Written by California’s Department of Health Care Services (DHCS) has made significant strides with the introduction of CalAIM, a program designed to help the state’s most vulnerable populations by providing integrated care that addresses both health and social needs. This initiative aims to transform care delivery, reaching those who need support the most.
Under this model, managed care plans are playing a crucial role by supporting community-based providers in delivering enhanced care management and community supports. These providers, often deeply embedded in their communities, are critical in addressing complex needs such as housing instability and chronic health conditions. The state’s funding for this initiative has provided a strong foundation, ensuring that the program can sustain its long-term goals of better care and improved outcomes.
What makes this model unique is how it reaches members where they live, addressing their needs in real time and in their own environments. This transformative approach ensures more personalized and impactful care for individuals who would otherwise fall through the cracks.
However, this model also brings administrative challenges for community-based providers, particularly in areas like data sharing, assessments, billing, prior authorizations, and referral processes—all of which vary from plan to plan. For CBOs, many of whom are small organizations, these challenges are exacerbated by limited resources, such as a lack of dedicated IT staff or administrative teams. It is not uncommon to find providers who have not submitted RTFs for years or have not billed for services for an extended period.
As we approach the end of the third year of CalAIM implementation, it is unfortunate that these issues still persist. Managed Care Plans (MCPs) have the resources to support providers beyond repetitive trainings on their specific processes. The upcoming standardization of the ECM referral process across health plans is a good starting point. What we need from DHCS is clear guidance and enforcement of open standards that allow providers to perform all administrative tasks within their case management environment, rather than navigating custom portals.
Providers should be able to use FHIR or X12 270 inquiries to check eligibility and benefit status and receive 271 transaction responses. Similarly, they should be able to use FHIR-based processes or X12 278 for submitting prior authorization requests, responses, billing, and data sharing—without being required to log into multiple portals. This would allow providers to focus more on care rather than being burdened with administrative tasks.
Additionally, standardizing MIFs/ASFs and RTFs across plans, and enabling data exchange through open interfaces, would prevent the need for providers to use multiple, often unreliable portals. Claim systems should also be accessible via common clearinghouses, so providers don’t have to manage claims submission and tracking in different ways. Addressing these operational challenges is essential for the long-term success of CalAIM.
Sprite Health offers a highly comprehensive digital platform that enables the efficient management of all ECM/CS requirements in a single place. Our solution is purposefully designed to cater to the specific needs of the CalAIM ECM/CS initiative.
Connect with us to learn how you can enhance outreach efforts, streamline care planning and coordination, and fosters a data-driven and outcome-oriented approach that advances equity, and clinical outcomes.