Enhanced Care Management (ECM) and Community Supports (CS) Provider FAQs

The documentation guidance for the JI PoF is the same as the other ECM PoFs. Providers are expected to address the seven core service components as outlined in the ECM Policy Guide.

It is possible, but not ideal. Telehealth should be used sparingly as necessary, not as a foundation.

Managed care plans (MCPs) already offer telephonic case management support. ECM is intended to be interdisciplinary, high-touch and person-centered. It should be provided primarily through in-person interactions where members live, seek care and prefer to access services, as outlined in the ECM Policy Guide.

Central California Alliance for Health (the Alliance) sends a monthly email to providers providing capitated services with details regarding members without claims. This email tells you to check your SFTP folder, where you will find a folder named “Enrolled Members without Claims.”

This folder includes a spreadsheet that lists:

• Members enrolled to receive services.
• Provider who have received payment for those members in that month.

By the time you see the spreadsheet, you may have disenrolled the member. However, this spreadsheet is a valuable resource to assist with double checking your records on claims and activity.

For example, you may have submitted a claim that was denied, prompting you to investigate. When you submit a claim, it signals to the Alliance that you are working with the member.

You can check the spreadsheet at any time. You don’t need to wait for an email.

If you are using the Provider Portal, enter 9001 (CCAH) in the servicing provider section. This signals that you will not be the servicing provider, and that the member should be assigned to another ECM provider.

You can also leave a note on the Treatment Authorization Request (TAR) form or the referral forms stating: “We are unable to provide ECM services to this person. This person is interested in receiving services and would be better placed with another provider who addresses the appropriate Population of Focus.”

You don’t need to do anything! Those members will automatically be cycled back in and reassigned if you have not submitted a claim or authorization request.

We encourage you to thoroughly consider how you are screening your eligibility list. That being said, there are many overlaps with PoFs. The member may meet eligibility for a PoF you are serving, in addition to other PoFs.

Because the list is tailored by ECM provider and PoF, please ensure to update any changes to your list parameters. You can send these changes via email to [email protected].

The Alliance makes an effort to give ECM providers about a month to conduct outreach. This timing is important because if you have not reached out to a member and submitted an authorization request by the next cycle, those members will be reassigned and appear on someone else’s eligibility list the next month.

The lists include members who are eligible to receive services and have not been outreached to in the past six months. The lists are added to the SFTP folders on the 10th of the month (assuming it doesn’t fall on a weekend or holiday).

Note that member eligibility is month by month. For example, if you receive your list in October and make an outreach attempt on November 5, make sure you check whether the member is eligible, as they may no longer be eligible at the start of November. You also may find the authorization voided because another provider conducted outreach to the member in a different month.

If a provider receives ECM02 without an approved ECM01 (outreach) authorization, that is because another provider has already conducted outreach. The team will usually reach out via email to explain the situation to the providers.

There is no one number that fits all ECM models. Most reported caseloads range from 20 to 50 members per care manager.
The factors that impact caseload numbers include but are not limited to:

Support

Caseloads may vary depending on whether the care manager has support, such as administrative staff or community health workers. Some of our organizations have caseloads per care manager ranging from 30 to 40, including a community health worker (CHW). Others have a team-based approach allowing a caseload of 40-50, with three to four individuals working with members at different times.

Type of Care Management Delivery

If providing a high percentage of care management through in-person interactions, caseloads may need to be lower. DHCS’s expectations are that ECM is interdisciplinary, high-touch and person-centered. Services should be provided primarily through in-person interactions with members where they live, seek care and prefer to access services, as outlined in the ECM Policy Guide.

Member Acuity

Member acuity, which is assessable and assigned through various methods or check-ins ranging from one to 15 per month, should be considered. One organization in PATH Collaborative determines caseloads of 20-25.
For instance, one member may require a weekly call, while others may need multiple in-person visits monthly. Acuity is subject to change. For example, if housing issues contribute to high acuity, then securing housing can lower it.

Expertise and Experience

ECM providers in Santa Cruz County frequently determine caseloads based on the expertise (or strength) and experience of the care manager and other care team members.