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Enhanced Care Management (ECM) – Approval Request Form
(for Children/Youth Under the Age of 21)
The Alameda Alliance for Health (Alliance) Enhanced Care Management (ECM) – Approval
Request Form (for Children/Youth Under the Age of 21) is confidential. This form is for Alliance
members who are UNDER THE AGE OF 21.
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 who are UNDER THE AGE OF 21.
2.If the member being referred is a child, youth, or family (experiencing homelessness),
please review each indicator and select the box to all that apply across the child/youth
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
NPI Number:
Organization Name*:
Phone Number*: Fax Number:
Email*:
Relationship to Member*:
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SECTION 1: REFERRING PROVIDER INFORMATION (cont.)
ECM provider
If yes, please provide the start date:
community partner
If yes, please provide the ECM provider’s full name:
ECM provider
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:
Parent/Guardian/Caregiver Full Name (if applicable):
Parent/Guardian/Caregiver Phone Number (if applicable):
Parent/Guardian/Caregiver Email (if applicable):
Best Contact Method for Member/Caregiver: Phone Email
Best Contact Time for Member/Caregiver:
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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 1b – Homeless Families or Unaccompanied Children/Youth Experiencing
Homelessness: If you are referring a child/youth who is experiencing homelessness, and
their family members or caretakers are also experiencing homelessness and have coverage
through the Alliance, please consider referring all family members/caregivers for ECM
services.
POF Eligibility Indicator: A OR B = Member/family is eligible.
A. Child/youth or family with a member under 21 years of age, who is experiencing
homelessness (unhoused, in a shelter, losing housing in the next 30 days, exiting an
institution to homelessness, or fleeing interpersonal violence).
B. Child/youth or family is sharing the housing of other persons (i.e., couch surfing)
due to loss of housing, economic hardship, or a similar reason; or is living in a motel,
hotel, trailer park, or camping ground due to the lack of alternative adequate
accommodations; is living in emergency or transitional shelters; or is abandoned in
hospital (in a hospital without a safe place to be discharged to).
Option 2 – Children/Youth At Risk for Avoidable Hospital or ED Utilization:
POF Eligibility Indicator: At least one (1) of A OR B = Member is eligible.
A. Child/youth has three (3) or more emergency room visits that could have been
avoided with appropriate care within the last 12 months.
B. Child/youth has two (2) or more unplanned hospital and/or short-term skilled
nursing facility stays that could have been avoided with appropriate care, within the
last 12 months.
Option 3 – Children/Youth with Serious Mental Health and/or Substance Use Disorder:
POF Eligibility Indicator: At least one (1) factor in A = Member is eligible.
A. Member meets eligibility criteria for, and/or is obtaining services through:
A1. Specialty Mental Health Services (SMHS) delivered by MHPs: Members
under age 21 qualify to receive all medically necessary SMHS services.
A2. Drug Medi-Cal Organization Delivery System (DMC-ODS): Members
under age 21 qualify to receive all medically necessary DMC-ODS services.
A3. Drug Medi-Cal (DMC) Program: Covered services provided under DMC
shall include all medically necessary substance use disorder (SUD) services
for individuals under 21 years of age.
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Option 4 – Children/Youth Transitioning from a Youth Correction Facility:
POF Eligibility Indicator: A only = Member is eligible.
A. Member is transitioning from a youth correctional setting within the last 12 months.
(Option 5 and Option 6 are for ECM adults only, and intentionally excluded in this form.)
Option 7 – Children/Youth Enrolled in CCS with Additional Needs Beyond the CCS
Condition:
POF Eligibility Indictor: A AND B = Member is eligible.
A. Member is enrolled in California Children’s Services (CCS) or CCS Whole Child
Model (WCM).
B. Member is experiencing at least one (1) complex social factor influencing their
health. Examples include (but are not limited to) lack of access to food; lack of
access to stable housing; difficulty accessing transportation; high measure (four (4)
or more) of Adverse Childhood Experiences (ACEs) screening; history of recent
contacts with law enforcement; or crisis intervention services related to mental
health and/or substance use symptoms.
Option 8 – Children/Youth Involved in Child Welfare:
POF Eligibility Indicator: At least one (1) of A through E = Member is eligible.
A. Member is under age 21 and is currently receiving foster care in California.
B. Member is under age 21 and previously received foster care in California or
another state within the last 12 months.
C. Member is under age 26 and aged out of foster care (having been in foster care
on their 18th birthday or later) in California or another state.
D. Member is under age 18 and eligible for and/or in California’s Adoption
Assistance Program.
E. Member is under age 18 and is currently receiving or has received services from
California’s Family Maintenance program within the last 12 months.
Option 9 – Children/Youth 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,
Alaska Native, and Pacific Islander members meet this criteria (referring individuals
should prioritize member self-identification).
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ECM_PRVDR_APPRO REQ FORM (CHILDREN/YOUTH) 12/2024
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)
SECTION 5: ADDITIONAL COMMENTS (OPTIONAL)
Please use the space below to provide additional comments as needed: