Methods to Identify Potentially Eligible Members
Enhanced Care Management (ECM) providers are responsible for driving member identification and ECM enrollment primarily through community-based referrals. As such, the primary mechanism for member identification should be referrals from the community. ECM providers are responsible for informing members and their families, guardians and caregivers, Community Supports providers, other providers, and Community-Based Organizations, about ECM, the ECM Populations of Focus, and the process to request ECM. ECM providers are to consider requests for ECM from members and on behalf of members, from all entities described above. In addition, members may be identified as potentially eligible for the ECM benefit using multiple methods including:
- ECM member information file (MIF) is a list of all members who are assigned to each provider. This includes enrolled members, members reported to be currently in outreach and new potentially eligible members provided by the Plan to ECM providers on a regular basis.
- ECM provider referrals should be made to the Plan for members identified in the community who are not on the providers MIF. The ECM provider is encouraged to identify members who would benefit from ECM through any programs where they have direct contact with members. After the ECM provider identifies a member and validates eligibility with the Plan, the ECM provider needs to complete and send an ECM member referral to the Plan. Instructions on how to submit member referral are listed on the ECM referral form. All ECM member referrals will be reviewed for eligibility and validation that member is not already actively working with an ECM provider. Upon approval from the Plan, members will be added to the ECM MIF file and other files communicated through secure file transfer protocol (SFTP).
- ECM community referrals are eligible members who have been directly referred to ECM by non-contracted providers, community partners which include but are not limited to primary care physicians (PCPs), hospitals/inpatient facilities, shelters, recuperative care providers, correctional facilities, Community Support providers, Community-Based Organizations, members’ families, and other referral sources from the community.
- Member self-referrals to an ECM provider or the Plan due to the member receiving information about the ECM benefit through member-informing materials.
The Plan may request supporting documentation from referring entities (e.g., ECM and non-ECM providers, members, other organizations) to assist in the eligibility determination for members who are identified as potentially eligible for ECM. the Plan will ask referring entities to complete and submit a referral form to the Plan. The Plan will provide the ECM referral form to ECM providers, community partners, and other relevant service providers to complete and submit to the Plan.
Member Assignment to ECM Providers
The Plan is responsible for communicating new member assignments to the ECM provider as soon as possible, but no later than 10 business days after the member is assigned to an ECM provider.
The Plan conducts data mining and risk stratification of members to assign members to ECM providers and will distribute lists of the eligible members to the ECM provider.
The ECM provider is responsible to immediately accept all members assigned by the Plan for ECM, with the exception that if the ECM provider is at its pre-determined capacity, an ECM provider is allowed to decline a member assignment. If an ECM provider is at capacity, the ECM provider must notify the Plan if it does not have the capacity to accept a member assignment as timely as possible, so they may be referred to another provider.
ECM Eligibility Referral Process
Members, providers (ECM providers and non-ECM providers), Community-Based Organizations and the Plan are encouraged to refer members identified as potentially eligible for the ECM benefit. Providers may see members that are not listed on the ECM MIF distributed to each ECM provider from the Plan, which is an opportunity to connect a member to the ECM program prior to identification through plan data.
ECM Provider Initiated Eligibility Referral
If an ECM provider identifies a potentially eligible member, the ECM provider should complete the ECM referral form. This form will validate the member meets requirements to enroll in the program. The provider must also speak with the member to confirm consent to enroll in the program and then submit the completed referral form to the Plan.
The Plan has a variety of methods to receive the referral information, however the preferred method for the referrals is through the provider portal for ease to allow the provider access to real time status updates.
Once the referral form is received and reviewed, the Plan may follow up with the ECM provider to request supporting documentation and/or evidence to facilitate making an eligibility determination. Once the Plan makes a final ECM eligibility determination for the member, the Plan will notify the ECM provider. If the member is found to be ineligible and denied for ECM, the member will receive a notice of action from the Plan.
If enrolled, the ECM provider will notify us of member enrollment status in the monthly RTF.
Member Initiated Eligibility Referral
Members may self-refer into the ECM benefit: (1) by contacting the Plan’s Member Services Department, (2) with ECM provider assistance or (3) through the Findhelp platform. ECM providers must assist any member who expresses interest in enrolling in the ECM benefit and complete a referral form on their behalf if the ECM provider determines the member may be potentially eligible for participation in the ECM benefit.
ECM providers are required to notify the Plan of any members who express interest in enrolling in the ECM program. This includes members who may not be eligible for ECM, as well as those whom the provider does not have the capacity to support.
ECM Community Initiated Eligibility Referrals
Any member of the community may refer members into ECM benefit by: (1) contacting the Plan’s Member Services Department (2) with ECM provider assistance, (3) through the Findhelp platform or (4) by contacting an ECM provider directly to refer the member. Community referrals received by the Plan will be processed and the Plan will disseminate information about member assignment to the designated ECM provider. Upon notification of an assigned member, the ECM provider is responsible for assigning the member to an ECM Lead Care Manager to begin outreach and engagement within 72 hours.
Members who contact the Plan’s case management for any services may also be screened for ECM eligibility. If the case management team refers a member directly to a provider, that member should be prioritized for outreach since they have recently had interaction with the Plan and requested assistance.
Communication with Referring Entity
The Plan will communicate the status of the referral to the referring entity as required by the Department of Health Care Services (DHCS).