Comprehensive Guide for California Advancing and Innovating Medi-Cal Technology Needs
We have been hearing a lot of CalAIM misinformation that can be confusing to California Counties and Providers, so we want to set the record straight. We have put together a comprehensive guide with CalAIM Payment Reform information and technology needs.
What is CalAIM?
California Advancing and Innovating Medi-Cal (CalAIM) is an initiative to improve the health outcomes of the California population by transforming the care delivery system, expanding programs, and reforming payment methodologies across all of Medi-Cal. By embracing cutting-edge technologies, fostering collaboration among healthcare providers, and streamlining administrative processes CalAIM will pave the way for a more accessible, equitable, and patient-centric healthcare experience.
- New programs and requirements
- Approach a consumer’s needs with a whole-person care lens
- Make Medi-Cal consistent and seamless across counties
- Care delivery improvements
- Enhance outcome quality for consumers and reduce administrative burdens for staff
Impacts The Entire Medi-Cal Delivery System Across All Venues of Care:
- Medi-Medi Plans
- Managed Care Plans
- Mental Health Plans
California Advancing and Innovating Medi-Cal Goals:
- Make Medi-Cal a more consistent and seamless system, reducing complexity and increasing flexibility
- Comprehensively manage a consumer‘s needs through whole-person care (population health)
- Improve quality outcomes, reduce disparities, and transform the delivery system through value-based initiatives, modernization, and payment reform
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California Advancing and Innovating Medi-Cal Policy
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Go-Live Date
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Revised Criteria for Specialty Mental Health Services
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January 2022
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Drug Medi-Cal Organized Delivery System (DMC-ODS) Policy Improvements
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January 2022
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Drug Medi-Cal ASAM Level of Care Criteria for Counties
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January 2022
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Updated Reasons for Recoupment
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January 2022
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Documentation Redesign
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July 2022
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Co-Occurring Treatment
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July 2022
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No Wrong Door
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July 2022
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Standardized Screening and Transition Tools
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January 2023
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Behavioral Health Payment Reform
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July 2023
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Advancement of Data Sharing
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Ongoing
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Administrative Integration of SMH and SUD Services
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January 2027
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Please note: California Advancing and Innovating Medi-Cal Policy information and dates were provided from The California Department of Health Care Services website. For more information visit: https://www.dhcs.ca.gov/Pages/BH-CalAIM-Webpage.aspx
True or False: Counties Won’t Need Next-Generation Technology to Meet CalAIM Requirements
False!
There are new challenges created by the expansion of service offerings and the coordination of care across levels of care and multiple providers for consumers. Additionally, new reimbursement models create another level of complexity. To thrive under CalAIM, increased technological functionality is a necessity, enabling seamless participation in integrated care, provision of digital services, and acceptance of value-based reimbursement. As state requirements evolve, the need for reliable EHR support and seamless data sharing becomes vital for informed decision-making and quality improvement efforts. We expect to see California organizations plan for technology investment and expand their use of current technology to deliver services under California Advancing and Innovating Medi-Cal.
CalAIM Behavioral Health Payment Reform Initiative
Most Medi-Cal Specialty Mental Health and Substance Use Disorder services are funded by Counties using state-allocated revenue streams. Before the CalAIM initiatives, Counties were reimbursed for Medi-Cal specialty behavioral health unlike other Medi-Cal managed care plans. Counties did not receive per-member-per-month capitated payments. Counties claimed services and received a portion of reimbursement for specialty behavioral health services as an interim payment. Later Counties are subject to a cost reconciliation process and may receive additional funds which reflect the actual cost of providing services.
The CalAIM Behavioral Health Payment Reform initiative’s strategic direction is to transition from a cost-based system driven by auditing rules to a value-based (capitated) system over the next few years. As a result of this transition, both the State and Counties are reassessing long-standing practices and expectations accumulated over many years.
Goals:
- Maximize usage of federal funding
- Reduce administrative burden for state, counties, and providers
- Simplify payments to counties and providers
- Decrease audit liability associated with the cost-based system through simplification
- Decrease financial risk and budget challenges by reducing delays in audit timelines
- Reduce the administrative footprint to increase services with streamlined workflows (documentation)
Iterative Journey to Reach a Value-based System:
- Alignment across many departments to ensure consistent expectations
- Starts with alignment to a true fee-for-service model
- Changing the mindset around billing, audit complexities, and many years of history
- Begin evaluating quality over volume, along with new claiming practices
- Establishes an understanding of the data to prepare for value-based care (e.g. units, costs, value)
- Requires new or modified reporting and auditing requirements
The Transition
Beginning July 1, 2023, the CalAIM Behavioral Health Payment Reform initiative will change the way county BH plans claim federal reimbursement. As managed care plans, counties will continue to contract with specialty behavioral health providers and negotiate provider payments under those contracts.
Reimbursement Structure: Cost-based to Fee for Service
- Counties negotiate payment terms and rates with subcontracted providers
- Counties claim FFS rates established in a BH plan fee schedule
- Payments are final, there is no cost settlement
Financing: Intergovernmental Transfers (IGT) to fund BH Plans
- Reimbursement is claimed via fee schedules
- IGT’s allow counties to transfer funds to DHCS for funding (SDMC, UR)
- No cost settlement
- Non-federal shares are still available (SGF, MAA, etc)
Billing: Alignment to other delivery systems and CMS
- Use of CPT codes for more standardized definitions
- Usage of HCSPCS codes for certain providers/services
The Impact of Payment Reform
- Requires alignment across state departments to ensure consistency in expectations
- Re-evaluation of many years of practice and expectations
- Provides an opportunity to better understand data in preparation for value-based care
- Numerous new policies
- New reporting and auditing requirements
New Billing Requirements for MHP Highlights
Counties are using Medi-Cal’s new billing manuals and other supporting documentation to learn about the Medi-Cal requirements and establish new billing guidelines for contracted providers.
- Implementation of CPT codes instead of only HCPCS
- Updates to place of service definitions and usage
- Updates to modifier definitions and usage
- Use of add-on and/or dependent codes (service is dependent on completion of another service)
- Allows for claiming of peer support activity
- Threshold limits for certain services
- Rate establishment/new rate schedules
- Aligned more closely to standard billing
- Fractional Units are no longer allowed
- Continued usage of billing lockouts
- Rendering provider taxonomy requirements
Testing Information
Medi-Cal testing systems launched on January 23, 2023, for Counties (MHP’s) to initiate their testing process.
- State offering end-to-end testing
- Inclusive of Acknowledgement Files (TA1, 999, SR)
- Includes Remittance Advice (835)
- Processes to request Client Index Numbers (CIN) specific for testing
- When testing, the CIN, DOB, and gender must match the test data
- Testing processes for Contracted Providers are dependent on County testing procedures
- Medi-Cal Testing Resource Guide available in January assisted counties define the scenarios that should be considered
- Weekly testing QA sessions commenced for counties in February 2023
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Test Phases
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Description
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Timelines
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Phase 1
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Testing successful file submission of 10 claims and receiving the following acknowledgment reports: TA1, SR report and 999
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January 23 – September 30
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Phase 2
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Testing CalAIM business rules and submitting claims using CPT Codes
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February 1 – September 30
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Phase 3
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Testing add-ons and IGT process
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March 1 – September 30
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Tips for Counties to Prepare for the Change
- Gather and review Medi-Cal requirements (manuals, rates, testing processes, reporting)
- Treat this as a major project
- Assign a project owner
- Establish a project plan
- Determine the need for additional resources
- Determine if there are process and/or procedure changes
- New workflows
- Training
- Determine the need for configuration updates within EHR
- New service or visit types, modifiers, procedure codes
- New rates
- Establish a crosswalk from the old to new
- Determine assistance needed from EHR Vendor
- Support
- Development
- Prepare for testing
- Prepare for user training
True or False: CalMHSA is a State Organization and Counties Have to Only Take Their Advice
False!
California Mental Health Services Authority (CalMHSA) is not a state organization. CalMHSA is a Joint Powers of Authority (JPA) formed by counties throughout the state. As a JPA, CalMHSA is not a state agency.
Qualifacts has teamed up with Kings View Professional Services (KVPS) to provide California Counties with support and expertise. Over the past 25 years, KVPS has paved the way for clear and actionable technical data for California’s behavioral health data. They demonstrated their expertise at demystifying streams of California technical data, shaping it into a clear and compelling narrative.
KVPS customers receive expert support and benefit from the lowest denial rates along with the highest state reporting compliance rates reported by EQRO.*With over 34 California Counties served, as both a healthcare provider and IT services organization, KVPS has a unique in-market perspective and expertise to help its partners with integrated consumer data, billing, and clinical solutions.
Technology Supporting California Specific Requirements
Innovative and configurable EHR support has never been more crucial for California County Behavioral Health and Human Services Agencies. As state data collection and reporting requirements evolve, foundational EHR support and data sharing are vital for decision-making and ongoing quality improvement efforts.
Functionality Needed to Support California Advancing and Innovating Medi-Cal
- Full access to all critical data allows for the compilation and analysis of information received from providers, demonstrating improved outcomes, and better treatment protocols
- Ability to match consumers automatically or manually and seamlessly add or update insurance using the California specific MMEF file
- Module to share consumer and payer eligibility, authorize providers, process, adjudicate and pay claims, and track expenditures for services within defined covered benefits across care systems
- Monitor service authorizations and interventions, measure adherence to established benefit plans, authorize medically necessary services, and review utilization
- Consumer engagement tools, including a client portal providing online access to scheduling, medication renewals, completion of forms and assessments, and payment processing
- Connect with other systems and organizations — including patient data access and system-wide health information exchanges (HIE)
- Comprehensive reporting to track consumer movement and placement for those served by multiple providers
- Multiple reporting tools and a Business Intelligence model to provide real-time dashboards measuring Key Performance Indicators to demonstrate program impact, continuous improvement, and contract compliance
- Receive referrals, generate data exports into standard referral letter templates, and manage the referral process to outside providers with Integrated Primary Care
- California specific 837 file functionality and 835 processing capabilities
- Ability to collect, track, and submit data electronically to the State such as CSI, CalOMS, FAST, MHSA-FSP, OSHPD, ASAM LOC, and outcomes
True or False: Counties Only Have One EHR Vendor to Choose From
False!
There is no state EHR system that all Counties must use. Agencies are switching Qualifacts to support CalAIM program initiatives, including data analytics, consumer engagement, and care coordination tools. With Qualifacts, agencies benefit from next-generation technology that strengthens enhanced care management and community support services. Our EHR platforms help California behavioral health and human services providers achieve greater performance, take the burden out of compliance, and deliver outstanding care to those in need. From meeting MediCal and upcoming CalAIM requirements to optimizing clinical workflows and demonstrating positive outcomes.
Kings View Professional Services, powered by Qualifacts
Together, Kings View Professional Services (KVPS), Qualifacts, and the Credible EHR give agencies a secure, proven solution to overcome challenges in today’s complex care environment, that can flexibly enable expanded service offerings, while supporting changing requirements and payment models. Every County has unique requirements and workflows EHRs must support. Kings View Professional Services and Qualifacts provide:
- Next-generation EHR aligned with statewide requirements, adaptable to changing regulations, and configurable for County specific workflows
- Secure, proven solution that is currently helping Counties navigate and adhere to the objectives and challenges of the CalAIM initiative and emerging Value Based Reimbursement (VBR) payment models
Qualifacts Assistance for Payment Reform
- Our product teams, in collaboration with KVPS, have assessed Mental Health, Drug Medi-Cal, and ODS Waiver requirements comprehensively, and we’ve released enhancements
- Continuously involved in state activities, such as webinars, trainings, and more, while also providing sample project plans to assist organizations in getting started
- Collaborate with customers to interpret new Medi-Cal requirements and release enhancements for their implementation
- Offer guidance to County customers on operationalizing these requirements and defining testing approaches for their organizations
- To ensure preparedness, we partnered with KVPS for Medi-Cal testing. Our development teams are diligently testing various aspects, including claims submission, acknowledgement reports, CalAIM business rules, CPT codes usage, and IGT processes
Managed Care Solutions
- Comprehensive workflows to process the California specific monthly eligibility file, Meds Monthly Extract File (MMEF), including automatic and manual matching of consumers and insurance updates
- Workflows for managing calls from consumers or family members interested in services
- Capabilities and workflows for referring / authorizing consumers with a provider
- Monitor authorizations, measure adherence to benefit plans, authorize necessary services, and review utilization
- Support for provider reimbursements claiming and reimbursement workflows based on contracted rates
- Our system remains compliant with CPT/HCPCS procedure code changes
Population Health Management Solutions
- Full access to all critical data for compiling and analyzing information received from providers, demonstrating improved outcomes, and enhancing treatment protocols.
- Enable effective management of networks and providers, including tracking and managing contracts with providers and facilities
- CQM Reporting Tools automate reporting requirements by utilizing EHR data, eliminating manual report generation and simplifying data gathering
- Our flexible reporting outputs include over 80 standard reports, dashboards, and custom reporting capabilities for improved decision support.
- Comprehensive reporting to track consumer movement and placement across multiple providers and systems
- Access charts, dashboards, and five levels of reporting to identify care gaps, gain insight into the consumer population, and support providers in achieving clinical outcomes
- Ability to collect, track, and submit data electronically to State such as CSI, CalOMS, FAST, MHSA-FSP, OSHPD, ASAM LOC, and outcomes
Care Management Solutions
- Consumer engagement tools through a client portal for online scheduling, medication renewals, form completion, assessments, and payment processing.
- Enables efficient completion of admissions, transfers, referrals, and discharges both internally and externally.
- Workflows can be configured to initiate referrals and capture demographic details, assignment, activity, and urgency.
- Facilitates integration, communication, and collaboration between county-operated programs, contracts, and network provider
Billing Solutions
- Aligned with CalAIM Behavioral Health Payment Reform billing requirements, with functionality for CCBHC and VBR Models
- Module to authorize providers, process, adjudicate and pay claims and track expenditures for services within defined covered benefits across care systems
- Billing Module has predefined California billing rules to accommodate various scenarios with the ability to configure rules to comply with billing Lockouts
- Alternative Alias functionality to transmit alternative consumer name and demographics to payers
- Functionality to Void or Replace services (including add-ons) if primary code is voided or replaced
- Group functionality allows visits that were not originally part of the group to be manually added to the group if they share the same provider and visit date*
- California Specific Liability worksheet and expanded liability processing capabilities that support handling for UMDAP, Share of Cost, and Sliding Fee Scale
- Utilizes the Advanced Serach, Batch Claim Error Report and pre-billing checklist, preventing denials by the payer
- Billing Module integrates service documentation components for claims tracking, batch generation, editing, electronic posting, etc.
- Provides payment reconciliation and consumer financial reviews with sliding scale and UMDAP calculations
- Generate 837 files for Mental Health Claims (Short Doyle) and SUD Claims – Drug Medi-Cal (DMC) in accordance with Medi-Cal
- Electronic submission of Medi-Cal Medicare, and third-party services
- Enhanced 835 functionality for California specific requirements
- Functionality to “mass update” Aid Codes when new master files are published
- Mode of Service and Service Functions can be tied to service codes
Documentation Solutions
- Increase staff efficiency through highly configurable, easy-to-use single page workflow treatment plans or recovery service plans
- Dynamic notifications and “Golden Thread” support for participant(s) in plans
- Empower your decision-making and boost quality of care with clinical industry assessment tools, including CANS, ASAM, PHQ9, DLA-20, and more
- Document progress on goals and objectives through individual and group progress notes, with updated documentation standards for assessment domains and problem lists, and the ability to enter progress notes for services exceeding 24 hours.
- Highly configurable treatment planner that allows for collaborative contribution by inter-disciplinary teams to one or multiple treatment plans, incorporating data from assessments to inform plan development and drive improved outcomes throughout a consumer’s continuum of care
Assessment, Screening and Transition of Care Solutions
- Configure rules based upon the populations served and set actions, assessments, or recommendations based upon evidence-based practices
- With advanced reporting agencies can track various areas of interest, such as employee compliance to providing services aligned with Assessments and Individual Service Plans
- External referrals information can be sent via direct messaging or provider portal
- Release and tracking of consumer records for coordination of care
- Several standard assessments such as PHQ-9, DLA-20, ASAM and GAIN are available
- Form Builder empowers agencies to design custom or duplicate existing forms from a selection of 30,000 options in the Forms Library
- Create any open domain measures in Form Builder for staff completion or inclusion in the patient portal for self-reporting
- Logic guides staff through assessments by revealing hidden questions and fields based on previous answers
- Dynamic Forms Capability triggers documentation for required additional forms based on specific question responses
Substance Use Disorder Solutions
- Integrated and customizable assessments (i.e., ASAM, CANS, PSC-35, CSI, etc.)
- e-Prescribing (eRx) module provides clinicians a central location to view medications, add reported medications, create prescriptions, complete a med reconciliation, and check Rx eligibility and the PBM medication history
- Surescripts-certified to provide for Rx and electronic prescription of controlled substances (EPCS)
- Configurable group charting templates to seamlessly switch between group and individual notes
Integrated Care Solutions
- Self-services configure EHR to meet the unique clinical, compliance, and billing workflow needs without costly customization
- Integrated Care approach to consumer data supports care coordination by consolidating primary care and behavioral health care workflows, documentation, and billing into a single record.
- Reports are integrated and accessible across SUD and Behavioral Health, and our data protocols meet the highest security standards
- Manage and configure inbound and outbound transactions using industry standard and automated technical protocols such as HL7, XML, and FHIR.
- Connection modules make it simpler to send demographic and clinical data to Health Information Exchanges (HIEs), ACOs, commercial vendors, pharmacies, labs and federal, state, or local entities.
Mobile Solutions
- Mobile solution enables access to consumer records and documentation at the point of care, regardless of internet connectivity, ensuring care can be provided anytime and anywhere.
- Using the offline mode enables staff to add consumers, perform scheduled and unscheduled services, review previous consumer data, and queue completed services for upload.
- Utilize encrypted data with geolocation stamping, to record the precise device location during a session enabling you to meet reporting and compliance requirements effectively.
Compliance
- Updated to the latest FHIR (Fast Healthcare Interoperability Resources) v4 standards, APIs simplify compliance with 21st Century Cures Act interoperability requirements and enable a more streamlined care process for providers at every level
- Our EHR platforms will continue to support the USCDI standards in the future
True or False: Qualifacts Supports Counties with Efficient, Flexible EHR Tools and Support
True!
If you are looking for an EHR provider that supports California’s transition to the new payment system and assists customers in navigating the objectives and challenges of California Advancing and Innovating Medi-Cal (CalAIM) Behavioral Health Payment Reform, you have options.
When considering a new EHR vendor, consider Qualifacts. With over 160 customers in the state, including 17 California Counties, we have in-depth expertise and experience in CalAIM requirements.
Qualifacts is one of the largest behavioral health, rehabilitative and human services EHR vendors in the country. Its mission is to be an innovative and trusted technology and solutions partner, enabling exceptional outcomes for its customers and those they serve. With more than 20 years of experience, Qualifacts’ configurable and flexible products and services help customers achieve interoperability goals, optimize efficiency, improve productivity, and maximize reimbursement.
The time to act is now. Embrace technology, align with CalAIM, and be prepared to unlock new levels of efficiency, effectiveness, and consumer satisfaction. Together, we can drive transformative change in healthcare delivery, ultimately improving the lives of countless consumers across California.
Given the significant changes coming, there is no safer partner to assist agencies through the forthcoming transition than Qualifacts. Schedule a demo and see how utilizing a California-tailored EHR system can help your agency thrive under California Advancing and Innovating Medi-Cal. You can learn more about our solutions for California agencies here, you can also see our California County solutions here.
