Provider Certification
The purpose of the Enhanced Care Management (ECM) provider certification process is to certify organizations that are qualified to serve as an ECM provider. Certification is the process used by the Plan to evaluate and verify the potential ECM provider’s ability to comply with ECM requirements as outlined by Department of Health Care Services (DHCS), including the provision of ECM core services to the ECM Populations of Focus, and the ability to submit data files and claims.
To become an ECM provider, organizations must meet the criteria described in the DHCS CalAIM ECM guidance documents and submit a Provider Interest Form to the Plan. The Plan reviews all provider interest forms and invites select organizations to submit the ECM Provider Certification Application with accompanying documentation supportive of their application. Upon review, the Plan may approve providers to be contracted for ECM services, provide feedback on missing requirements within a prospective provider’s documentation, or decide not to move forward with providers who lack key qualifications to support the program.
Providers must have a pathway for community-based referrals to move forward in the application process. Although the Plan uses data to identify potentially eligible members, providers are expected to refer the majority of members in the Plan’s ECM program from the community. Providers should only apply to contract in counties where they have an established footprint and known name.
Providers will also be selected based on the Plan’s network needs. It is at the Plan’s discretion to extend providers’ contract requests, and these decisions are made to support a best-in-class and appropriately sized network that supports our members and sets up our providers for long-term success in the program.
Once a provider passes the initial documentation review, a live system walk through will be completed of the provider’s case management system and process that will be used for documenting all ECM activities. Key areas of focus for the Readiness and Gap Closure Plan are driven by the 12 required areas in the ECM Certification Application:
# | Area of Focus |
|---|---|
1 | Overview of ECM Structure |
2 | ECM Core Service Components: Outreach & Engagement |
3 | ECM Core Service Components: Comprehensive Assessment & Care Plan Management |
4 | ECM Core Service Components: Enhanced Coordination of Care |
5 | ECM Core Service Components: Health Promotion |
6 | ECM Core Service Components: Comprehensive Transitional Care |
7 | ECM Core Service Components: Member & Family Supports |
8 | ECM Core Service Components: Coordination & Referrals to Community & Social Support Services |
9 | ECM Provider Administration & Operations: Claims/Encounters |
10 | ECM Provider Administration & Operations: File Data Exchange |
11 | ECM Provider Administration & Operations: Staffing |
12 | ECM Provider Administration & Operations: Oversight & Monitoring |
If the prospective ECM provider is unable to fulfill the ECM requirements and/or determines the ECM provider will not be able to meet ECM requirements, the prospective ECM provider cannot be certified by the Plan and therefore will not be contracted with the Plan to provide ECM services under the ECM benefit. The Plan may request an on-site visit with the prospective ECM provider during the certification process and/or program administration period.1 On-site visits will be subject to the standard public health protocols and may need to occur virtually.
If you have not completed your Medi-Cal provider enrollment, do not submit a Provider Interest Form. After you receive your Medi-Cal approval, submit the Provider Interest Form and indicate your Medi-Cal approval status.
1 On-site visits will be subject to the standard public health protocols and may need to occur virtually.