California - Case Management Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-09

The California Department of Health Care Services (DHCS) administers case management through distinct structural pathways, including Local Governmental Agency (LGA) Targeted Case Management (TCM), 1915(c) waiver Care Management Agencies (CMAs), and CalAIM Enhanced Care Management (ECM). The service encompasses comprehensive assessment, specific care plan development, referral, and monitoring activities to ensure Medi-Cal beneficiaries receive necessary medical, social, and educational supports.

Participation as a direct billing provider for traditional TCM requires the entity to be a recognized LGA, meaning private agencies must subcontract with a participating county or municipality rather than enrolling independently. For waiver and CalAIM pathways, private entities must secure contracts with Medi-Cal Managed Care Plans (MCPs) or be selected as a waiver CMA before submitting enrollment applications through the Provider Application and Validation for Enrollment (PAVE) portal.

1. Service Definition and Scope

In California, case management is defined under Title 22 of the California Code of Regulations (CCR) and the Medicaid State Plan as services that assist eligible individuals in gaining access to needed medical, social, educational, and other services. The scope varies depending on whether the service is delivered via TCM, a 1915(c) waiver like the Home and Community-Based Alternatives (HCBA) Waiver, or CalAIM's ECM benefit.

The core components remain consistent across authorities, requiring a person-centered approach that is independent of direct service provision to avoid conflicts of interest.

• Comprehensive Assessment: Identifying the beneficiary's needs, conditions, and preferences initially and at least every six months.
• Care Plan Development: Creating a specific, person-centered service plan (PCSP) based on the assessment.
• Referral and Related Activities: Connecting the beneficiary to appropriate providers and community resources.
• Monitoring and Follow-Up: Ensuring services are implemented and addressing any changes in the beneficiary's status.
• Target Populations: Specific groups defined in the State Plan, such as individuals with developmental disabilities or those at risk of institutionalization.
• Conflict of Interest: Case managers must be independent of and separate from the individual's direct HCBS service providers.

2. Regulatory and Oversight Agencies

The Department of Health Care Services (DHCS) is the single state agency responsible for administering the Medi-Cal program, including all case management modalities. Within DHCS, specific divisions handle different aspects of oversight, from provider enrollment to waiver compliance.

Local Governmental Agencies (LGAs) and Managed Care Plans (MCPs) act as intermediary oversight bodies for subcontracted private providers.

• Department of Health Care Services (DHCS): The primary state Medicaid agency overseeing all programs (https://www.dhcs.ca.gov/).
• Provider Enrollment Division (PED): Responsible for the enrollment and re-enrollment of fee-for-service providers (https://www.dhcs.ca.gov/provgovpart/Pages/PED.aspx).
• Integrated Systems of Care Division (ISCD): Manages 1915(c) HCBS waivers including the HCBA and Assisted Living Waiver (ALW) (https://www.dhcs.ca.gov/services/ltc/Pages/IntegratedSystemsOfCare.aspx).
• Medi-Cal Managed Care Plans (MCPs): Contracted entities that oversee ECM and Community Supports providers (https://www.dhcs.ca.gov/services/Pages/Medi-CalManagedCare.aspx).
• Centers for Medicare and Medicaid Services (CMS): Federal agency approving California's State Plan Amendments and waivers (https://www.cms.gov/).

3. Gatekeeping Prerequisites: Who Can Even Apply

California imposes strict structural preconditions on who can bill Medi-Cal directly for case management. For the traditional Targeted Case Management (TCM) program, only Local Governmental Agencies (LGAs) can be enrolled providers; private entities cannot apply directly and must instead operate as subcontractors to an LGA.

For CalAIM Enhanced Care Management (ECM), providers must secure a contract with a Medi-Cal Managed Care Plan (MCP) operating in their county before they can provide and bill for services. For 1915(c) waivers, DHCS utilizes procurement-like selection processes or limits enrollment to specific Care Management Agencies (CMAs) based on regional capacity.

• LGA Restriction (TCM): Only recognized Local Governmental Agencies can participate and submit Certified Public Expenditures (CPEs) for TCM.
• MCP Contracting (ECM): Private providers must execute a contract with a designated Medi-Cal Managed Care Plan to deliver Enhanced Care Management.
• Waiver CMA Selection: Entities wishing to provide case management under the HCBA waiver must be selected by DHCS as a designated Care Management Agency for a specific region.
• HCBS Settings Final Rule Compliance: Providers must complete an HCBS Setting Characteristics Provider Attestation confirming non-institutional operation before enrollment.
• Geographic Limitations: Waiver programs like the ALW cap enrollment and target specific regions, meaning applications may not be accepted if a county is at capacity.

4. Licensure and Certification Requirements

California does not issue a distinct "Case Management Agency" license through the Department of Public Health or Department of Social Services. Instead, approval is based on agency certification by DHCS and the professional licensure of the individual staff members employed by the agency.

Agencies must demonstrate compliance with federal HCBS regulations and state-specific programmatic standards during the DHCS readiness review.

• Agency Certification: DHCS conducts initial on-site assessments and policy reviews to validate compliance with waiver and State Plan requirements.
• Professional Licensure: Individual case managers typically must hold active California licenses as Registered Nurses (RNs) or Licensed Clinical Social Workers (LCSWs), depending on the specific program.
• HCBS Settings Attestation: Submission of the HCBS Setting Characteristics Provider Attestation document to verify community integration.
• Business Licensing: Standard local city/county business licenses and Secretary of State corporate registration are required.
• NPI Registration: The agency must obtain a Type 2 National Provider Identifier (NPI) specific to case management services.

5. Medicaid Provider Enrollment

All Medi-Cal provider enrollment applications must be submitted electronically through the Provider Application and Validation for Enrollment (PAVE) portal. The Provider Enrollment Division (PED) processes these applications for fee-for-service programs.

Providers must submit specific DHCS forms and undergo screening based on their categorical risk level.

• PAVE Portal: The mandatory electronic system for submitting Medi-Cal enrollment applications (https://pave.dhcs.ca.gov/).
• Form DHCS 6209: The Medi-Cal Provider Agreement that must be signed and submitted.
• Application Fee: Providers may be subject to the ACA institutional provider application fee (set annually by CMS) unless enrolled in Medicare or another state's Medicaid program.
• Risk Screening: Case management agencies are subject to categorical risk screening, which may include fingerprint-based background checks for owners.
• Revalidation: Enrolled providers must revalidate their Medi-Cal enrollment every five years through PAVE.

6. Staffing, Training and Background Checks

Staffing qualifications for case management in California are stringent and program-specific. TCM and waiver programs generally require a multidisciplinary team approach, often mandating the involvement of Registered Nurses and licensed social workers.

All personnel with direct beneficiary contact must clear background checks and complete state-mandated training on person-centered planning and abuse reporting.

• Case Manager Qualifications: Typically requires a California-licensed RN, LCSW, or an individual with a bachelor's degree in a health or human services field plus specific experience.
• Supervisor Qualifications: Supervisors must meet higher experience thresholds and hold appropriate clinical licensure.
• Background Checks: Live Scan fingerprinting and criminal record clearance through the Department of Justice (DOJ) for all direct-care staff.
• OIG Exclusion Checks: Monthly screening of all employees and owners against the LEIE and Medi-Cal Suspended and Ineligible Provider List.
• Mandated Training: Completion of training on person-centered service planning, HCBS Settings rules, and mandated reporting of abuse/neglect.

7. Documentation, Policies and Records

The Medi-Cal TCM Provider Manual and Title 22 CCR dictate rigorous documentation standards. Providers must maintain comprehensive case records that justify the need for services and prove that services were delivered as billed.

Failure to maintain adequate documentation, particularly regarding the avoidance of duplicated services, is a primary source of audit recoupments.

• Comprehensive Assessment Record: Must document the beneficiary's medical, social, and educational needs, updated at least every six months.
• Care Plan Documentation: The specific care plan must be signed, dated, and clearly link identified needs to planned interventions.
• Encounter Notes: Progress notes must include the date, location, specific nature of the service, outcome, and the case manager's signature.
• Duplication Check: Records must explicitly document that the case manager investigated and confirmed no other programs (e.g., regional centers) are duplicating the billed services.
• Record Retention: All Medi-Cal records must be retained for a minimum of ten years from the date of service.

8. Billing, Rates and Claims

Reimbursement methodologies depend entirely on the program authority. TCM utilizes a Certified Public Expenditure (CPE) model where LGAs claim the federal share of costs based on interim encounter rates and annual cost reports.

Waiver case management is billed fee-for-service via the California Medicaid Management Information System (CA-MMIS), while ECM is billed directly to the contracted Managed Care Plans.

• TCM CPE Model: LGAs fund the non-federal share and are reimbursed the federal share (typically 50%) based on submitted cost reports.
• CA-MMIS: The system used for processing fee-for-service claims for waiver programs.
• ECM Rates: Negotiated directly between the provider and the Medi-Cal Managed Care Plan; not set by a statewide fee schedule.
• Time Surveys: TCM providers must maintain continuous time surveys to support cost report allocations.
• Billing Codes: Specific HCPCS codes (e.g., T1016 for case management) must be used, often with program-specific modifiers.

9. Approval Sequence and Timeline

The timeline to become an active case management provider varies by pathway. For waiver CMAs, the process begins with DHCS selection, followed by PAVE enrollment, which can take several months.

For ECM, the timeline is dictated by the Managed Care Plan's credentialing and contracting cycle.

• Step 1: Program Selection/Contracting: Secure an LGA MOU, DHCS waiver CMA designation, or MCP contract.
• Step 2: PAVE Submission: Submit the complete enrollment application via the PAVE portal.
• Step 3: Readiness Review: DHCS or the MCP conducts policy reviews and potential on-site assessments.
• Step 4: Application Processing: DHCS PED typically processes complete PAVE applications within 90 to 180 days.
• Step 5: Provider Number Issuance: Receipt of the Medi-Cal Provider Identification Number (PIN) allowing claims submission.

10. Common Denials and Survey Findings

DHCS conducts regular oversight and audits of case management providers. Findings often center on documentation deficiencies and failure to coordinate care across multiple systems.

Providers must implement robust Quality Management plans to monitor compliance and prevent recoupments.

• Duplication of Services: Billing for case management when the beneficiary is receiving similar coordination from a Regional Center or other waiver.
• Incomplete Assessments: Failure to conduct or document the required six-month periodic reassessment.
• Missing Signatures: Care plans or encounter notes lacking the required beneficiary or supervisor signatures.
• Unallowable Activities: Billing for direct service provision (e.g., client transport) under case management codes.
• Location Errors: Failing to specifically document the location of the service (e.g., writing "Other" without specifying the exact community location).

11. Key Contacts and Resources

Providers should utilize official DHCS resources and manuals for the most current requirements. The Medi-Cal Provider Manuals are updated monthly and serve as the definitive guide for billing and policy.

Help desks are available for both programmatic questions and technical assistance with the PAVE portal.

• DHCS Provider Enrollment Division: For questions regarding PAVE and Medi-Cal enrollment (https://www.dhcs.ca.gov/provgovpart/Pages/PED.aspx).
• PAVE Help Desk: Technical support for the enrollment portal (866-252-1949).
• Medi-Cal TCM Provider Manual: The official policy document for Targeted Case Management (https://files.medi-cal.ca.gov/).
• CalAIM ECM Resources: DHCS guidance on Enhanced Care Management (https://www.dhcs.ca.gov/calaim/Pages/ecm.aspx).
• DHCS Integrated Systems of Care Division: For inquiries related to 1915(c) waivers (https://www.dhcs.ca.gov/services/ltc/Pages/IntegratedSystemsOfCare.aspx).

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