Lactation Consultants Step-by-Step Process

Verify if the member is eligible for LC services by checking eligibility through:

• The provider portal. Log in and select Eligibility at the top of the page > Eligibility Check. For guidance on how to access to the provider portal and verify eligibility, refer to the below brochure:
  • Save Time Navigating the Provider Portal brochure – Health Net (PDF) 
• The Oregon Medicaid Management Information System (MMIS) Provider Portal. Refer to the OHA (PDF) Guide  for steps on how to use the MMIS Portal. 

If you are a provider who currently does not have access to the Oregon Medicaid Management Information System (MMIS) portal call Provider Services at 800-336-6016 (option 5) or visit the OHP provider website at https://www.oregon.gov/oha/HSD/OHP/Pages/Provider-Splash.aspx

Refer to the Referral and Auths Guidance for CS Providers training located on the CalAIM Provider Training page to see the steps to check eligibility and submit authorizations through the provider portal.

1. Add Refer to member step by step guide.or see Medi-Cal
2. Medi-Cal Member Recommendation for Doula Services – Health Net (PDF)
3. DHCS recommendation form

Make a referral by using one of the following:

• Refer a member to CS services through findhelp (recommended).
  
  Make a referral by following the steps below:
  1. Sign in or create an account by selecting Sign-up at the top right corner. Fill in your information and create a password.
  2. Go in to CalAIM Assessment to complete and document the member's information and view available CS programs.
  3. If the provider's program card has a check mark on the upper right-hand corner, that means the CS provider is setup to receive referrals through findhelp (if the checkmark is missing, contact the CS provider directly to make a referral). Click the REFER button to make a referral.
• Refer a member by contacting the CS provider directly:
  1. Find a CS provider through our Provider Directory:
  2. Contact the contracted CS provider and provide the member's contact and any supplemental information used to determine the member's eligibility for CS services.

CS providers may receive referrals through findhelp or other means.

findhelp

• CS providers will receive a referral notification letting them know they have a new referral. The referrals will automatically be added to their Inbound Referrals dashboard.
• The member's contact information is included in the notification so that CS providers can connect with the member directly. If a comment was included at the time of the referral, that will be in the body of the email.
• CS providers will be responsible for checking the CS authorization guide to qualify the member for the CS services and submit an authorization prior to providing the services (refer to step 6).
• When the authorization is approved, CS providers can update the status of the referral directly from the email notification or their inbound dashboards. The updated status will be reflected in real time in each respective dashboard (refer to step 7).

Other means

• CS providers can receive referrals directly from other entities by using the contact information listed in the provider directory.
• CS providers will be responsible for checking the CS authorization guide to qualify the member for the CS services and submit an authorization prior to providing the services (refer to step 6).
• When the authorization is approved, we recommend CS providers notify the referring entity (refer to step 7).

The CS provider will follow up with the member to collect their consent and all supporting documents needed for authorization. Refer to the CS authorization guides to determine what documents to submit with the authorization request. Note: Member consent can be written or verbal as long as you have a record of it. We do not have a template for consent and you are not required to submit it to us.

How do I submit authorizations?

Submit authorizations by either of the following:

• Online (recommended): Go to the provider portal and log in.
• Fax: Complete the prior authorization request and fax it to 866-724-5057. The authorization form can be found at the Prior Authorization webpage.

For more information on how to submit authorization requests, refer to the Referral and Auths Guidance for CS Providers training located on the CalAIM Provider Training page.

Note: The training deck is available after viewing the training video.

Billing

Providers can bill CS services by submitting a claim or an invoice form. Note: If you submit a claim, you won't have to submit an invoice and vice versa.

Bill with a claim

Submit claims using one of the following:

• Electronic data interchange (EDI) through a clearinghouse or Availity (recommended).
• The CMS-1500 (version 02/12) form for paper claims. Refer to the Claims Procedures section for more information.

Bill by invoice

Complete and submit Invoice forms:

• Download the Invoice form from the Claims Procedures section.
• Submit by email, mail, fax or Conduent portal:
  • Email: CalAIM_CS_invoicesubmission@centene.com
  • Address:
    California Health and Wellness Plan – CalAIM Invoice
    PO Box 10439
    Van Nuys, CA 91410-0439
  • Fax: 833-386-1043
  • Conduent Web Portal

Billing training

To learn more about how to bill for CS services, refer to the Claims and Invoice Guidance for CS Providers training on the CalAIM Provider Training page.

Note: The training deck is available after viewing the training video.