Foundation Living — Management Dashboard

Agreement Tracker

Patient name

CIN

Auth date

6 month date

Agreement exp.

Re-auth / Move out

Invoice Tracker

Patient name

CIN

Auth date

Last used

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→

Next invoice

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Patient name

CIN

First day

Last day

Eligibility Tracker — Anthem

Patient name

CIN

Date checked

Status

Notes

Show moved out

Patient name	CIN	Last checked	Status	Notes

Subcontractors

Phoenix Haven LLC

PH Portion: $66/day · FL Portion: $33/day

Patient name

CIN

Auth date

Next invoice

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PH Agreement Document

Foundation Living

Subcontractor Agreement

Short-Term Post Hospitalization Housing (STPHH) Agreement

This agreement facilitates the safe discharge of the Patient/Resident (listed below) from acute care or SNF to a Room and Board facility operated by the subcontractor of Foundation Living.

The Patient/Resident is enrolled in the Anthem Blue Cross Managed Care Program and has been authorized for STPHH services. Authorization is valid for 90 days, with reauthorization required to continue services beyond that period. Total housing support is limited to 180 days from the date of move-in; no extensions will be granted.

Billing & Payment Terms

• Daily Rate: $66.00

• Foundation Living will pay the Room and Board provider within 45 days of invoice receipt.

• If the Patient/Resident leaves and does not return within 24 hours, this agreement ends. This applies even if the Resident is hospitalized or incarcerated. Payment is made through the date of departure only.

Additional Terms

• Room and Board may not bill the Patient/Resident for services during this agreement.

• A Field Care Navigator will be assigned to the Patient/Resident.

• The Patient/Resident must maintain Medi-Cal eligibility and assigned to Anthem Blue Cross for this agreement to remain valid.

Room & Board Requirements

The Room and Board agrees to provide a sober living environment that is clean, safe, and in good repair, with the following amenities:

• Hot and cold running water; central heating and air conditioning

• Fully functioning bathroom(s) with toilet, shower/tub, and sink; fully functioning kitchen with refrigerator, freezer, cooktop, microwave, and sink

• Furnished home with necessary linens and bath towels; availability of basic household cleaning supplies

• Provisions for three meals per day

Provider Name

Point of Contact

Address

Patient / Resident Name

DOB

CIN

Phone

Start Date (move-in) / Authorized Date

End Date (180 days after)

Room and Board — Owner or Manager Signature

Foundation Living Representative Signature

MasterCare ECM Referral Form

Page 1 of 3

Referral for ECM (ENHANCED CARE MANAGEMENT) Services

TO REFER:

Secure Email: Notification@MasterCarePlan.com or Secure Fax: 877.924.7010

Questions? Call 855.836.6355

Referral source information
External referral by (Select one):	Hospital Primary medical group (PMG) PCP Clinic Enhanced Care Management (ECM) provider Other
Referring individual name:
Referring organization name:
Referrer phone number:
Referrer fax number:
Referrer email address:
Member provides consent for requested services: Yes or No
By checking this box, you are attesting that all information provided on this form has been validated.
Note to referrers: Please only mark the services you are referring to.

Member information
Member name:
Member Medi-Cal client ID # (CIN):		Member DOB:
Member address:
Member primary phone number:		Best time to contact:
Member preferred pronoun:
Caregiver name:
Caregiver's phone number (if available):
Contact Phone/fax/email:

Page 2 of 3

MasterCarePlan.com • 604 Sutter Street #290 • Folsom, CA 95630 • (855) 836-6355

Population of Focus – Please check all that apply:

Adult – Individuals at Risk for Avoidable Hospital or Emergency Department (ED) Utilization

5 or more repeated ED visits in a six-month period that could have been avoided with appropriate outpatient care or improved treatment, OR
3 or more unplanned hospital or short-term skilled nursing facility (SNF) stays in a six-month period that could have been avoided with appropriate outpatient care or improved treatment OR
Any unplanned ED or inpatient stays in 6 months for members who have medical, psychiatric, or SUD-related conditions that require intensive coordination or members who have significant functional limitations or adverse social determinates of health that impede navigation their health care and other services

Adult – Nursing Facility Resident: Transition to Community

3 or more ED visits in a 12-month period that could have been avoided with appropriate outpatient care or improved treatment adherence OR
2 or more unplanned hospital and/or short-term skilled nursing facility (SNF) stays in a 12-month period that could have been avoided with appropriate outpatient care or improved treatment adherence

Adult – LTC Eligible; At Risk for Institutionalization

Adults living in the community who meet the Skilled Nursing Facility (SNF) Level of Care criteria; OR require lower-acuity skilled nursing, such as time-limited and/or intermittent medical and nursing services, support, and/or equipment for prevention, diagnosis, or treatment of acute illness or injury.
Actively experiencing at least one complex social or environmental factor influencing their health (including, but not limited to, needing assistance with activities of daily living (ADLs), communication difficulties, access to food, access to stable housing, living alone, the need for conservatorship or guided decision-making, poor or inadequate caregiving which may appear as a lack of safety monitoring),
Able to reside continuously in the community with wraparound supports (i.e., some individuals may not be eligible because they have high acuity needs or conditions that are not suitable for home-based care due to safety or other concerns).

CONT'D…

Page 3 of 3

MasterCarePlan.com • 604 Sutter Street #290 • Folsom, CA 95630 • (855) 836-6355

Complex physical and behavioral health conditions (Check all that apply)
Physical health Asthma History of stroke or heart attack Chronic liver disease Diabetes Traumatic brain injury (TBI) Chronic kidney disease Dementia Congestive heart failure (CHF) Coronary artery disease Hypertension Chronic obstructive pulmonary disease (COPD)
Behavioral health SUD Major depressive disorder bipolar disorder Psychotic disorders, including schizophrenia
Additional social criteria Limited social support/isolated creating poor quality of life Barriers to self-management/poor treatment adherence Not suitable for telephonic care management Please explain:
Additional notes: Quick address: CIN: [CIN] DOB: [Date of Birth] Move-in Date: [Move-in Date] Address: [Address] Patient was admitted to [Facility Name] on [Admission Date] to [Discharge Date] for [Medical Conditions] and homelessness. Patient was transported to Foundation Living on [Foundation Living Admission Date] to [Address] and will remain placed through STPHH program. CIN: [CIN] DOB: [Date of Birth] Move-in Date: [Move-in Date] Address: [Address] Patient was admitted to [Facility Name] on [Admission Date] to [Discharge Date] for [Medical Conditions] and homelessness. Patient was transported to Foundation Living on [Foundation Living Admission Date] to [Address] and will remain placed through STPHH program. Copy patients to Select which patients to copy. Assign Invoice Numbers · Starting from PatientInclude Print All Invoices Select patients to print for Update Statuses Set billed / paid status for PatientBilledPaid Billing Periods Weekly Eligibility Check Set status for all patients as of today Generate Inactive Insurance Email Select patients to include in the email Connect to Google Sheets Enter your Google Apps Script URL to sync data Re-auth Reminder Select patients needing re-authorization 0 selected Add Existing Patient Select patients from your agreement tracker to add to invoices only PatientAdd