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Enhanced Care Management (ECM) – Approval Request Form
(for Adults 21 Years of Age and Over)
The Alameda Alliance for Health (Alliance) Enhanced Care Management (ECM) – Approval
Request Form (for Adults 21 Years of Age and Over) is confidential. This form is for Alliance
members 21 YEARS OF AGE AND OVER.
If you believe that your patient may be appropriate for ECM services, please complete this form.
Approvals are based on member eligibility.
INSTRUCTIONS
1.This form is for members 21 YEARS OF AGE AND OVER.
2.If the member being referred is an adult, please review each indicator and select the
box to all that apply across each Population of Focus (PoF). Please leave blank any
elements that do not apply to the extent of your knowledge.
3.Please use Section 5: Additional Comments to provide any areas where further Alliance
review may be warranted. For additional guidance on the ECM PoF definitions, please
refer to the ECM Policy Guide at www.dhcs.ca.gov/CalAIM/Documents/ECM-Referral-
Standards-and-Form-Templates.pdf.
4.Please print clearly, or type in all the fields below. Fields marked with * are required.
5.Attach a clinical summary and/or supporting documentation for ECM (e.g., clinic notes,
hospital discharge summary, etc.).
6.Fax or send by secure email the completed form to the Alliance ECM Department at
1.510.995.3725 or ECM@alamedaalliance.org.
For questions, please call the Alliance Case Management Department at 1.510.747.4512.
Please Note: Handwritten or incomplete forms may be delayed. Forms submitted without
supporting information may also be delayed.
Date of Referral*: Type of Referral*:
SECTION 1: REFERRING PROVIDER INFORMATION
Last Name*: First Name*:
Title: NPI Number:
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SECTION 1: REFERRING PROVIDER INFORMATION (cont.)
If the referring organization is an ECM provider that is eligible for presumptive authorization,
does the member have an ECM benefit start date? Yes No
If yes, please provide the start date:
If the referring organization is a community partner, does the member have a preferred
ECM provider? Yes No
If yes, please provide the ECM provider’s full name:
If the referring organization is an ECM provider, does the referring organization recommend
that the member be assigned to it as their ECM provider? Yes No
SECTION 2: MEMBER INFORMATION
Last Name*: First Name*:
Date Of Birth* (MM/DD/YYYY):
Alliance Member ID Number: Client Index Number (CIN):
Address:
City: State: Zip Code:
Email:
Primary Phone Number*: Home Cell
Preferred Written Language:
Preferred Spoken Language:
PCP Full Name:
SECTION 3: MEMBER’S QUALIFYING CONDITION(S)
Please select all that apply, the member must meet all requirements in one (1) of the options to
be eligible.
Option 1a – Adults without Dependent Children/Youth Living with them Experiencing
Homelessness: (Homeless families should complete the ECM Approval Request Form (for
Children/Youth Under the Age of 21))
Population of Focus (POF) Eligibility Indicator: If A = Yes AND B = Yes, member is eligible.
A. Member is experiencing homelessness (unhoused, in a shelter, losing housing in
the next 30 days, exiting an institution to homelessness, or fleeing interpersonal
violence).
B. Member has at least one (1) complex physical, behavioral, or developmental
health need (includes pregnancy or post-partum, 12 months from delivery), for
which the member would benefit from care coordination.
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Option 2 – Adults at Risk for Avoidable Hospital or Emergency Room Utilization:
POF Eligibility Indicator: At least one (1) of A OR B = Member is eligible.
A. Over the last 12 months, the member has had four (4) or more emergency room
visits that could have been avoided with appropriate care.
B. Over the last 12 months, the member has had two (2) or more unplanned hospital
and/or short-term skilled nursing facility (SNF) stays that could have been avoided
with appropriate care.
Option 3 – Adults with Serious Mental Health and/or Substance Use Disorder:
POF Eligibility Indicator: At least one (1) factor in A AND B AND at least one (1) factor in C =
Member is eligible.
A. Member meets eligibility criteria for, and/or is obtaining services through:
A1. Specialty Mental Health Services (SMHS) delivered by MHPs: Significant
impairment (distress, disability, or dysfunction in social, occupational, or
other important activities) OR a reasonable probability of significant
deterioration in an important area of life functioning.
A2. Drug Medi-Cal Organization Delivery System (DMC-ODS): Have at least one
(1) diagnosis for substance-related and addictive disorder with the exception
of tobacco-related disorders and non-substance-related disorders.
A3. Drug Medi-Cal (DMC) Program: Have at least one (1) diagnosis for
substance-related and addictive disorder with the exception of tobacco-
related disorders and non-substance-related disorders.
B. Member is actively experiencing at least one (1) complex social factor influencing
their health, which may include, but is not limited to lack of access to food; lack of
access to stable housing; inability to work or engage in the community; high
measure (four (4) or more) of ACEs based on screening; former foster youth; or
history of recent contacts with law enforcement related to mental health or
substance use symptoms.
C. Member meets one (1) or more of the following criteria:
C1. High risk for institutionalization, overdose and/or suicide.
C2. Use crisis services, emergency rooms, urgent care, or inpatient stays as
the primary source of care.
C3. Two (2) or more emergency room visits due to serious mental health or
SUD in the past 12 months.
C4. Two (2) or more hospitalizations due to serious mental or SUD in the past
12 months.
C5. Pregnant or post-partum (up to 12 months from delivery).
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Option 4 – Adults Transitioning from Incarceration:
POF Eligibility Indicator: If A = Yes AND at least one (1) factor in B = Member is eligible.
A. Member is transitioning from a correctional facility (e.g., prison, jail, or youth
correctional facility) or has transitioned from a correctional facility within the past
12 months.
B. Member has a diagnosis of:
Mental illness
Substance Use Disorder (SUD)
Chronic Condition/Significant Non-Chronic Clinical Condition
Intellectual or Developmental Disability (I/DD)
Traumatic Brain Injury (TBI)
HIV/AIDS
Pregnancy or postpartum (up to 12 months from delivery)
Option 5 – Adults Living in the Community and At Risk for Long-Term Care Institutionalization:
POF Eligibility Indicator: At least one (1) factor in A AND B AND C = Member is eligible.
A. Member meets at least one (1) of the following criteria:
A1. Living in the community and meets the Skilled Nursing Facility (SNF) level
of care criteria.
A2. Requires lower-acuity skilled nursing, such as time-limited and/or
intermittent medical and nursing services, support, and/or equipment for
prevention, diagnosis, or treatment of acute illness/injury.
B. Member is actively experiencing at least one (1) complex social or environmental
factor influencing their health (including but not limited to, needing assistance with
activities of daily living (ADLs), communication difficulties, access to food, access to
stable housing, living alone, the need for conservatorship or guided decision-making,
poor or inadequate caregiving which may appear as a lack of safety monitoring).
C. Member is able to reside continuously in the community with wraparound supports.
Option 6 – Adult Nursing Facility Residents Transitioning to the Community:
POF Eligibility Indicator: A AND B AND C = Member is eligible.
A. Member is in a nursing facility who is interested in moving out of the institution.
B. Member is a likely candidate to move out of the institution successfully.
C. Member is able to reside continuously in the community.
(Option 7 and Option 8 are for ECM children/youth only, and intentionally excluded in this form.)
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ECM_PRVDR_APPROV REQ FORM (ADULTS) 11/2024
Option 9 – Adults Who are Pregnant or Postpartum:
POF Eligibility Indicator: A AND B = Member is eligible.
A. Member is pregnant OR postpartum (through 12 months period).
B. Member is subject to racial and ethnic disparities as defined by California public
health data on maternal morbidity and mortality. As of 2024, Black, American Indian
or Alaska Native, and Pacific Islander members meet this criteria (referring
individuals should prioritize member self-identification).
SECTION 4: OTHER MEDI-CAL PROGRAMS OR SERVICES
Other Medi-Cal programs or services that the member is enrolled in (please select all that apply):
A. Dual Eligible Special Needs Plan (D-SNP)
B. Hospice
C. Fully Integrated Special Needs Plan (FIDE-SNP)
D. Program for All-Inclusive Care for the Elderly (PACE)
E. Multipurpose Senior Services Program (MSSP)
F. Assisted Living Waiver (ALW)
G. Self-Determination Program for Individuals with Intellectual or Developmental
Disability (I/DD)
H. Home and Community-Based Alternatives (HCBA) Waiver
I. California Community Transitions (CCT)
J. Medi-Cal Waiver Program (MCWP) (formerly HIV/AIDS Waiver)
SECTION 5: ADDITIONAL COMMENTS (OPTIONAL)
Please use the space below to provide additional comments as needed: