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CalAIM

Sample form letter that an RCFE administrator or care coordinator can submit to the Managed Care Plan (MCP) to request approval for accepting a CalAIM member under Community Supports (e.g., Housing Transition/Navigation or Tenancy with RCFE placement).

 [RCFE to MCP CalAIM Placement Request Form Letter]

[Your Facility Letterhead or Name]
[Facility Name]
[Facility Address]
[City, State ZIP]
[Phone Number]
[Email]
[License Number]

[Date]

To: [Managed Care Plan Name]
Attn: CalAIM/Community Supports Authorization Team
[Plan Address or Fax/Email if known]

Subject: Request for CalAIM Community Supports Authorization – RCFE Placement

Resident Full Name: __________________________  
Date of Birth: __________________________  
Health Plan ID#: __________________________  

Dear CalAIM Authorization Team,

We are writing to formally request authorization for [Resident Full Name] to receive **Community Supports** services under the **CalAIM initiative**, specifically:

- ☐ Housing Transition Navigation Services  
- ☐ Housing Tenancy Services  
- ☐ Ongoing tenancy support while residing in a **licensed Residential Care Facility for the Elderly (RCFE)**

Our facility, [Facility Name], is a licensed RCFE (CDSS License # __________), and we are able to provide care and supervision within our scope under Title 22 regulations. Based on the resident’s current health status and completed LIC 602 Physician’s Report, this individual qualifies for and is appropriate for RCFE-level care.

**Attached documents for your review include:**
1. Completed **LIC 602** (Physician’s Report)
2. RCFE Admission Agreement (draft or signed, if available)
3. [Optional] Functional Needs Assessment or Case Manager Summary
4. [Optional] Statement of Coordination with Community Supports Provider (if applicable)

We will coordinate with any assigned Community Supports provider for tenancy support services, case management, and care coordination, as necessary.

Please advise of any additional documentation or procedures needed to move forward with approval. We appreciate your support in facilitating this placement, which will help avoid institutionalization and ensure housing stability for this CalAIM member.

Sincerely,  
[Name of Administrator or Designated Contact]  
[Title]  
[Facility Name]  
[Phone Number]  
[Email Address]

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✅ What You Should Do Next:

  1. Fill in the resident’s and your facility’s details.

  2. Attach the LIC 602 and any other support documentation.

  3. Send it via email, secure fax, or upload to the MCP’s CalAIM portal (if applicable).

  4. Keep a copy and follow up for authorization.

 

managed care plan (e.g., Anthem Blue Cross, HealthNet, etc.)

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Steps to Submit a CalAIM Community Supports Authorization Request to Health Net

1. Verify Member Eligibility

2. Determine Appropriate Community Supports Services

3. Prepare Required Documentation

  • Complete the Medi-Cal Prior Authorization Request Form – Outpatient.

  • Attach supporting documents, which may include:

    • LIC 602 (Physician’s Report)

    • Functional Needs Assessment

    • Draft or signed RCFE Admission Agreement

    • Any other relevant assessments or case manager summarieshealthnet.com+1hpsm.org+1

4. Submit the Authorization Request

5. Await Authorization Decision

  • Health Net typically processes authorization requests within five business days.

  • You can check the status of your request through the Provider Portal.

  • If additional information is needed, Health Net's authorization team will contact you.healthnet.com

6. Provide Services Upon Approval

  • Once authorization is approved, coordinate with the assigned Community Supports provider to deliver the approved services to the member.healthnet.com

7. Billing and Claims Submission

📌 Additional Resources

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