CBAS Emergency Remote Services (ERS) Initiation Form Instructions
This file contains instructions for completing the CBAS Emergency Remote Services (ERS) Initiation Form (CEIF) (CDA 4000). It is a standardized form required by all CBAS providers. This document outlines the requirements as specified by the California Advancing and Innovating Medi-Cal (CalAIM) and other relevant guidelines.
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How do I fill this out?
Filling out the CBAS Emergency Remote Services (ERS) Initiation Form is crucial for compliance. This section will guide you through the process step-by-step to ensure accuracy. Follow these steps carefully to complete your form.
How to fill out the CBAS Emergency Remote Services (ERS) Initiation Form Instructions?
1
Log in to the Peach Portal.
2
Select ERS from the list of options.
3
Find and select the appropriate center from the dropdown menu.
4
Complete the participant details and emergency details sections.
5
Submit the form as instructed.
Who needs the CBAS Emergency Remote Services (ERS) Initiation Form Instructions?
1
CBAS providers need this form to comply with ERS requirements.
2
Managed care plans require this form to coordinate with CBAS centers.
3
Participants enrolled in Medi-Cal may need this form for ERS approval.
4
Nurses and social workers at CBAS centers need this form for assessing participants' emergency circumstances.
5
Administrators or Program Directors at CBAS centers need this form for filing and submission purposes.
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What are the instructions for submitting this form?
To submit the form, log in to the Peach Portal and complete the CEIF (CDA 4000). Submit the form within three working days of the ERS initiation. Coordination with managed care plans or DHCS is required for service extensions. Ensure the form is filed in the participant's health record and maintain accuracy and completeness. Use alternative contact methods as necessary.
What are the important dates for this form in 2024 and 2025?
Key dates for this form include initial submission within three working days of ERS initiation and managed care approval one week prior to extending services beyond three months.
What is the purpose of this form?
The purpose of the CBAS Emergency Remote Services (ERS) Initiation Form is to ensure compliance with ERS requirements specified by the California Advancing and Innovating Medi-Cal (CalAIM) and other relevant guidelines. It provides a standardized method for CBAS providers to document and coordinate emergency remote services for participants. Proper completion and submission of this form facilitate effective communication and coordination between CBAS providers, managed care plans, and others involved in the process.
Tell me about this form and its components and fields line-by-line.
- 1. Participant Details: Includes information such as Last Name, First Name, and Medi-Cal Identification Number.
- 2. Emergency Details: Covers the nature of the emergency, date of emergency, and date of participant consent for ERS.
- 3. Managed Care Plan: Selection of the participant's Managed Care Plan from a dropdown menu.
- 4. First Date ERS Provided: The initial date ERS was provided.
- 5. Signatures: Signatures of the CBAS center Administrator or Program Director.
What happens if I fail to submit this form?
Failure to submit this form can lead to non-compliance and potential service disruptions for participants.
- Non-Compliance: Non-compliance with ERS requirements can result in penalties and loss of funding.
- Service Disruption: Participants may experience disruptions in receiving necessary services.
How do I know when to use this form?
- 1. Emergency Situations: To document emergency circumstances that necessitate the provision of ERS.
- 2. Managed Care Approval: When seeking approval from managed care plans for extended ERS services.
- 3. Record Keeping: For filing in the participant's health record to ensure accurate documentation.
Frequently Asked Question
What is the purpose of the CBAS ERS Initiation Form?
The form ensures compliance with ERS requirements and facilitates coordination between CBAS providers and managed care plans.
How can I access the CEIF (CDA 4000)?
Log in to the Peach Portal and select the ERS option to access the form.
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Yes, you can upload and edit the PDF using PrintFriendly's PDF editor.
How do I add my signature to the form?
Upload the PDF to PrintFriendly, add your digital signature, and save the signed document.
What are the steps to fill out the form?
Log in to the Peach Portal, select ERS, complete participant and emergency details, and submit as instructed.
Who needs to use this form?
CBAS providers, managed care plans, participants, nurses, social workers, and administrators at CBAS centers.
How do I share the completed form?
Use PrintFriendly's share feature to send the document via email or generate a shareable link.
What if I fail to submit the form?
Failure to submit the form can result in non-compliance and potential service disruptions for participants.
Where can I find the instructions for this form?
Instructions are available on the CBAS website under Forms & Instructions - Emergency Remote Services.
Can I use PrintFriendly to download the completed form?
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