26-999 ECM Billing Limits Take Effect October 15, 2026

Date: 08/11/26

Follow ECM billing requirements to help prevent claim denials

Beginning October 15, 2026, Enhanced Care Management (ECM) claims are subject to a monthly billing limit of 10 units per member, per calendar month. Claims exceeding 10 units will be denied.

Understand the new monthly billing limits

Prior authorization is not required for ECM services. To maintain streamlined access to care while supporting accurate billing, claims controls are being added.

These controls help ensure ECM providers bill only for covered services delivered to members.

• Most members require 3 to 5 units of ECM service per month.
• Providers may bill up to 10 units per member, per calendar month.
• For ECM services, 1 unit equals 1 hour.
• Standard Medicare rounding rules apply when billing ECM units.

What you need to do

1. Review ECM service delivery practices to ensure they align with ECM program requirements.
2. Bill only for covered ECM services and report units accurately, with 1 unit representing 1 hour of covered ECM service.
3. Apply standard Medicare rounding rules when billing units.
4. Maintain records supporting billed ECM services and retain documentation for audit requests.

Documentation required for appeals

If a claim exceeding the monthly billing limit is denied and you believe the services were covered and appropriately billed, submit an appeal through the provider dispute resolution process.

Include:

• Detailed evidence of the services provided.
• Documentation showing the time spent providing the services.
• Identification of the team member(s) who provided each service.

ECM billing codes subject to monthly limit

HCPCS code	Modifier
G9008	U1
G9008	U1, GQ
G9012	U2
G9012	U2, GQ
G9007	No modifier

 

Examples of billable and nonbillable ECM activities

The examples below are for reference only and are not all-inclusive.

Covered ECM services
Maintaining ongoing contact with members, caregivers and the care team. Completing assessments to identify clinical and non-clinical needs, including gaps in care. Creating, updating and maintaining a person-centered care management plan. Coordinating care across providers, care settings and community resources, including making and following up on referrals to help ensure services are received. Making referrals to medical, behavioral health, long-term services and supports, community-based services, and social drivers of health supports. Helping ensure members have and work with a primary care provider. Assisting members with appointment scheduling, reminders and access to covered services, including non-emergency medical transportation and interpretation services. Using care coordination strategies to help reduce avoidable hospital and emergency department use.
Non-covered ECM services
Physical transportation: Arranging or providing transportation services is not billable under ECM. Help members access available transportation benefits when needed. Housing navigation: Housing navigation services should be provided through appropriate housing support programs and are not separately billable under ECM. Medical care or prescribing medication: ECM is a care coordination program. Do not provide or bill medical services under ECM. Attendance at all medical appointments: Accompanying members to appointments is only appropriate when medically or clinically necessary and should not be provided as a routine chaperone, caretaker or translation service. Translation services: Providing interpretation or translation services is not billable under ECM. Help members access available interpretation services when needed.

 

Questions?

If you have questions, contact the Health Net Provider Services Center at 800-675-6110.

 

This information applies to Enhanced Care Management (ECM) Providers.

For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.