Santa Clara Family Health Plan Enhanced Care Management User Guide
- June 3, 2024
- Santa Clara Family Health Plan
Table of Contents
Santa Clara Family Health Plan Enhanced Care Management
ECM Billing Guide Overview
The purpose of this guide is to describe Santa Clara Family Health Plan’s (SCFHP’s) expectation regarding billing for Enhanced Care Management (ECM) by community based Providers contracted for ECM services. As required by the Department of Health Care Services (DHCS), SCFHP and all contracted ECM Providers are expected to administer program services starting on January 1, 2022 for members with qualify and/or enroll under one of the ECM Populations of Focus (POF):
- Individuals and Families Experiencing Homelessness
- Adult High Utilizers
- Adult Serious Mental Illness and Substance Use Disorder
- Individuals Transitioning from Incarceration
- Adults Living in the Community who Are at Risk for Long-Term Care (LTC) Institutionalization
- Nursing Facility Residents Transitioning to the Community
- Children and Youth
ECM Submission Topics Included in this Guide
- SCFHP Billing and Payment
- DHCS Approved Encounter Code Table for ECM
- Member Tiering and Payments
- Z-Codes
- Invoicing for Services and Outreach
- Viewing Claim Status and Retrieving Remittance Advice
SCFHP Billing and Payment
Billing
- A. Claim Submission
- a. For each ECM services performed, the CB-CME will submit an 837 Professional (837P) claim. The 837P is the standard format used by health care professionals and suppliers to transmit health care claims electronically.
- b. Claims are to be submitted through a clearinghouse that has a contractual relationship with SCFHP (Change HealthCare and OfficeAlly) using payor ID 24077.
- B. Minimum Required Fields for the 837P claim:
- a. Member Identification Information: Name, Date of Birth (DOB), Medi-Cal Client Identification Number (CIN), etc.
- b. Rendering Provider1
- c. Billing Provider
- d. Dx2
- e. Date of Service (DOS)
- f. Place of Service (POS)
- g. Procedure Code
- i. G9008 or G9012
- ii. Modifier
- a. Refer to billing table 1.1 under section “Payment”
- b. Each claim should have one service modifier and one population modifiers
- iii. Units
- a. 1 unit of service is 15 minutes 3
- iv. Location4
Payment
- C. For service modifiers U1 and U2 with or without GQ, assigned Providers are paid on the first claim submitted for that service month, then $0 for following claims submitted on the same month for that enrolled member. Providers are required to bill for all services provided for each month, even for services provided that are paid $0
- a. For ECM billed services for enrolled members, the provider must submit on HCPC code (G9008, G9012), with one service modifier (U1, U1-GQ, U2, U2-GQ) and one population modifier (O1, O2, O3, O4)
- D. For outreach modifier U8 with or without GQ, assigned Providers are paid on the first two claims submitted for that service month, then $0 for the following claims submitted on the same month for that eligible (not enrolled) member
- a. For ECM outreach, the Provider must submit one HCPC code (G9008, G9012), with one outreach modifier (U8, U8-GQ) and one population modifier (OA, OB)
- b. Number of outreach attempts should follow according to the member’s tier and billed as such for frequency
- E. Providers who are submitting multiple claims for the same member and for the same service month, should bill all claims that do not qualify for payments with the payment amount of $0 or bill the same amount as the payable claims.
- F. Members reassigned from one Provider to another Provider should begin services the month the member is reflected on the Provider’s member information file (MIF)
- a. Two Providers cannot bill for the same member within the same month
- G. Retro submissions (additions and/or deletions) are allowed up to 12 months
Billing Table 1.1
HCPCS
Level II Code
| HCPCS Description| Modifiers| Modifier Description
G9008| ECM In-Person: Provided by Clinical Staff. Coordinated care fee,
physician coordinated care oversight services.| U1| Used by Managed Care with
HCPCS code G9008 to indicate Enhanced Care Management services
G9008| ECM Phone/Telehealth: Provided by Clinical Staff. Coordinated
care fee, physician coordinated care oversight services.| U1, GQ| Used by
Managed Care with HCPCS code G9008 to indicate Enhanced Care Management
services.
G9008| ECM Outreach In Person: Provided by Clinical Staff. Other
specified case management service not elsewhere classified.| U8| Used by
Managed Care with HCPCS code G9008 to indicate a single in- person Enhanced
Care Management outreach attempt for an individual member, for the purpose of
initiation into Enhanced Care Management.
G9008| ECM Outreach Telephonic/Electronic: Provided by Clinical Staff.
Other specified case management service not elsewhere classified.| U8, GQ|
Used by Managed Care with HCPCS code G9008 to indicate a single
telephonic/electronic Enhanced Care Management outreach attempt for an
individual member, for the purpose of initiation into Enhanced Care
Management.
Telephonic/electronic methods can include text messaging or secure email individualized to the Member. However, mass communications (e.g., mass mailings, distribution emails, and text messages) do not count as outreach and should not be included.
G9012| ECM In-Person: Provided by Non- Clinical Staff. Other specified
case management service not elsewhere classified.| U2| Used by Managed Care
with HCPCS code G9012 to indicate Enhanced Care Management services
G9012| ECM Phone/Telehealth: Provided by Non-Clinical Staff. Other
specified case management service not elsewhere classified.| U2, GQ| Used by
Managed Care with HCPCS code G9012 to indicate Enhanced Care Management
services.
---|---|---|---
G9012| ECM Outreach In Person: Provided by Non-Clinical Staff. Other
specified case management service not elsewhere classified.| U8| Used by
Managed Care with HCPCS code G9012 to indicate a single in – person Enhanced
Care Management outreach attempt for an individual member, for the purpose of
initiation into Enhanced Care Management.
G9012| ECM Outreach Telephonic/Electronic: Provided by Non-Clinical
Staff. Other specified case management service not elsewhere classified.| U8,
GQ| Used by Managed Care with HCPCS code G9012 to indicate a single
telephonic/electronic Enhanced Care Management outreach attempt for an
individual member, for the purpose of initiation into Enhanced Care
Management.
Telephonic/electronic methods can include text messaging or secure email individualized to the Member. However, mass communications (e.g., mass mailings, distribution emails, and text messages) do not count as outreach and should not be included.
Additional Modifiers for Populations
HCPC
Level II Code
| Population Modifiers5| Modifier Description
G9008, G9012
| O1| Monthly touch-In for WPC/HHP SNF, Homeless, and SMI
O2| Monthly touch-in for WPC/HHP High Utilizers, Incarcerated, LTC, Children
O3| Monthly touch-in for newly eligible ECM members for SNF, Homeless, and SMI
O4| Monthly touch-in for newly eligible ECM members for High Utilizers,
Incarcerated, LTC, and Children
| OA| Non-enrolled outreach for newly eligible Homeless, SMI, and SNF
---|---|---
OB| Non-enrolled outreach for newly eligible High Utilizer, Incarcerated, LTC,
and Children
HCPCS Codes and Modifiers Combinations for ECM Services
Reimbursement POF| Acceptable HCPC Codes| Acceptable Modifiers
for Service| Modifier for POF
WPC/HHP SNF| · G9008
· G9012
| · U1
· U1, GQ
· U2
· U2, GQ
|
O1
WPC/HHP Homeless
WPC/HHP SMI
WPC/HHP High Utilizers| · G9008
· G9012
| · U1
· U1, GQ
· U2
· U2, GQ
|
O2
WPC/HHP Incarceration
WPC/HHP LTC
WPC/HHP Children
Non WPC/HHP SNF| · G9008
· G9012
| · U1
· U1, GQ
· U2
· U2, GQ
|
O3
Non WPC/HHP Homeless
Non WPC/HHP SMI
Non WPC/HHP High Utilizers| · G9008
· G9012
| · U1
· U1, GQ
· U2
· U2, GQ
|
O4
Non WPC/HHP Incarceration
Non WPC/HHP LTC
Non WPC/HHP Children
HCPCS Codes and Modifiers Combinations for ECM Outreach
Reimbursement POF| Acceptable HCPC Codes| Acceptable Modifiers
for Service| Modifier for POF
Non WPC/HHP SNF| · G9008
· G9012
| · U8
· U8, GQ
· U8
· U8, GQ
|
OA
Non WPC/HHP Homeless
Non WPC/HHP SMI
Non WPC/HHP High Utilizers| · G9008
· G9012
| · U8
· U8, GQ
· U8
· U8, GQ
|
OB
Non WPC/HHP Incarceration
Non WPC/HHP LTC
Non WPC/HHP Children
Member Tiering and Payments
Overview
Member tiering (risk grouping) allows for members with higher acuity levels to
receive more intensive ECM services. To ensure ECM Providers are providing
services and billing appropriately in accordance with a member’s tier, SCFHP
will monitor claim submissions. During this process, SCFHP will be looking to
see that each ECM Provider submits claims for eligible, enrolled members for
appropriate services and eligible, assigned members for appropriate outreach.
Each ECM Provider should submit claims for services provided to eligible
members on a timely basis – recommendation is within 30 days of service.
SCFHP will assign a preliminary tier to all ECM members the first month the
member qualifies for ECM. This is reflected on the MIF. After receiving and
reviewing the MIF, Providers are required to reassess the member’s tier to
ensure the member’s needs meets the level of service determined by their tier.
If the member’s tier should be change to reflect a more appropriate tier, the
ECM Provider will report this through inbound transmission file.
Defining Outreach
- A. In-person: Outreach completed in the community to locate the member and/or meet the member where they are the most comfortable in the community
- B. Telephonic:
- a. Outreach completed over the phone. The member answered and the conversation lasted at least for seven minutes, explaining the program and addressing the member’s needs.
- b. Outreach completed over the phone. Member did not answer but Provider attempted at least one additional attempts on the same day and/or sought out an alternative phone number from member’s PCP.
- C. Mail and Email: Outreach completed by mail or email. Provider completed outreach by mail or email for a specific member. Mail cannot be mass mailing or email. Letter should address and identify the purpose of the program, the member’s assigned care manager, and contact information.
Tier Requirements for Outreach for ECM
The ECM Provider are required to follow SCFHP’s tiering criteria and provide
the appropriate levels of outreach. Billing for outreach should follow the
member’s tier:
-
A. Tier 1 (highest acuity):
-
a. Members will receive at least two outreach attempt per month in-person or through other lines of communications outlined under, “Defining Outreach” in the first three month the Member is eligible for ECM services. This includes:
-
i. The ECM Provider must connect with one of the member’s health providers (primary care, behavioral health, housing provider, etc.) to assist in locating the member.
ii. At least one outreach attempt must be done by mail notifying the member of their outreach efforts. -
b. Three months after their initial eligibility, the ECM Provider continues to conduct additional outreach attempts at least once per month
-
i. Outreach will continue until Member no longer qualifies or has declined services.
-
-
B. Tier 2 (middle acuity): Members will receive at least one outreach per month attempt by phone or in-person the first four months the Member is eligible for ECM
- a. Members will receive at least one outreach attempt per month in-person or through other lines of communications outlined under, “Defining Outreach” in the first four months the Member is eligible for ECM services. This includes:
- i. The ECM Provider must connect with one of the member’s health providers (primary care, behavioral health, housing provider, etc.) to assist in locating the member.
- ii. At least one outreach attempt must be done by mail notifying the member of their outreach efforts.
- b. Four months after their initial eligibility, ECM Providers continues to conduct additional outreach attempts at least once every other month either by phone, in-person, or by mail.
c. Outreach will continue until Member no longer qualifies or has declined services.
-
C. Tier 3 (lowest acuity): Members will receive at least one outreach attempt every other month by phone or in-person the first six months the Member is eligible for ECM.
- a. In the first four months of the member’s initial eligibility, at least one attempt to contact the member’s Provider to locate the member is required:
- i. At least one outreach attempt by mail notifying the member of their outreach efforts
- b. Six months after their initial eligibility, the ECM Provider continues to conduct additional outreach attempts at least once every quarter by phone, in-person, or by mail
- i. Outreach will continue until Member no longer qualifies or has declined services
Tier Requirements for Monthly Case Management Service
Once the member consents to enroll into ECM, the ECM Provider will begin
providing monthly ECM services under one of the core services:
- Comprehensive Assessment and Care Management Plan
- Enhanced Coordination of Care
- Health Promotion
- Comprehensive Transitional Care
- Member and Family Supports
- Coordination of and Referral to Community and Social Support Services
To ensure appropriate levels of care are being provided to the member, the ECM Provider is required to follow SCFHP’s tiering criteria:
- Tier 1: Requires two in-person visits per month in addition to other ECM services
- Tier 2: Requires one in-person visit per month in addition to other ECM services
- Tier 3: Requires one in-person or telehealth visit per month in addition to other ECM services
- Members in tier 3 are ready to “graduate”6 from ECM services
Utilizing Z-Codes
In accordance with All Plan Letter 21-009, DHCS prioritizes the submission and
tracking of Priority Social Determinants of Health (SDOH) Codes. DHCS has
issued a list of 18 DHCS Priority SDOH Codes, based on the International
Classification of Diseases, Tenth Revision, Clinical Modification
(ICD-10-CM), for managed care plans and providers to utilize when coding for
SDOH to ensure correct coding and capture of reliable data. The DHCS Priority
SDOH Codes were chosen based on an assessment of existing managed care plan
code utilization and by determining what may have the greatest impact on
identifying and addressing SDOH. In partnership with DHCS, SCFHP expects
contracted ECM Providers to use DHCS Priority SDOH Codes and incorporate in
ECM billing, when applicable to the member.
| DHCS Priority Social Determinants of Health Codes
---|---
Z55.0| Illiteracy and low-level literacy
Z59.00| Homelessness unspecified
Z59.01| Sheltered homelessness
Z59.02| Unsheltered homelessness
Z59.1| Inadequate housing (lack of heating/space, unsatisfactory
surroundings)
Z59.3| Problems related to living in residential institution
Z59.41| Food insecurity
Z59.48| Other specified lack of adequate food
Z59.7| Insufficient social insurance and welfare support
Z59.8| Other problems related to housing and economic circumstances
(foreclosure, isolated dwelling, problems with creditors)
Z59.811| Housing instability, housed with risk of homelessness
Z59.812| Housing instability, homelessness in past 12 months
Z59.819| Housing instability, unspecified
Z60.2| Problems related to living alone
Z60.4| Social exclusion and rejection (physical appearance, illness or
behavior)
Z62.819| Personal history of unspecified abuse in childhood
Z63.0| Problems in relationship with spouse or partner
Z63.4| Disappearance & death of family member (assumed death,
bereavement)
Z63.5| Disruption of family by separation and divorce (marital
estrangement)
Z63.6| Dependent relative needing care at home
Z63.72| Alcoholism and drug addiction in family
Z65.1| Imprisonment and other incarceration
Z65.2| Problems related to release from prison
Z65.8| Other specified problems related to psychosocial circumstances
(religious or spiritual problem)
Additional Z-Codes
The following Z-codes should be utilized if it applies to the member:
Z59.9| Problem related to housing and economic circumstances,
unspecified
---|---
Z56.89| Other problems related to employment
Z56.9| Unspecified problems related to employment
Z60.4| Social exclusion and rejection
Z60.9| Other problems related to social environment
Z56.0| Unemployment, unspecified
Z62.3| Other upbringing away from parents
Z62.810| Personal history of physical and sexual abuse in childhood
Z62.811| Personal history of psychological abuse in childhood
Z62.813| Personal HX forced labor/sex exploit in childhood
Z62.9| Problem related to upbringing, unspecified
Z65.0| Conviction in civil and criminal proceedings without imprisonment
Z65.3| Problems related to other legal circumstances
Z81.1| Family history of alcohol abuse and dependence
Z81.3| Family history of other psychoactive substance abuse and
dependence
Z81.4| Family history of other substance abuse and dependence
Invoicing for Services and Outreach
Enhanced Care Management (ECM) will be expected to submit claims to SCFHP using national standards (e.g., ANSI ASC x12N 837P) to the greatest extent possible. Providers who are unable to submit compliant claims may instead submit invoices to SCFHP with “minimum necessary data elements defined by DHCS.” This guidance defines these “minimum elements,” which include information about the Member, service(s) rendered, and the Provider, as well as standards for file formats, transmission methods, submission timing, and adjudication. The purpose of this guidance is to standardize invoicing to mitigate provider burden and promote data quality.
| Data Elements | Required |
|---|---|
| Billing Provider National Provider Identifier (NPI)7 | Yes |
| Billing Provider Tax Identification Number (TIN) | Yes |
| Billing Provider Name | Yes |
| Billing Provider First Name | Optional |
| Billing Provider Last Name | Optional |
| Billing Provider Phone Number | Yes |
| Billing Provider Address | Yes |
| Billing Provider City | Yes |
| Billing Provider State | Yes |
| Billing Provider Zip | Yes |
| Rendering Provider National Provider Identifier (NPI) | Yes |
| Rendering Provider Tax Identification Number (TIN) | Yes |
| --- | --- |
| Rendering Provider Name | Yes |
| Rendering Provider First Name | Optional |
| Rendering Provider Last Name | Optional |
| Rendering Provider Phone Number | Yes |
| Rendering Provider Address | Yes |
| Rendering Provider City | Yes |
| Rendering Provider State | Yes |
| Rendering Provider Zip | Yes |
| Member Client Identification Number (CIN) | Yes |
| Medical Record Number (MRN) | Optional |
| Member First Name | Yes |
| Member Last Name | Yes |
| Member Homelessness Indicator | Yes |
| Member Residential Address | Yes |
| Member Residential City | Yes |
| Member Residential Zip | Yes |
| Member Date of Birth (MM/DD/YYYY) | Yes |
| Primary Payer Identifier | Yes |
| Payer Name | Yes |
| Procedure Code(s) | Yes |
| Procedure Code Modifier(s) | Yes |
| Service Start Date | Yes |
| Service End Date | Yes |
| Service Name(s) | Optional |
| Service Unit Count(s) | Yes |
| Place of Service (POS) | Yes |
| Member Diagnosis Code(s) | Yes |
| Service Unit Cost(s) | Yes |
| Service Charge Amount(s) | Yes |
| Invoice Amount | Yes |
| Invoice Date (MM/DD/YYYY) | Yes |
| Invoice Number | Yes |
| Control Number | Optional |
| Authorization Number | Optional |
Viewing Claim Status and Retrieving Remittance Advice
Payspan
SCFHP has transitioned to Payspan, a new payment system at no cost to our
providers. This change occurred during the claims payment cycle of November
15, 2021 and had no effect on any relationship you have with claims
clearinghouse partners. Providers who register for Payspan will have access to
payment details and be able to initiate or resume receipt of electronic
payments from the plan in place of hard copy checks.
Providers who have not yet registered for Payspan email should request a
registration code by emailing
providersupport@payspanhealth.com or by
visiting
https://www.payspanhealth.com/RequestRegCode.
The submitting provider would then receive their registration code along with
instructions to complete registration within 24 to 48 hours from the time of
the submitted request. Payspan registration can be completed at any time.
Registration instructions will be included with hard copy checks. Questions
specific to registration and related steps should be directed to the Payspan
Customer Service by writing
providersupport@payspanhealth.com.
Provider Portal
To check status on claims, go to the portal at:
https://providerportal.scfhp.com.If you
have not registered to use the portal, click on “REGISTER”:
If you are already registered, under “Login”, enter your Username and Password and click “SUBMIT”:
The Home screen will appear. From here, click on the Claims tab:
The default is to show the last 3 months claims. Enter other parameters in the available boxes as desired and click “Search”
References
Read User Manual Online (PDF format)
Read User Manual Online (PDF format) >>