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The Truth About CalAIM

We have been hearing a lot of CalAIM misinformation that can be confusing to California Counties and Providers, so we want to set the record straight. We have put together a comprehensive guide with CalAIM Payment Reform information and technology needs. 

Guide Sections:
    1. What Is CalAIM?
    2. CalAIM Behavioral Health Payment Reform Initiative
    3. Technology Supporting California Specific Requirements 
    4. Kings View Professional Services, powered by Qualifacts Credible EHR

California Advancing and Innovating Medi-Cal (CalAIM) is an initiative to improve the health outcomes of the California population by transforming the care delivery system, expanding programs, and reforming payment methodologies across all of Medi-Cal. By embracing cutting-edge technologies, fostering collaboration among healthcare providers, and streamlining administrative processes CalAIM will pave the way for a more accessible, equitable, and patient-centric healthcare experience.  

 

  • New programs and requirements 
  • Approach a consumer’s needs with a whole-person care lens  
  • Make Medi-Cal consistent and seamless across counties 
  • Care delivery improvements 
  • Enhance outcome quality for consumers and reduce administrative burdens for staff 

 

Impacts The Entire Medi-Cal Delivery System Across All Venues of Care: 

  • Medi-Medi Plans 
  • Managed Care Plans 
  • Mental Health Plans 

 

CalAIM Goals: 

  • Make Medi-Cal a more consistent and seamless system, reducing complexity and increasing flexibility 
  • Comprehensively manage a consumer‘s needs through whole-person care (population health) 
  • Improve quality outcomes, reduce disparities, and transform the delivery system through value-based initiatives, modernization, and payment reform 

 

 
 
 
 
 
 

Policy 

 
 
 
 

Go-Live Date 

 
 
 
 

Revised Criteria for Specialty Mental Health Services 

 
 

January 2022 

 
 
 
 

Drug Medi-Cal Organized Delivery System (DMC-ODS) Policy Improvements 

 
 

January 2022 

 
 
 
 

Drug Medi-Cal ASAM Level of Care Criteria for Counties 

 
 

January 2022 

 
 
 
 

Updated Reasons for Recoupment 

 
 

January 2022 

 
 
 
 

Documentation Redesign 

 
 

July 2022 

 
 
 
 

Co-Occurring Treatment 

 
 

July 2022 

 
 
 
 

No Wrong Door 

 
 

July 2022 

 
 
 
 

Standardized Screening and Transition Tools 

 
 

January 2023 

 
 
 
 

Behavioral Health Payment Reform 

 
 

July 2023 

 
 
 
 

Advancement of Data Sharing 

 
 

Ongoing 

 
 
 
 

Administrative Integration of SMH and SUD Services 

 
 

January 2027 

 

Please note: Policy information and dates were provided from The California Department of Health Care Services website. For more information visit: https://www.dhcs.ca.gov/Pages/BH-CalAIM-Webpage.aspx  

 

True or False: Counties Won’t Need Next-Generation Technology to Meet CalAIM Requirements 

False!

 

There are new challenges created by the expansion of service offerings and the coordination of care across levels of care and multiple providers for consumers. Additionally, new reimbursement models create another level of complexity. To thrive under CalAIM, increased technological functionality is a necessity, enabling seamless participation in integrated care, provision of digital services, and acceptance of value-based reimbursement. As state requirements evolve, the need for reliable EHR support and seamless data sharing becomes vital for informed decision-making and quality improvement efforts. We expect to see California organizations plan for technology investment and expand their use of current technology to deliver services under CalAIM. 

CalAIM Behavioral Health Payment Reform Initiative 

Most Medi-Cal Specialty Mental Health and Substance Use Disorder services are funded by Counties using state-allocated revenue streams. Before the CalAIM initiatives, Counties were reimbursed for Medi-Cal specialty behavioral health unlike other Medi-Cal managed care plans. Counties did not receive per-member-per-month capitated payments. Counties claimed services and received a portion of reimbursement for specialty behavioral health services as an interim paymentLater Counties are subject to a cost reconciliation process and may receive additional funds which reflect the actual cost of providing services.

 

The CalAIM Behavioral Health Payment Reform initiative’s strategic direction is to transition from a cost-based system driven by auditing rules to a value-based (capitated) system over the next few years. As a result of this transition, both the State and Counties are reassessing long-standing practices and expectations accumulated over many years. 

 

Goals: 

  • Maximize usage of federal funding 
  • Reduce administrative burden for state, counties, and providers 
  • Simplify payments to counties and providers 
  • Decrease audit liability associated with the cost-based system through simplification 
  • Decrease financial risk and budget challenges by reducing delays in audit timelines 
  • Reduce the administrative footprint to increase services with streamlined workflows (documentation) 

 

Iterative Journey to Reach a Value-based System: 

  • Alignment across many departments to ensure consistent expectations 
  • Starts with alignment to a true fee-for-service model 
  • Changing the mindset around billing, audit complexities, and many years of history 
  • Begin evaluating quality over volume, along with new claiming practices 
  • Establishes an understanding of the data to prepare for value-based care (e.g. units, costs, value) 
  • Requires new or modified reporting and auditing requirements 
 

 

The Transition 

 

Beginning July 1, 2023, the CalAIM Behavioral Health Payment Reform initiative will change the way county BH plans claim federal reimbursement. As managed care plans, counties will continue to contract with specialty behavioral health providers and negotiate provider payments under those contracts. 

 

Reimbursement Structure: Cost-based to Fee for Service 

  • Counties negotiate payment terms and rates with subcontracted providers
  • Counties claim FFS rates established in a BH plan fee schedule
  • Payments are final, there is no cost settlement

 

Financing: Intergovernmental Transfers (IGT) to fund BH Plans 

  • Reimbursement is claimed via fee schedules  
  • IGT’s allow counties to transfer funds to DHCS for funding (SDMC, UR)   
  • No cost settlement 
  • Non-federal shares are still available (SGF, MAA, etc) 

 

Billing: Alignment to other delivery systems and CMS  

  • Use of CPT codes for more standardized definitions 
  • Usage of HCSPCS codes for certain providers/services 

  

The Impact of Payment Reform 

 

  • Requires alignment across state departments to ensure consistency in expectations 
  • Re-evaluation of many years of practice and expectations 
  • Provides an opportunity to better understand data in preparation for value-based care 
  • Numerous new policies 
  • New reporting and auditing requirements 

 

New Billing Requirements for MHP Highlights 

 

Counties are using Medi-Cal’s new billing manuals and other supporting documentation to learn about the Medi-Cal requirements and establish new billing guidelines for contracted providers. 

 

  • Implementation of CPT codes instead of only HCPCS 
  • Updates to place of service definitions and usage 
  • Updates to modifier definitions and usage 
  • Use of add-on and/or dependent codes (service is dependent on completion of another service) 
  • Allows for claiming of peer support activity 
  • Threshold limits for certain services 
  • Rate establishment/new rate schedules 
  • Aligned more closely to standard billing 
  • Fractional Units are no longer allowed 
  • Continued usage of billing lockouts 
  • Rendering provider taxonomy requirements 

 

Testing Information 

 

Medi-Cal testing systems launched on January 23, 2023, for Counties (MHP’s) to initiate their testing process. 

 

  • State offering end-to-end testing 
    • Inclusive of Acknowledgement Files (TA1, 999, SR) 
    • Includes Remittance Advice (835) 
  • Processes to request Client Index Numbers (CIN) specific for testing 
  • When testing, the CIN, DOB, and gender must match the test data  
  • Testing processes for Contracted Providers are dependent on County testing procedures 
  • Medi-Cal Testing Resource Guide available in January assisted counties define the scenarios that should be considered 
  • Weekly testing QA sessions commenced for counties in February 2023 

 

 
 
 
 
 
 

Test Phases 

 
 
 
 

Description 

 
 
 
 

Timelines 

 
 
 
 

Phase 1 

 
 

Testing successful file submission of 10 claims and receiving the following acknowledgment reports: TA1, SR report and 999 

 
 

January 23 – September 30 

 
 
 
 

Phase 2 

 
 

Testing CalAIM business rules and submitting claims using CPT Codes 

 
 

February 1 – September 30 

 
 
 
 

Phase 3 

 
 

Testing add-ons and IGT process 

 
 

March 1 – September 30 

  

Tips for Counties to Prepare for the Change 

  • Gather and review Medi-Cal requirements (manuals, rates, testing processes, reporting) 
  • Treat this as a major project 
    • Assign a project owner 
    • Establish a project plan 
    • Determine the need for additional resources 
  • Determine if there are process and/or procedure changes 
    • New workflows 
    • Training
  • Determine the need for configuration updates within EHR 
    • New service or visit types, modifiers, procedure codes 
    • New rates 
    • Establish a crosswalk from the old to new
  • Determine assistance needed from EHR Vendor 
    • Support  
    • Development 
  • Prepare for testing 
  • Prepare for user training 

 

 

True or False: CalMHSA is a State Organization and Counties Have to Only Take Their Advice 

False!

California Mental Health Services Authority (CalMHSA) is not a state organization. CalMHSA is a Joint Powers of Authority (JPA) formed by counties throughout the state. As a JPA, CalMHSA is not a state agency.  

 

Qualifacts has teamed up with Kings View Professional Services (KVPS) to provide California Counties with support and expertise. Over the past 25 years, KVPS has paved the way for clear and actionable technical data for California’s behavioral health data. They demonstrated their expertise at demystifying streams of California technical data, shaping it into a clear and compelling narrative. 

 

KVPS customers receive expert support and benefit from the lowest denial rates along with the highest state reporting compliance rates reported by EQRO.*  With over 34 California Counties served, as both a healthcare provider and IT services organization, KVPS has a unique in-market perspective and expertise to help its partners with integrated consumer data, billing, and clinical solutions. 

Technology Supporting California Specific Requirements 

 

Innovative and configurable EHR support has never been more crucial for California County Behavioral Health and Human Services Agencies. As state data collection and reporting requirements evolve, foundational EHR support and data sharing are vital for decision-making and ongoing quality improvement efforts. 

 

Functionality Needed to Support CalAIM  

  • Full access to all critical data allows for the compilation and analysis of information received from providers, demonstrating improved outcomes, and better treatment protocols  
  • Ability to match consumers automatically or manually and seamlessly add or update insurance using the California specific MMEF file  
  • Module to share consumer and payer eligibility, authorize providers, process, adjudicate and pay claims, and track expenditures for services within defined covered benefits across care systems  
  • Monitor service authorizations and interventions, measure adherence to established benefit plans, authorize medically necessary services, and review utilization  
  • Consumer engagement tools, including a client portal providing online access to scheduling, medication renewals, completion of forms and assessments, and payment processing  
  • Connect with other systems and organizations — including patient data access and system-wide health information exchanges (HIE)  
  • Comprehensive reporting to track consumer movement and placement for those served by multiple providers  
  • Multiple reporting tools and a Business Intelligence model to provide real-time dashboards measuring Key Performance Indicators to demonstrate program impact, continuous improvement, and contract compliance  
  • Receive referrals, generate data exports into standard referral letter templates, and manage the referral process to outside providers with Integrated Primary Care  
  • California specific 837 file functionality and 835 processing capabilities 
  • Ability to collect, track, and submit data electronically to the State such as CSI, CalOMS, FAST, MHSA-FSP, OSHPD, ASAM LOC, and outcomes 


True or False: Counties Only Have One EHR Vendor to Choose From 

False!

There is no state EHR system that all Counties must use. Agencies are switching Qualifacts to support CalAIM program initiatives, including data analytics, consumer engagement, and care coordination tools. With Qualifacts, agencies benefit from next-generation technology that strengthens enhanced care management and community support services. Our EHR platforms help California behavioral health and human services providers achieve greater performance, take the burden out of compliance, and deliver outstanding care to those in need. From meeting MediCal and upcoming CalAIM requirements to optimizing clinical workflows and demonstrating positive outcomes.  

 

Kings View Professional Services, powered by Qualifacts Credible EHR 

 

Together, Kings View Professional Services (KVPS), Qualifacts, and the Credible EHR give agencies a secure, proven solution to overcome challenges in today’s complex care environment, that can flexibly enable expanded service offerings, while supporting changing requirements and payment models. Every County has unique requirements and workflows EHRs must support. Kings View Professional Services and Qualifacts provide: 

  • Next-generation EHR aligned with statewide requirements, adaptable to changing regulations, and configurable for County specific workflows  
  • Secure, proven solution that is currently helping Counties navigate and adhere to the objectives and challenges of the CalAIM initiative and emerging Value Based Reimbursement (VBR) payment models 

 

 
  • Our product teams, in collaboration with KVPS, have assessed Mental Health, Drug Medi-Cal, and ODS Waiver requirements comprehensively, and we’ve released enhancements 
  • Continuously involved in state activities, such as webinars, training, and more, while also providing sample project plans to assist organizations in getting started 
  • Collaborate with customers to interpret new Medi-Cal requirements and release enhancements for their implementation 
  • Offer guidance to County customers on operationalizing these requirements and defining testing approaches for their organizations 
  • To ensure preparedness, we partnered with KVPS for Medi-Cal testing. Our development teams are diligently testing various aspects, including claims submission, acknowledgment reports, CalAIM business rules, CPT codes usage, and IGT processes 
  • Comprehensive workflows to process the California specific monthly eligibility file, Meds Monthly Extract File (MMEF), including automatic and manual matching of consumers and insurance updates 
  • Workflows for managing calls from consumers or family members interested in services 
  • Capabilities and w