Medi-Cal Managed Care Referral Form
This Medi-Cal Managed Care Referral Form is designed for case management referrals for both physical and behavioral health services. It contains detailed sections for referrer and member information. Completing this form accurately ensures appropriate care management support for Medi-Cal members.
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How do I fill this out?
To fill out this form, start by gathering all required information about the member and the referring individual. Ensure that you choose the appropriate program—either physical health or behavioral health. Follow the instructions carefully to complete each section accurately.
How to fill out the Medi-Cal Managed Care Referral Form?
1
Gather all necessary information about the member and referrer.
2
Choose the appropriate case management program (physical or behavioral health).
3
Complete the referrer information section.
4
Fill out the member's information and conditions.
5
Review the form for accuracy before submission.
Who needs the Medi-Cal Managed Care Referral Form?
1
Case managers who require documentation for Medi-Cal referrals.
2
Healthcare providers directing patients to case management services.
3
Medi-Cal members seeking assistance in managing their health.
4
Care coordinators working with multiple health services.
5
Social workers who need to coordinate healthcare for individuals.
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What are the instructions for submitting this form?
To submit the Medi-Cal Managed Care Referral Form, you can fax it to the appropriate numbers: physical health referrals to 866-333-4827 and behavioral health referrals to 855-473-7902. Additionally, you can email the completed form to bhcmreferrals@anthem.com for behavioral health or CAMedicaidPHCM@anthem.com for physical health referrals. Ensure that all information is accurate and complete to facilitate timely processing.
What are the important dates for this form in 2024 and 2025?
Important dates for the Medi-Cal Managed Care Referral Form will vary by year and specific case management needs. Ensure that referrals are submitted timely to meet care management guidelines in 2024 and 2025. Following the procedures outlined ensures compliance with service requirements.
What is the purpose of this form?
The purpose of the Medi-Cal Managed Care Referral Form is to facilitate the process of referring Medi-Cal members to appropriate case management services. This structured format ensures that all necessary information is collected to assess and manage the health needs of the member effectively. By streamlining the referral process, case managers and providers can ensure timely access to essential health services.
Tell me about this form and its components and fields line-by-line.
- 1. Referrer Information: Enter the date, name, organization, and contact details of the individual submitting the referral.
- 2. Member Information: Details required include member ID, name, date of birth, contact information, and primary diagnoses.
- 3. Referral Reason: Select and explain the reasons for the referral to case management services.
- 4. Admission History: Indicate the member's hospitalization and emergency visit history.
- 5. Care Management Needs: Specify any support needed with accessing care or managing health conditions.
What happens if I fail to submit this form?
Failure to submit this form can result in delayed access to necessary case management services for the member. Without timely referral, individuals may miss out on essential healthcare coordination and support. It is critical to ensure all required sections are completed before submission.
- Delayed Access to Care: Members may experience a lag in receiving necessary health services.
- Inadequate Care Coordination: Lack of unified management can lead to fragmented healthcare.
- Potential Health Risks: Failure to refer timely can exacerbate medical conditions.
How do I know when to use this form?
- 1. Complex Medical Needs: For members with multiple health conditions requiring coordinated care.
- 2. Transitioning Care: When members are moving between care settings and need support.
- 3. Special Health Conditions: For members with specific health issues needing specialized management.
Frequently Asked Question
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What if I need assistance with completing the form?
Feel free to refer to the form instructions which provide guidance on completing each section.
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What information is required to fill out this form?
You’ll need basic member information, referrer details, and any relevant medical history.
Is this form specific to Medi-Cal?
Yes, this referral form is specifically designed for Medi-Cal Managed Care members.
Where do I submit the completed form?
You can submit the completed form via fax or email as indicated on the document.
What is the purpose of this form?
This form serves to initiate case management referrals for Medi-Cal members.
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