Enhanced Care Management End-to-End Process

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:
  1. Log into the secure provider portal at provider.healthnetcalifornia.com
  2. Select the Eligibility tab or use Quick Eligibility Check on the main page and search eligibility for the member.
  3. Select Enhanced Care Management on the left navigation.
• Calling Provider Services – Providers with no provider portal access can find out if the member is already assigned to an ECM provider by calling:
  • Health Net: 800-675-6110
  • CalViva Health: 888-893-1569
  • Community Health Plan of Imperial Valley: 833-236-4141

Confirm Medi-Cal member eligibility through either of the following:

1. The provider portal (preferred method). Log into the secure provider portal provider.healthnetcalifornia.com > Eligibility, then select Enhanced Care Management.
2. 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 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)

Complete ECM Benefit Referral Form on the CalAIM Resources for Providers page to determine if the member qualifies for ECM.

ECM Benefit Referral form can be found at CalAIM Resources for Providers > Forms and Tools > Enhanced Care Management (ECM).

Refer a member from the community to ECM by submitting a referral through the provider portal or fax. Attach ECM Benefit Referral Form and other documents that will help identify why the member might qualify for ECM. Note: Prior authorization for ECM services is not needed.

• Online (preferred): Go to provider.healthnetcalifornia.com and log in.
• Fax: 800-743-1655

ECM Benefit Referral form can be found at CalAIM Resources for Providers > Forms and Tools > Enhanced Care Management (ECM).

Important notes:

• ECM referral is submitted through the authorization tab for new members not on the Member Information Form (MIF). The referral is the way to add members to an ECM provider's MIF file.
• 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:
  • Provider Directory – Health Net
  • Provider Directory – CalViva Health
  • Provider Directory – Community Health Plan of Imperial Valley
• Go to the Claims Procedures section online to find the HCPC code to use when submitting the ECM referral.
• 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 update:
  • Use the Most Descriptive SDOH Z Codes on Claims and Encounters – Health Net
  • Use the Most Descriptive SDOH Z Codes on Claims and Encounters – CalViva Health
  • Use the Most Descriptive SDOH Z Codes on Claims and Encounters – Community Health Plan of Imperial Valley
  • Additional diagnosis codes can be found on the ICD-10 website

After making the referral (submit through the ECM authorization tab), if the referral is approved, the member will be added to the ECM provider's monthly MIF. The MIF is sent out to each ECM provider by the 15th of each month.

In addition to the monthly MIF, the assigned ECM provider will receive an ad hoc mini-MIF through sFTP or secure email 5-10 calendar days after the referral is approved. If a mini-MIF is not received within this timeline after submitting a referral, providers should follow up with their Plan Provider Services:

• Calling Provider Services –
  • Health Net: 800-675-6110
  • CalViva Health: 888-893-1569
  • Community Health Plan of Imperial Valley: 833-236-4141

• After the ECM provider receives the MIF, they will contact the member to determine if the member qualifies and wants to enroll in ECM.
• All outreach attempts to enroll members will be reported back to the health plan through the Outreach Tracking File (OTF).
• 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 Benefit Start Date.
• RTF and OTF are due back to the Plan by the 5th of each month.

Important Note: If an ECM provider enrolls a member but the plan does not successfully receive 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 standard ECM assessment 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 timely as possible following enrollment.
• ECM assessment forms can be found at CalAIM Resources for Providers > Forms and Tools > Enhanced Care Management (ECM)

For more details on risk assessment and care plan, refer to the ECM provider guide:

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

Providers can bill through claims submission or invoice submission.

Important note: Authorization number is not a required field for billing.

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

• Electronic data interchange (EDI) (preferred)
• 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 the Claims Procedures section 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 ECM, refer to the refer to the Claims and Invoice for Providers training: CalAIM Resources for Providers > CalAIM training > Required Onboard Trainings

ECM providers need to complete a program completion questionnaire every 12 months following enrollment to assess the member for readiness to:

• Graduate from the ECM program
• Transition to a lower level of care

Please use the program completion questionnaire template:

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

Program completion questionnaires do not need to be submitted to the Plan. Validation of completion of questionnaires will be done via file review upon request.