Data to Support ECM
Care Management Documentation System or Process
The Enhanced Care Management (ECM) provider must use a care management documentation system or process that supports the documentation and integration of physical, behavioral, social service, and administrative data and information from other entities – including the Plan, ECM, Community Supports and other county and community-based providers – to support the management, maintenance, and sharing of a member care plan that can be shared with other providers and organizations involved in each member’s care.
Care management documentation systems may include Certified Electronic Health Record Technology or other documentation tools that can support the documentation of:
Member’s enrollment into ECM.
- Member’s authorization/approval to release information to other providers in the care team and anyone involved in execution of the care plan.
- Member’s goals and goal attainment status as part of member care plan.
- Member’s care coordination and care management needs (e.g., allow for documenting closed looped referrals to ensure follow up with the member is tracked and completed).
- Information from other sources to identify member needs.
- The development and assignment of care team tasks.
- Care team coordination and communication.
- Member health status and transitions in care (e.g., discharges from a hospital, long-term care facility, housing status).
- Referrals to other providers and support persons.
- Screenings and assessments (e.g., Health Risk Assessment, Patient Health Questionnaire (PHQ)-9, etc.).
Care management documentation systems also need to be able to:
- Support the sharing of the member’s care plan amongst the member’s care team.
- Support the sharing of the member’s assessment, care plan and other required data to the Plan, as requested.
- Assist with informing the ECM provider’s regular reporting to the Plan, as requested.
- Support and track the ECM services provided to the member to enable ECM providers to appropriately submit claims[1] to the Plan.
A care management documentation system is not required to be a certified electronic health record technology, and it may include systems that are securely managed and hosted by third parties, including the Plan partners.
Provision of Data/Reports from the Plan to the ECM Provider
The Plan and the ECM provider will exchange data on members on a regular basis. The Plan will provide the following data to the ECM provider at the time of assignment and periodically thereafter, and following Department of Health Care Services (DHCS) guidance for data sharing where applicable:
- Member Information File (MIF), defined as a list of Medi-Cal members enrolled for ECM and assigned to the ECM provider (referred to as Targeted Engagement List).
- Encounter and/or claims data, including admission-discharge-transfer data feeds.
- Physical, behavioral, administrative and social determinants of health (SDOH) data for all assigned members.
- Reports of performance on quality measures and/or metrics, as requested.
Provision of Data/Reports from the ECM Provider to the Plan
ECM providers are responsible to submit and confirm receipt of required reports to the Plan. Required ECM provider reports include but are not limited to the following:
- Monthly ECM provider reporting
Return Transmission File (RTF)
- Outreach tracking file (OTF)
- Quarterly
- Staffing and capacity reports
Providers who are unable to consistently and accurately provide monthly data files will not be in good standing with the Plan. Ongoing lack of submission will be escalated, up to and including termination of the ECM contract.
Data and File Exchange Operations
On a monthly basis, ECM providers must retrieve the ECM MIF via secure file transfer protocol (SFTP) site that contains assigned ECM members that are eligible to receive ECM services, including both new and existing members.
On a monthly basis, ECM providers must complete the RTF and OTF to report back to the Plan via an SFTP file upload identifying the services provided and status of each ECM member assigned to their organization. Reporting requirements for ECM providers are defined by DHCS.
The Plan may also utilize the SFTP site to exchange other data files to support ECM provider service delivery (e.g., admission-discharge-transfer reports, capitation reports, etc.).
[1] DHCS has indicated that ECM providers may also submit invoices and/or an additional report or data to the Plan if they are unable to produce and submit ECM claims for submissions. DHCS has not yet identified the provider criteria that would qualify them to submit services via invoice or through the submission of minimum necessary data elements (i.e., not through claims or encounters submission).