Enhanced Care Management Presumptive Authorization – Live as of 01/01/2025
| Date: | December 30, 2024 |
| From: | Health Plan |
| To: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) Enhanced Care Management (ECM) Providers |
| Type: | Informational |
| Subject: | Enhanced Care Management Presumptive Authorization – Live as of 01/01/2025 |
| Business: | Medi-Cal Managed Care |
Presumptive authorization enables the Enhanced Care Management (ECM) Provider to deliver ECM for a 30-calendar day timeframe without prior authorization and be paid by Health Plan for ECM services delivered during the first 30 days.
During the presumptive authorization period, the ECM Provider must submit the Member’s referral information to Health Plan for formal authorization to continue to receive reimbursement for services from the 31st day onwards.
The ECM provider must submit their authorization request 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.
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
