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["Community Supports Provider Name","Community Supports Provider National Provider Identifier (NPI)","Community Supports Provider TIN","Medi-Cal Member Client Index Number (CIN)","Medical Record Number (MRN)","Member Last Name","Member First Name","Member Homelessness Indicator","Member Residential Address Line 1","Member Residential Address Line 2","Member Residential City","Member Residential State","Member Residential Zip Code","Member Mailing Address Line 1","Member Mailing Address Line 2","Member Mailing City","Member Mailing State","Member Mailing Zip Code","Member Phone Number","Member Email Address","Preferred Member Contact Method","Member Date of Birth","Member Gender Code","Member Preferred Language (Spoken)","Member Preferred Language (Written)","Member Race or Ethnicity","Medi-Cal Renewal Date","Community Supports Service Name","Current Status of Member Engagement","Date MCP Received Request for Authorization","Reauthorization Request","Date MCP Provides a Response About the Request for Authorization","Referral Authorization Status","Authorization Number","Authorization Effective Date","Authorization End Date","Denial Reason Code","Community Supports Authorization Status File Production Date","Community Supports Authorization Status File Reporting Period","Primary Payer (MCP) Identifier","MCP Name","MCP Provider Services Phone Number","MCP Community Supports Contact Person","MCP Community Supports Person Phone Number","Community Supports Member Record: New/Continuing/Termed","ECM Provider Name","ECM Provider Phone Number","Z-codes (25 total)","Best Contact Method for Member/Caregiver","Best Contact Time for Member/Caregiver","Referring Organization Name","Referring Individual Name","Referring Individual Phone Number","Referring Individual Fax number","Referring Individual Email Address","Referring Individual Relationship to Member","CLR ID","Referral Type","Date of Referral","Referral Status","Date of Referral Status","Reason for Referral Loop Closure"]

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["Name: Community Supports Authorization Status File (CSASF)",null,null,"Effective: 7/15/2025"]
["Data Element","Required Inclusion on CSASF\n(From Health Plan)","Field Size","Sample Data","Notes"]
["Community Supports Provider Name","Yes",20,"CS Provider Name"]
["Community Supports Provider National Provider Identifier (NPI)","Yes",10,1234567890]
["Community Supports Provider TIN","Yes",9,123456789]
["Medi-Cal Member Client Index Number (CIN)","Yes",9,123456789,"Member's Client Index Number (CIN)"]
["Medical Record Number (MRN)","Optional",10,123456789,"This may be used by Health Plans.  It would be our internal ID #"]
["Member Last Name","Yes",30,"Smith"]
["Member First Name","Yes",30,"John"]
["Member Homelessness Indicator","Yes",1,1,"1 for Yes; \"0\" for No, or unknown."]
["Member Residential Address Line 1","Yes - When Available",30,"123 MAIN ST.","Health Plans will leave field as blank if address is unknown."]
["Member Residential Address Line 2","Yes - When Available",30,"APT 2"]
["Member Residential City","Yes - When Available",30,"SALINAS"]
["Member Residential State","Yes - When Available",2,"CA"]
["Member Residential Zip Code","Yes - When Available",9,93905,"Health Plans will leave field as blank if zip is unknown"]
["Member Mailing Address Line 1","Yes - When Available",30,"123 MAIN ST.","Health Plans will leave field as blank if address is unknown."]
["Member Mailing Address Line 2","Yes - When Available",30,"APT 2"]
["Member Mailing City","Yes - When Available",30,"SALINAS"]
["Member Mailing State","Yes - When Available",2,"CA"]
["Member Mailing Zip Code","Yes - When Available",9,93905,"Health Plans will leave field as blank if zip is unknown"]
["Member Phone Number","Yes - When Available",10,8888888888,"Health Plans will leave field blank if unknown"]
["Member Email Address","Optional",30,"ABCDEFG@HEALTHNET.COM","Populated if available."]
["Preferred Member Contact Method","Yes",20,"1. Call","Options: 1. Call; 2. Text; 3. In Person Outreach; 4. Email; 5. Unknown."]
["Member Date of Birth","Yes",10,"2021-01-01"]
["Member Gender Code","Yes",1,"F","Current Valid Values = \"M\" or \"F\""]
["Member Preferred Language (Spoken)","Yes",20,"ENGLISH"]
["Member Preferred Language (Written)","Yes - When Available",20,"ENGLISH"]
["Member Race or Ethnicity","Yes - When Available",20,"CHINESE","Health Plans will use values present on DHCS 834 file"]
["Medi-Cal Renewal Date","Yes",10,"2021-01-01","If unknown Health Plans must notify DHCS of missing info. and leave blank"]
["Community Supports Service Name","Yes",30,"1. Asthma Remediation","If a member has been referred to receive more than one community supports service by the CS Provider, that service shall appear on a separate row.\n1. Asthma Remediation\n2. Community Transition Services/Nursing Facility Transition to a Home\n3. Day Habilitation Programs\n4. Environmental Accessibility Adaptations (Home Modifications)\n5. Housing Deposits\n6. Housing Tenancy and Sustaining Services\n7. Housing Transition Navigation Services\n8. Medically Tailored Meals/Medically-Supportive Food\n9. Nursing Facility Transition/Diversion to Assisted Living Facilities, such as Residential Care Facilities for Elderly and Adult Residential Facilities\n10. Personal Care and Homemaker Services\n11. Recuperative Care (Medical Respite)\n12. Respite Services\n13. Short-Term Post Hospitalization Housing\n14. Sobering Centers"]
["Current Status of Member Engagement","Yes",30,"1. Pending Outreach","One reason code per Member. Reason code: 1. Pending Outreach; 2. Currently in Outreach; 3.Currently Delivering Service; 4. Services Discontinued; If selecting Services Discontinued, please complete the field below."]
["Date MCP Received Request for Authorization","Yes - When Available",10,"2021-01-01"]
["Reauthorization Request","Yes",1,1,"MCP to select “0” for Initial Request, “1” for the f irst reauthorization, “2” for the second reauthorization\nrequest, “3” f or the third reauthorization request, and so on. Each reauthorization must be recorded as a\nseparate entry for that Member."]
["Date MCP Provides a Response About the Request for Authorization","Yes",10,"2021-01-01"]
["Referral Authorization Status","Yes",30,"1. Approved","One reason code per Member. Reason codes include: 1. Approved; 2. Under Review; 3. Need Additional Information f rom Community Supports Provider/Referral Source; 4. Denied"]
["Authorization Number","Optional",15,"AB1234567890"]
["Authorization Effective Date","Yes",10,"2021-01-01"]
["Authorization End Date","Yes",10,"2021-01-01"]
["Denial Reason Code","Yes",30,"1. Member not in Medi-Cal Managed Care","One reason code per Member. Reason codes include: 1. Member not in Medi-Cal Managed Care; 2. Member not enrolled in MCP; 3. Clinical supporting information or documentation missing; 4. Additional information or documentation needed to evaluate cost ef fectiveness and/or medical appropriateness; 5. Member not eligible under the MCP’s policies and procedures; 6. Member already approved to receive\nthe service; 7. Other"]
["Community Supports Authorization Status File Production Date","Yes",10,"2021-01-01","Date extract was generated by MCP."]
["Community Supports Authorization Status File Reporting Period","Yes",25,"01/01/2023.01/31/2023","Start and end dates reported as two sets of numbers separated by a period delimiter (i.e., MM/DD/YYYY.MM/DD/YYYY)"]
["Primary Payer (MCP) Identifier","Yes",3,352,"See Primary Payer (MCP) Identifier in the following tab: PrimaryPayerMCPIdentifier Xwalk"]
["MCP Name","Optional",30,"HEALTH NET","Health Net, CalViva, CHPIV"]
["MCP Provider Services Phone Number","Yes",10,8888888888]
["MCP Community Supports Contact Person","Optional",30,"Smith, John","Last name, first name, title, separated by commas"]
["MCP Community Supports Person Phone Number","Optional",10,8888888888]
["Community Supports Member Record: New/Continuing/Termed","Yes",15,"New","“New” to indicate Members who are newly authorized to receive\nCommunity Supports since the previous reporting period; “Continuing” to indicate Members who are continuing to receive Community Supports since the previous reporting period; “Termed” to indicate Members who are no longer receiving Community Supports during this reporting period."]
["ECM Provider Name","Yes",30,"ECM Provider Name","If member is assigned to an ECM Provider, capture the name of that provider"]
["ECM Provider Phone Number","Yes",10,8888888888,"If member is assigned to an ECM Provider, capture the phone number of that provider"]
["Z-codes (25 total)","Optional",50,"Z59.01 Sheltered Homelessness; Z59.02 Unsheltered Homelessness; Z59.41 Food Insecurity","DHCS has issued a list of 25 DHCS Priority SDOH Codes for MCPs\nand providers to utilize when coding for SDOH to ensure correct coding and capture of\nreliable data.   DHCS APL on collecting SDOH data--https://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2021/APL21-009.pdf; "]
["Best Contact Method for Member/Caregiver","Optional ",6,"Phone","Phone\nText\nEmail"]
["Best Contact Time for Member/Caregiver","Optional ",10,"Morning","Morning\nAfternoon\nEvening"]
["Referring Organization Name","Optional ",30]
["Referring Individual Name","Optional ",30,"Doe, Jane"]
["Referring Individual Phone Number","Optional ",10,5555555555]
["Referring Individual Fax number","Optional ",10,1234567890]
["Referring Individual Email Address","Optional ",30]
["Referring Individual Relationship to Member","Optional ",20,"(1) Medical provider","(1) Medical provider\n(2) Social services provider\n(3) Member/family\n(4) Other"]
["CLR ID","Optional ",15,"XYZ12345AZ55"]
["Referral Type","Yes",20,"(1) Community Referral","(1) Community Referral\n(2) Identified by the MCP"]
["Date of Referral","Yes",10,"2025-01-01"]
["Referral Status","Optional",20,"(5) Referral Loop Closed","(1) Accepted\n(3) Pending\n(4) Outreach Initiated\n(5) Referral Loop Closed"]
["Date of Referral Status","Optional",10,"2024-12-13"]
["Reason for Referral Loop Closure","Optional",30,"(1) Services Received","(1) Services Received\n(2) Service Provider Declined\n(3) Unable to Reach Member\n(4) Member No Longer Eligible for Services\n(5) Member No Longer Needs Services or Declines Services"]