Asthma Preventative Services Benefit and Asthma Remediation Community Support 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)

Asthma preventive services must be recommended by a physician or other licensed practitioner of the healing arts within their scope of practice under state law to initiate services. The provider order must be maintained by the organization delivering the Asthma Preventive Services and provided to Health Net upon request.

Asthma Self-Management Education

• All members with an Asthma diagnosis can receive Asthma self-management education.

In-Home Environmental Trigger Assessment

In order to receive an "in-home environmental trigger assessment", beneficiaries must meet the criteria for have a current diagnosis of poorly controlled asthma, or a recommendation from a licensed physician, nurse practitioner (NP), or physician assistant (PA).

Asthma prevention services which includes both the asthma education and the in-home trigger assessment may be provided by licensed providers such as Physicians, NP's and PA's. These services may also be provided by unlicensed providers such as community health workers (CHW), promotores, or community health representatives who meet the qualifications of an asthma preventive service provider as stated in the Medi-Cal Provider Manual: Asthma Preventive Services (PDF).

Asthma Preventive Services Authorization Forms for units beyond the maximum

Asthma education limit: there is a maximum frequency is four units (two hours) daily per member, any provider, up to two times a year. Additional visits may be provided with an approved Asthma Preventive Services Authorization Request form for medical necessity.

Asthma environmental trigger assessment limit: Two visits per year; additional visits require authorization request demonstrating medical necessity for additional visits and/or when there has been a change of primary residence Use the Asthma Preventive Services Authorization Request Form for additional visit requests.

If the Asthma Preventative Services Provider and Asthma Remediation Provider are the same organization:

• Confirm Member Eligibility: It is important to verify that the member is still active and enrolled in the Medi-Cal Plan. Confirm member eligibility for the month of service (go to step 1).
• Request Authorization (Form Required): Asthma Remediation providers must submit a previously completed in-home environmental trigger assessment under the Asthma Preventative Services Benefit with the Asthma Remediation Referral Form for prior authorization. See referral forms for prior authorization under “Forms and Tools” on the CalAIM Provider resource page.
• Note: An in-home trigger assessment must be conducted within the last 12 months, assuming no change in the Member's residence. This can only be billed under the Asthma Preventive Services Benefit.

If the Asthma Preventative Services Provider and Asthma Remediation Provider are not the same organization: The Asthma Preventative Service provider can use findhelp or Find A Provider to find an Asthma Remediation provider to submit a referral to connect the member to Asthma Remediation Services provider.

findhelp

• 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)

Find a Provider

• Health Net – Find a Provider
• CalViva Health – Find a Provider
• Community Health Plan of Imperial Valley – Directory of Health Care Providers

See authorization guide under Forms and Tools for eligible services.

Billing

Contracted Providers can bill for either Asthma Preventative services or Asthma Remediation 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) (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 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 services, refer to Claims and Invoice for Providers training > Required Onboard Trainings