CurrentmhnPolicy N/A

Enhanced Care Management (ECM) Benefit Referral Form - ADULT

A referral form and instructions for submitting Adult ECM referrals so the managed care plan can determine Medi‑Cal member eligibility and assign an ECM provider; applies to referring organizations, ECM providers, community partners, and MCPs in California.

Policy Summary

Payermhn

PolicyEnhanced Care Management (ECM) Benefit Referral Form - ADULT

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed ECM Referral Form to the member's MCP via the MCP provider portal or secure fax so the MCP can determine eligibility and assign an ECM provider.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Sections 1-6Required form sections to complete

5 business daysMCP decision timeframe

21+Applies to age

Not requiredNo supplemental docs

Portal / FaxSubmission methods

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Adult Populations of Focus Eligibility

Adult ECM eligibility requires meeting DHCS criteria for at least one Population of Focus; referring provider should check applicable indicators and provide details in Section 5 as needed.

Homelessness (POF)

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

Avoidable Hospital/ED Utilization (POF)

Over the last six months, the member has had five or more emergency room visits that could have been avoided with appropriate care
Over the last six months, the member has had three or more unplanned hospital and/or short-term skilled nursing facility stays that could have been avoided with appropriate care
Member is at risk for avoidable hospital or emergency room (ED) utilization and would benefit from ECM but may not meet numeric thresholds (provide details in Section 5)

Serious Mental Health/Substance Use (POF)

Member meets eligibility for and/or is obtaining services through at least one: Specialty Mental Health Services (SMHS) delivered by MHPs, Drug Medi‑Cal Organization Delivery System (DMC‑ODS), or Drug Medi‑Cal (DMC) with relevant substance‑related diagnoses (excluding tobacco and non‑substance disorders)
Member is actively experiencing at least one complex social factor influencing health (e.g., lack of food, unstable housing, inability to work or engage in community, former foster youth, recent law enforcement contacts related to mental health or substance use)
Meets one or more: high risk for institutionalization/overdose/suicide; uses crisis services/ER/inpatient as primary source of care; 2+ ER visits or 2+ hospitalizations due to SMI or SUD in past 12 months; pregnant or post‑partum up to 12 months

Justice Involved (POF)

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

Long Term Care (LTC) Institutionalization Risk (POF)

Living in the community and meets Skilled Nursing Facility (SNF) level of care criteria OR requires lower‑acuity skilled nursing (time‑limited/intermittent medical and nursing services/support/equipment)
Member is actively experiencing at least one complex social or environmental factor influencing health (e.g., assistance with ADLs, communication difficulties, food or housing access, living alone, need for conservatorship, inadequate caregiving)
Member is able to reside continuously in the community with wraparound supports

Nursing Residents Transitioning to Community (POF)

Member is a nursing facility resident who is interested in moving out of the institution
Member is a likely candidate to move out of the institution successfully
Member is able to reside continuously in the community

Birth Equity (POF)

Member is pregnant or postpartum (through 12 months)
Member is subject to racial/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)

Coordination and Potential Exclusions

Enrollment in other Medi‑Cal programs may require coordination with ECM or may exclude simultaneous ECM enrollment; the Managed Care Plan will review and determine eligibility.

Other Programs and Services

Dual Eligible Special Needs Plan (D‑SNP)
Hospice
Fully Integrated Dual Eligible (FIDE‑SNP)
Program of All‑Inclusive Care for the Elderly (PACE)
Multipurpose Senior Services Program (MSSP)

Coding, Utilization Thresholds, and Related Metrics

No codes requiredmixed

No codes listed

Avoidable utilization numeric thresholds

ED visits (6-month lookback)5 or more emergency department visits in the past 6 months that could have been avoided with appropriate care

Unplanned hospital/SNF stays (6-month lookback)3 or more unplanned hospital and/or short-term skilled nursing facility stays in the past 6 months that could have been avoided with appropriate care

At‑risk exception (clinical discretion)Members who are at risk for avoidable hospital or ED utilization and would benefit from ECM may qualify even if they do not meet the numeric thresholds; provide details in Section 5

SUD/Mental health utilization threshold

ER visits or hospitalizations (12-month lookback)2 or more emergency room visits or 2 or more hospitalizations due to Serious Mental Illness or Substance Use Disorder in the past 12 months

SMHS / DMC eligibilityMember meets eligibility for or is obtaining services through Specialty Mental Health Services (SMHS) or Drug Medi‑Cal (DMC/DMC‑ODS) programs (excluding tobacco/non‑substance disorders)

Additional risk criteriaMember is actively experiencing at least one complex social factor and meets one or more high‑risk indicators (e.g., high risk for institutionalization/overdose/suicide; uses crisis services/ER/inpatient as primary care; pregnant/post‑partum up to 12 months)

Referral Submission and Authorization

Prior Authorization

Submission and Authorization Timeline

Submit the completed ECM Referral Form to the member's managed care plan (MCP) using the MCP submission method: ECM providers via the Plan provider portal (provider.healthnetcalifornia.com) or secure fax 800-743-1655; community (non-ECM) providers via secure fax 800-743-1655. After submission, the MCP will make an ECM authorization decision within five business days. If the member is determined eligible, an ECM provider will contact the member to confirm interest and enroll them in services.

ECM provider: provider.healthnetcalifornia.com or secure fax 800-743-1655
Community (non-ECM) provider: secure fax 800-743-1655
MCP decision timeframe: within 5 business days of submission

Documentation Required

No Additional Documentation Required

Per DHCS policy, the MCP may not require any additional documentation to authorize ECM. Do not submit supplemental checklists, ICD-10 codes, Treatment Authorization Request (TAR) forms, or other supporting documents unless specifically requested by the MCP.

Do not provide supplemental checklists, ICD-10 codes, TAR forms, or other ancillary documents unless requested
Complete sections 1–6 of the ECM Referral Form; contact the MCP at 833-236-4141 for assistance if you cannot complete a required section

Key Terms

Population(s) of Focus (POF)

DefinitionPopulation(s) of Focus (POF): Defined groups of Medi‑Cal members with complex needs for whom ECM is intended; members must meet DHCS eligibility criteria for at least one POF to receive ECM

Adult POFs includedExamples of adult POFs include Homelessness; Avoidable Hospital/ED Utilization; Serious Mental Health/Substance Use; Justice Involved; Long‑term Care Institutionalization Risk; Nursing Residents Transitioning to Community; Birth Equity

Form requirementReferring providers must review and complete applicable POF indicators on the Adult ECM Referral Form (Sections 1–6) and provide details in Section 5 as needed

Expedited — definition

Expedited request — when to useAn Expedited request is used when the provider indicates, or the MCP determines, that the standard request timeframe may seriously jeopardize the member's life, health, or ability to attain, maintain, or regain maximum function in accordance with APL 21-011

Selection on formType of Referral field on the ECM Referral Form includes an option to indicate Expedited versus Routine

ImplicationExpedited classification triggers accelerated review consistent with MCP procedures and applicable APL guidance

OpenPayer

Enhanced Care Management (ECM) Benefit Referral Form - ADULT

Eligibility and Enrollment Criteria

Coding, Utilization Thresholds, and Related Metrics

Referral Submission and Authorization

Key Terms