menu
5. Enter written recommendation information

Health education to promote the beneficiary’s health or address barriers to physical and mental health care, including providing information or instruction on health topics. The content of health education must be consistent with established or recognized health care standards.

Health Education Resources:

• Health Net Wellness Resources
• CalViva Health Wellness Programs
• Community Health plan of the Imperial Valley Member Resources

Health navigation to provide information, training, referrals, or support to assist the member.

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 & Community Health Plan of Imperial Valley
• 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)
• Findhelp How-To Guide – 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)

Individual support or advocacy that assists a beneficiary in preventing the onset or exacerbation of a health condition or preventing injury or violence.

• Health Net Medi-Cal Member Resources
• CalViva Health Member Resources
• Community Health plan of the Imperial Valley Member Resources

Screening and assessment that does not require a license and that assists a beneficiary to connect to appropriate services to improve their health.

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

A written plan of care is required for continued CHW services after 12 units of care per beneficiary in a single year, with the exception of services provided in the Emergency Department. The written plan of care must be developed by one or more licensed providers. The provider ordering the plan of care does not need to be the same provider who initially recommended CHW services or the supervising provider for CHW services. CHWs may participate on the team that develops the plan of care. The plan of care may not exceed a period of one year.

The plan must meet the following conditions:

• Specifies the condition that the service is being ordered for and be relevant to the condition
• Includes a list of other health care professionals providing treatment for the condition or barrier
• Contains written objectives that specifically address the recipient's condition or barrier affecting their health
• Lists the specific services required for meeting the written objectives

Includes the frequency and duration of CHW services (not to exceed the provider's order) to be provided to meet the care plan's objectives

Once the care plan is developed, the supervising provider must go to provider portal and attest to a care plan. See screenshot.

A licensed provider must review the beneficiary's plan of care at least every six months from the effective date of the initial plan of care. The licensed provider must determine if progress is being made toward the written objective and whether services are still medically necessary. If there is a significant change in the recipient's condition, providers should consider amending the plan for continuing care or discontinuing services if the objectives have been met.

Billing

Providers can bill Community Health Worker services by submitting a claim or an invoice form.

Bill with a claim

Submit claims or invoice forms and supporting information to one of the options:

• Electronic data interchange (EDI) (recommended)
• Availity Essentials
• Bill by invoice – Please contact your assigned Point of Contact
• Submit paper CMS-1500 (version 02/12) form for paper claims
  Refer to Claims Procedures for more information.
  • Address:
    Health Net – CalAIM Invoice
    PO Box 10439
    Van Nuys, CA 91410-0439
  • Fax: 833-386-1043

Billing training

To learn more about how to bill for Community Health Worker services, refer to Claims and Invoice for Providers training: CalAIM training > Required Onboard Trainings