CurrentHealth NetPolicy N/A

Enhanced Care Management (ECM) Benefit Referral Form - ADULT

This document is an ECM referral form and guidance for referring adult Medi‑Cal members to determine eligibility for Enhanced Care Management and guide submission to the member's managed care plan (MCP). It affects referring providers, ECM providers, community partners, and MCP staff in North Carolina (NC).

Policy Summary

PayerHealth Net

PolicyEnhanced Care Management (ECM) Benefit Referral Form - ADULT

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed ECM Referral Form to member's MCP via provider portal or secure fax; MCP will make ECM authorization decision within five business days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysMCP authorization decision timeframe after submission

21+Adult population covered

800-743-1655Secure fax

833-236-4141Care Plan support phone

Eligibility and Populations of Focus

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Adult ECM Populations of Focus — criteria for age 21+ and DHCS POF indicators

ADULT (AGE 21 OR OLDER) ECM ELIGIBILITY CHECK — POPULATIONS OF FOCUS. If the member being referred is an adult (age 21 or older), review each Population of Focus below and indicate yes to all indicators that apply. Leave blank indicators that do not apply to the extent of your knowledge. Use Section 5 Additional Comments to note areas needing further MCP review. If uncertain about eligibility, contact the member's MCP. For ECM POF definitions, see the ECM Policy Guide.

Member is age 21 or older.

HOMELESSNESS: Member is experiencing homelessness (unhoused, in a shelter, losing housing within 30 days, exiting an institution to homelessness, or fleeing interpersonal violence) AND member has at least one complex physical, behavioral, or developmental health need (includes pregnancy or postpartum up to 12 months) for which the member would benefit from care coordination.

AVOIDABLE HOSPITAL OR EMERGENCY DEPARTMENT UTILIZATION: Over the last six months, member has had five or more emergency room visits that could have been avoided with appropriate care OR three or more unplanned hospital and/or short-term skilled nursing facility stays that could have been avoided with appropriate care OR is at risk for avoidable hospital/ED utilization and would benefit from ECM (provide details in Section 5).

SERIOUS MENTAL HEALTH/SUBSTANCE USE: Member meets eligibility for and/or is obtaining services through at least one of the following: Specialty Mental Health Services (SMHS) delivered by MHPs, Drug Medi-Cal Organization Delivery System (DMC-ODS), or Drug Medi-Cal (DMC) Program (diagnosis for Substance-Related and Addictive Disorder, excluding tobacco-related and non-substance-related disorders). AND member is actively experiencing at least one complex social factor (e.g., lack of food, unstable housing, inability to work, former foster youth, recent law enforcement contacts related to mental health/substance use). AND member meets one or more of: high risk for institutionalization/overdose/suicide; uses crisis services/ERs/urgent care/inpatient as primary care; pregnant or postpartum (up to 12 months).

JUSTICE INVOLVED: Member is transitioning from a correctional facility or transitioned within the past 12 months AND has a diagnosis of at least one of: mental illness, substance use disorder, chronic/significant non-chronic clinical condition, intellectual or developmental disability, traumatic brain injury, HIV/AIDS, or is pregnant/postpartum (up to 12 months).

NURSING FACILITY TRANSITION: Member is a nursing facility resident interested in moving out of the institution, is a likely candidate to move out successfully, is able to reside continuously in the community with wraparound supports, and is actively experiencing at least one complex social/environmental factor influencing health (e.g., needs assistance with ADLs, communication difficulties, food/housing insecurity, living alone, need for conservatorship, inadequate caregiving).

BIRTH EQUITY — PREGNANT AND POSTPARTUM: Member is pregnant or postpartum (through 12 months) AND is subject to racial and ethnic disparities as defined by California public health data on maternal morbidity and mortality (as of 2024 includes Black, American Indian or Alaska Native, and Pacific Islander members; prioritize member self-identification).

Enrollment in other programs — note coordination or exclusion when concurrent program enrollment exists.

ENROLLMENT IN OTHER PROGRAMS AND SERVICES — Indicate any other Medi‑Cal programs or services the member is receiving. Some Medi‑Cal services may require coordination with ECM; because other Medi‑Cal programs may offer similar support, members may be excluded from concurrent ECM enrollment. The Managed Care Plan (MCP) will review and determine ECM eligibility. The referring individual should provide known details and use Section 5 Additional Comments for coordination information.

If the member is enrolled in any other care management or coordination programs that may require coordination with ECM (to the extent known), list program(s) and provide details in Section 5 Additional Comments (examples include California Children’s Services, Targeted Care Management within Specialty Mental Health Services, etc.).

Programs to indicate (select all that apply when known): Dual Eligible Special Needs Plan (D‑SNP); Hospice; Fully Integrated Dual/Special Needs Plans (FIDE‑SNPs); Program for All‑Inclusive Care for the Elderly (PACE); Multipurpose Senior Services Program (MSSP); Self‑Determination Program for Individuals with I/DD; Assisted Living Waiver (ALW); California Community Transitions (CCT); Home and Community‑Based Alternatives (HCBA) Waiver; HIV/AIDS Waiver.

Operational note: The Managed Care Plan is responsible for the final determination of ECM eligibility — referring individuals should not make eligibility decisions. Leave blank any elements that do not apply to the extent of your knowledge.

Referral Submission and Documentation Requirements

Note

Referral submission and MCP decision timeframe — where to submit (portal or secure fax) and MCP will decide within 5 business days.

ECM referrals should be submitted to the Plan as follows: - ECM provider: Submit via the Plan's provider portal: provider.healthnetcalifornia.com or secure fax: 800-743-1655. - Community provider (non-ECM provider): Submit via secure fax: 800-743-1655. After submission, the MCP will make an ECM authorization decision within five business days. If the member is eligible, an ECM provider will reach out to the member to confirm interest and enroll them in services.

Submit completed ECM Referral Form to the member's MCP using the submission methods above.
MCP will decide on ECM authorization within 5 business days of receipt.
If eligible, an ECM provider will contact the member to confirm interest and enroll.

Documentation Required

Documentation limitations — MCP may not require additional documentation (supplemental checklists, ICD-10 codes, TAR forms) per DHCS policy.

Per DHCS policy, the MCP may not require any additional documentation (for example: supplemental checklists, ICD-10 codes, Treatment Authorization Request forms) beyond the completed ECM Referral Form to authorize ECM.

Do not attach or expect to be asked for supplemental checklists, ICD-10 coding lists, TAR forms, or other extra paperwork as a condition of ECM authorization.

Key Terms

Enhanced Care Management (ECM)

DefinitionEnhanced Care Management (ECM) is a statewide Medi‑Cal benefit available to eligible members with complex needs to provide care coordination and link members to services through assignment to an ECM provider by the member's MCP

Purpose of referral formCollect key member information so the managed health care plan (MCP) can confirm ECM eligibility and assign an ECM provider aligned to Populations of Focus

Submission routesECM provider submissions via MCP provider portal or secure fax (800-743-1655); community providers via secure fax (800-743-1655)

Populations of Focus (POF)

DefinitionPopulations of Focus (POF) are DHCS‑defined groups of members with specific complex clinical and social needs used to determine ECM eligibility (e.g., homelessness; avoidable hospital/ED utilization; serious mental health/substance use; justice‑involved; nursing facility transition; pregnant/postpartum),

Adult eligibility noteFor adults (age 21+), referring individuals should review each POF indicator and indicate Yes for all that apply; members may qualify under more than one POF

Examples of POFs (selection) Homelessness; Adults at risk for avoidable hospital or ED utilization; Serious mental health and/or substance use needs; Justice‑involved transitioning from incarceration; Nursing facility residents seeking community transition; Pregnant/postpartum individuals at risk for adverse perinatal outcomes

OpenPayer

Enhanced Care Management (ECM) Benefit Referral Form - ADULT

Eligibility and Populations of Focus

Coding and Utilization Thresholds

Referral Submission and Documentation Requirements

Key Terms