Provider Alerts

As part of ongoing efforts for efficiency and accuracy, Health Plan has implemented internal process improvements for payments of Enhanced Care Management (ECM) services.

Please follow these guidelines when billing Health Plan for ECM services to ensure timely and accurate payment.

Note: Billing and payment for ECM outreach services is not impacted by this informational update.

Billing Guidelines

ECM providers must bill for ECM services according to the latest billing guidance from the Department of Health Care Services (DHCS) at the following link: https://www.dhcs.ca.gov/Documents/MCQMD/Coding-Options-for-ECM-and-Community-Supports.pdf

Failure to submit timely or accurate claims may result in payment delays or denials.

Payment Process

Claims with dates of service beginning October 1, 2025, will be paid on a monthly capitated cycle beginning with November’s capitation payment. Capitation payments will be processed on a monthly basis for the previous calendar month. You will have access to a Remittance Advice (RA) via Health Plan’s Provider Portal, Doctors Referral Express (DRE), with check information. A separate supplemental document with member-level detail will be emailed to you.

Note: You will only receive your ECM capitation payment if the member received an ECM authorized service (as applicable – see section ECM Presumptive Authorization below) during the month and a claim for that service month was submitted. If no ECM service was provided or no claim was submitted, you will not be paid an ECM capitation payment for services rendered to the member during that service month.

ECM Presumptive Authorization

In accordance with DHCS guidelines, contracted ECM providers covered under presumptive authorization requirements can provide ECM services to members for the first 30 days of participation without pre-authorization. ECM providers should submit their referral for ECM to Health Plan as soon as possible and no later than five working days before the end of the presumptive authorization period to limit gaps in authorization and reimbursement for ECM services provided to members.

ECM payments issued under the presumptive authorization period will also be capped at one payment per service month as described above.

Summary

• You must continue to submit claims for services rendered in accordance with DHCS billing guidelines to receive payment.
• Payment for ECM outreach will remain unchanged and will be paid under the standard fee-for-service reimbursement checks.
• Payment for authorized (as applicable) ECM services will be paid on a monthly capitation, separate from standard fee-for-service reimbursement checks currently received by providers, starting in November 2025.
• Member specific payment details will be sent to you separately from the standard RA.
• These changes go into effect for dates of service beginning October 1, 2025.

If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org