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CalAIM Resources for Providers

What is CalAIM?

CalAIM (California Advancing and Innovating Medi-Cal) is a multi-year initiative by the California Department of Health Care Services (DHCS) to improve the quality of life and health outcomes of Medi-Cal members through broad delivery system, program and payment reform across the Medi-Cal program.

This resource page has been developed to provide tools and resources to help providers easily navigate the CalAIM program so they can better serve our members. On this page you will find the most current information – guides, forms, trainings and more – as well as the latest updates from our Plan. This page will be updated as new information and guidelines are available.

Training & Webinars

CalAIM training

General Information

Guides & processes

Forms & Tools

Forms & Tools

Communications

Communication resources

Data Collection

Data collection resources

Forms & Tools

Community Supports (CS) authorization guides were developed to provide guidance to CS providers based on the Department of Health Care Services (DHCS) eligibility criteria. We encourage all CS providers to use the guides to help determine member eligibility for DHCS pre-approved CS services.

Health Net

CalViva Health

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.

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.

CalAIM Frequently Asked Questions

Health Net/CalViva Health Provider FAQs

Q: How do I request a secure file transfer protocol (sFTP) account?
A. Request an sFTP account by filling out the ECM sFTP Details Request Form. You can find the form at CalAIM Resources for Providers, under Forms & Tools > Enhanced Care Management (ECM).

Q: Where do we submit the Member Information File (MIF)?
A. MIFs are submitted via the sFTP site. If your sFTP connection is not yet set up, you can send in the MIFs via secure email to ECM_sFTP_Request@healthnet.com.

Q: For those with an sFTP account, will files be delivered via secured email as well?
A. No. Files will be transmitted via sFTP on the 15th of each month.

Q: What do we do if our MIF includes patients who are not enrolled in our program?
A. Members/patients labeled with status code 1 – Pending Outreach are included in the MIF. Providers can reach out and enroll them in the program if they qualify based on provider assessment.

Q: Are we able to add in any dates prior to 1/1/2022 for existing patients with us? (e.g. assessment dates, case conference dates)
A. No. The earliest date that should be included is 1/1/2022.

Q: Will we receive cobranded letters or packets to use as part of our outreach efforts?
A. We are in the process of developing content. At this time, please review materials in the ECM Outreach Toolkit (PDF).

Q: Who can I contact for information regarding an outreach list or an ECM guide?
A. Your ECM-assigned liaison will reach out to you. You can also send inquires to your Health Plan's mailbox at ECM_ILOS@healthnet.com (Health Net) or CalViva_ECM_ILOS@healthnet.com (CalViva Health) if a liaison has not yet contacted you.

Q: For grandfathered members, do we need to provide the Response Transmission File (RTF) by the 5th?
A. Yes. Any updates to grandfathered members should be included in the RTF by the 5th of the month.

Q: Do I enter one row on the Outreach Tracker File (OTF) per outreach attempt?
A. Yes.

Q: Can I round up the outreach time spent or does it need to be the exact number?
A. Yes. You can round it up to the nearest minute.

Q: Is there an area to submit time spent on case staffing (case manager-to-case manager hand off) prior to working with the client?
A. No.

Q: How do we count the total number of encounters in the RTF?
A. You can count total number of in-person encounters via the data element labeled In-Person. You can count total number of telephonic encounters via the data element labeled Telephonic.

Q: Is the RTF due by the 5th regardless of when the MIF was received?
A. Yes. The MIF is sent no later than the 15th of the month and the RTF is due the 5th of the following month. If for some reason the RTF is not submitted on time, the updates can be included in following month's RTF.

Q: What is the phone number for the Community Supports (CS) team?
A. Health Net Provider Services Center: 800-675-6110.
CalViva Health Provider Services Center: 888-893-1569.

Q: If outreach is performed for a patient already in a board and care home/assisted living facility or skilled nursing facility, is that considered a successful outreach?
A. Yes.

Q: Are ECM providers responsible for adding all previously enrolled patients to the RTF?
A. Yes. The RTF should include all new and past enrollments present in the most recent MIF.

Q: If a member enrolls and then decides to not participate in the program, what would the code be?
A. The member can be marked with status code 4 – Declined. The date of enrollment should be populated under ECM Enrollment Start Date. The date the member decided not to participate in the program should be populated under ECM Enrollment End Date.

Q: If the outreach attempt is by mail, which code should be used?
A. This can be captured under Telephonic/Electronic and Time Spent. This should be defaulted to 1 minute.

Q: Will the Health Plan keep and provide historical data submitted by providers on the monthly RTF? Or will we need to re-enter details every month?
A. Yes. Provider updates sent on the monthly RTF will be included in the MIF.

Q: Will there be ongoing office hours for questions?
A. Yes. ECM office hours are scheduled to occur at least once a month.

Q: Is there training for the ECM data exchange files?
A. Yes. ECM data exchange training is available on the provider portal.

Q: What if I get a Blocked Content message when uploading my file?
A. This is most likely due to your organization's firewall settings. Contact your IT department for help to whitelist the website or webpage.

Q: Are patients who are transitioning from the home health program (HHP) or whole person care (WPC) automatically enrolled into the ECM program?
A. Yes.

Q: For those who transition into the ECM program, what information do we need to complete for outreach?
A. To help providers with outreach, member demographic/contact information, chronic conditions and populations of focus are included in the MIF. During outreach, providers should assess members' current condition to see if they still qualify for the program.

Q: Due to limited capacity, our provider group elected only to serve members assigned to our group's primary care physicians (PCPs). Can you confirm this will be the case under ECM?
A. Special requests for member assignment preference should be communicated to your ECM liaison at the Health Plan.

Q: For members who have declined or never accepted ECM services, what date do we enter for the ECM Enrollment Date since it cannot be left blank?
A. A revised copy of the RTF was shared with providers. ECM Enrollment Start and End Dates are not required for members who declined or who do not qualify for ECM.

Q: Do we have an authorization form for ECM?
A. We have an ECM Member Referral Form template that you can use when submitting an authorization to request ECM service for a member. It is an optional template. You can find the template and screening forms at CalAIM Resources for Providers, under the Forms & Tools section.

Q: Do we have an authorization form for CS?
A. No, we do not have a required referral or authorization form template for CS. You can use any existing form that your organization uses for referrals when submitting for CS. The recommended method is to submit authorization requests through the provider portal.

Q: If a member is listed on our MIF provided by the Health Plan, have they been authorized for ECM services?
A. If a member is on the TEL file without status of "Enroll," that means you are authorized to reach out to member. After you submit an RTF indicating the member qualified and consented to be enrolled into ECM, you will receive a separate authorization letter for ECM services.

Q: Is the member's signature needed on the claim form every time, even if we provide services telephonically?
A. If you have the member's signature on file, you don't need to provide it on each claim/invoice. You can indicate "signature on file/SOF" on the claim or invoice when submitting. Signatures can be collected through various methods, such as electronic signatures, telephonic audio recording or documentation in case notes. For reference, please see the Department of Health Care Services (DHCS) letter that gives general guidance on capturing telephonic signatures (PDF).

Q: Should we use point of service (POS) 02 for telehealth visit/over the phone?
A. There is no requirement on POS. Please ensure you follow the billing guidance and add modifier GQ when billing for telehealth.

Q: Can we submit a claim for mailers sent to members as a part of outreach attempts or reaching out to grandfathered members?
A. Providers can bill for a one-time outreach for new members regardless of outreach outcome. Grandfathered members do not require an initial outreach so the one-time outreach does not apply to them.

Q: Can we submit one claim for all members or are individual claims needed?
A. You will need to submit one claim per member.

Q: If we are making phone calls to access services for the member, can these be billed as ECM phone services or can we only bill for phone calls with the member?
A. The ECM encounter can and should be billed directly to the Health Plan for those visits when the provider develops and/or performs work related to the health action plan. This work is separate from any clinical care coordination provided to the member.

Q: Do you have to use the provider portal to submit authorization?
A. No, you can submit authorization requests by fax at 800-743-1655.

Q: How will approvals and denials be sent back to providers?
A. You can see determinations on the secure portal in real time (once this goes live), otherwise providers will receive a letter/fax with the determination.

Q: What's the turnaround time (TAT) for authorization decisions?
A. TAT is dependent on the receipt of all clinical information necessary to render a decision.

Q: Is an authorization needed to submit claims?
A. You do not need to add the authorization number on the claim/invoice, but you will need an approved authorization before you can bill for services. The authorization letter will provide you with information on what services have been approved to guide you with billing.

Q: Who is allowed to make a referral to CS?
A. All providers are able to refer a member to our contracted CS providers if they have deemed that the member qualifies for CS services. We highly encourage providers to use the CS authorization guides to determine if the member qualifies for CS services. Providers can refer members to CS by referring them through findhelp or sending the member information to contracted CS providers in our ECM/CS provider directory.

Members can also self-refer to CS services by calling the Member Services Department at Health Net: 800-675-6110 or CalViva Health: 888-893-1569.

Q: Will CS providers get referrals from medical providers or ECM providers through this system?
A. Referrals can come from any providers through findhelp.

Q: Will there be additional training for claims and billing through findhelp?
A. Billing guidance will be available on findhelp by the end of December 2022. Recorded Billing trainings are available online.

Q: Which medical providers will be using the system: Health Net, Molina, Aetna and Anthem?
A. As of January 1, 2022, findhelp is working with Health Net and Aetna to roll out the assessment function.

Q: Is there any particular order in which the ECM provider will see the list of available partners?
A. There is currently no specific order. All of the program cards will be categorized by CS services specific to county and ZIP Code.

Q: Are ECM providers the only entity that can start a referral?
A. No, the link to the findhelp portal is made available on our website and other providers can also access findhelp to start a referral.

Q: Are Medi-Cal members able to self-refer?
A. Yes, but not through findhelp at this time. Members can call the Member Services Department to self-refer for CalAIM services.

Q: Is there a suggested timeframe to accept a referral as a provider offering CS service?
A. It depends on the CS services. For example, for recuperative care and sobering center, there is a higher sense of urgency to respond. We will rely on our experienced CS providers to follow the best practice for turnaround time.

Q: Who is the best person to contact to get set up as a service provider?
A. General findhelp website. If your program is already listed on findhelp, there is a quick link on the program card that says "work here." Click on it to claim the service.

CalAIM findhelp function: As a CS provider, you will be added to the CalAIM function and categorized in specific CS services after you contract with our Health Plan.

Q: Can we refer to all Community Supports services through findhelp?
A. Our Health Plan opted into specific CS services on January 1, 2022. We are phasing in additional services every six months, which may vary by county.

Q: We already signed up through Health Net to provide support services. How do we get linked to findhelp to track referrals?
A. If you have finalized your contract, please contact findhelp directly and they can help you set up. If your contract has not been finalized yet, please be patient and wait until that has happened before contacting findhelp.

Q: What will be the data requirement as a care manager referring to ECM in the system?
A. Data requirements are different for ECM and CS. We are following DHCS guidance in terms of minimum data required. We will be working with our providers to identify additional data that will be helpful for program expansion.

Our contracted ECM providers will receive a monthly potential MIF from us and are expected to provide us back with a monthly outreach RTF.

Q: Who can use CalAIM findhelp website?
A. The CalAIM findhelp website is available to all providers and does not require a log in to access the network of contracted CalAIM CS providers.

Q: Will the Health Plan be monitoring the number of referrals to each provider to ensure there are no capacity issues or should each provider turn off access to their program once capacity has been met?
A. CS providers will have the ability to update their capacity in the findhelp platform.

Q: Can I submit claims through the provider portal?
A. Claims cannot be submitted through the provider portal at this time. For information on how to bill for ECM and CS services, please refer to our billing guidance page.

Q: What is the difference between the provider portal, Conduent and findhelp?
A.

  • The Provider Portal currently allows you to verify member eligibility, review authorization status and submit authorization for ECM and CS.
  • Conduent is for billing by invoice; if you are set up with a clearinghouse or submitting paper claims, you do not need to bill by invoice through Conduent.
  • Findhelp is a closed-loop referral system to help providers identify CS providers contracted with the Health Plan and refer members to them. See the findhelp FAQs section above for more information.

Q: We have registered and created an account for the provider portal, but are unable to access certain sections (e.g. authorization, medical information)?
A. Each organization can have at least one user with Account Management access to the provider portal that will allow them to control access for other members in the organization. Contact the Provider Services Center at Health Net: 800-675-6110 or CalViva Health: 888-893-1569 to identify the user with Account Management access in your organization if you do not know who it is or need to assign a user with that access.

Q: Is a member able to request a specific ECM or CS provider they want to be assigned to?
A. Yes, members can call the Member Services Department to switch provider assignment. If the member is new to ECM or CS at the point of the referral, it is the member's choice to select the provider they want to be referred to based on our contracted provider directory.

Q: How can we update the contact information listed for our organization in the provider directory?
A. You can contact your assigned point of contact or the Provider Services Center at
Health Net: 800-675-6110 or CalViva Health: 888-893-1569.

Q: Can CS providers submit multiple Housing Deposit claims for member reimbursement?
A. Providers can only submit reimbursement claims once. It is recommended that CS providers strategize to incorporate as many allowable expenses in the request as possible.

Q: What if a member does not use the full $5,000. Does that amount rollover?
A. Housing Deposits are available once in an individual's lifetime and a member can request and receive up to $5,000 in Housing Deposit assistance. Any remaining amount will no longer be available.

Q: Will reimbursements received by the CS provider count as revenue for the agency?
A. Housing Deposit reimbursements will be treated the same as other CS reimbursements and will follow all tax reporting requirements. CS providers are strongly encouraged to consult with a certified public accountant (CPA).

Q: Will CS providers be required to collect a W-9 form from a landlord or other vendors they pay for services on behalf of the member?
A. CS providers may need to collect W-9s from each vendor they provided payments to. CS providers are encouraged to consult with a CPA.

Q: Do Housing Deposits need to follow rent reasonableness requirements?
A. There is no rent reasonableness standard or fair market rent requirement for Housing Deposits. Housing choice should follow the member's tenancy preferences as a primary consideration when selecting a housing unit, to the fullest extent possible. Taking into consideration Housing Choice Voucher requirements, location, size, reasonable accommodations and affordability based on member's budget.

Q: Do CS providers need to conduct a housing quality inspection?
A. CS providers must take reasonable measures to confirm the prospective units are safe and habitable and submit documentation to that effect. However, housing inspections do not have to be completed by a housing and urban development (HUD)-certified inspector.

Q: What happens to the rental or utility security deposit if the member moves out?
A. The landlord/owner must return any security deposit amount collected (less any amounts the landlord may withhold under the terms of the lease and state and local law) directly to the member.

Q: Can a member access Housing Deposits a second time?
A. Housing Deposits can only be approved one additional time with documentation as to what conditions have changed to demonstrate why provided Housing Deposits would be more successful on the second attempt.

Data Collection

For Enhanced Care Management (ECM) members who you believe are ready for program completion of ECM, please complete the Enhanced Care Management Program Completion Questionnaire below. This questionnaire does not need to be submitted to the Plan. Please save the questionnaire to your files for audit purposes.

Enhanced Care Management Program Completion Questionnaire (PDF)
Enhanced Care Management Program Completion Questionnaire – CalViva Health (PDF)

Last Updated: 07/01/2022