Care management program enrollment

How do we enroll a member in a care management program from an outreach or a referral, with the consent and the health assessment captured and the member assigned to a care manager?

Run enrollment from the first contact to the assignment as one process the member can finish on their phone. When an outreach reaches a member or a referral arrives, Callvu prefills the member's eligibility for the program, the conditions and the utilization that triggered it, and the care team on file, captures the member's consent to participate and to share information with their providers, presents the program's health assessment in the version the program and the line of business require with only the questions that apply, classifies the member's risk and needs from the answers, matches them to a care manager by program, language and caseload, writes the enrollment, the consent, the assessment and the assignment to the care management system of record and the EHR or the member record, and schedules the first care manager contact.

In scopeComplex: multi-party handoffsCallvu moves: prefill, classify, write back

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Last updated November 7, 2026.

The problem today

The member agreed to the program on the call, but the assessment was mailed, the consent was never returned, and the care manager's first contact came six weeks later.

Today, without Callvu

Care management programs work when the member is reached early after the trigger (a discharge, a new diagnosis, a high-risk score) and assigned to a person quickly. The reality is an outreach call, a verbal yes, a mailed assessment, a consent form nobody returns, and an assignment that waits for the paperwork. The member's engagement, which was highest on the call, is gone by the time the care manager phones.

Each program has its rules: the eligibility criteria, the consent the line of business requires (Medicare Advantage chronic care, Medicaid care management, a commercial disease program), the health assessment version and its required timing (the Medicare Advantage special needs plan assessment within ninety days of enrollment, the Medicaid health risk assessment on the state's schedule), the risk stratification, and the privacy rules for sharing the care plan with providers. The member record and the care management system are where the program's measures are reported from.

The call that gets the yes should also get the consent and the assessment, on the member's phone, before it ends.

How it runs

From the requestto the system of record.

An outreach campaign reaches a member identified as eligible, a provider or a discharge planner refers a member, or a member asks to join. Callvu opens the enrollment with the trigger.

Member: Consents to participate and to share information, completes the health assessment on their phone, and meets their care manager.
Care manager: Receives the assigned member with the assessment and the risk classification, and makes the first contact.
Callvu: Prefills eligibility, captures consent and the assessment, classifies risk, assigns, writes and schedules.

Prefill
The member's identity, the program they are eligible for and why (the conditions, the utilization, the risk score, the referral's reason), the line of business and its consent and assessment requirements, the providers and the care team on file, the language and the contact preferences are prefilled from the member record and the referral; the outreach or the member's request is linked to the enrollment.
Capture consent and the assessment
The program is explained in plain terms on the member's phone (what it is, what the care manager does, what is shared and with whom, that participation is voluntary and can end), and the consent to participate and the authorization to share the care plan with the member's providers are captured with the signature; the health assessment in the version the program and the line require is presented with only the questions that apply (conditions, medications, functional status, social needs, caregiver, goals), with the member's answers saved as they go.
Classify and assign
The answers classify the member's risk level and needs (clinical, behavioral, social) by the program's stratification, which sets the program track, the contact frequency and the care manager skill required; the member is matched to a care manager by program, language, location where it matters, and caseload, by rule; a member who declines, a result that indicates an urgent need, or an assessment the member cannot complete goes to the care management lead in the Decision Desk with the answers and only the allowed outcomes.
Write back and schedule
The enrollment with its date, the consent and the authorization, the completed assessment, the risk classification and the care manager assignment are written to the care management system of record and reflected in the EHR or the member record for the providers the member authorized, the first care manager contact is scheduled within the program's period and the member is told who will call and when, and the program's reporting measures (assessment completion, time to assignment) are produced from the record.

Where it ends: The member consented, completed the assessment and was assigned to a care manager while they were still engaged, and the care management system of record and the member record hold the enrollment the program reports from. The Decision Trace shows the eligibility, the assessment version, the risk classification and the assignment rule; the Audit Trace shows the consent, the assessment completion, the write and the first contact scheduled.

Runtime enforcement

What is enforcedwhile the work runs.

The regulations preloaded in Callvu Studio and the bank's own policies, applied as steps that run, not lines in a binder. A step that breaks a rule does not run, so a completed run was compliant.

Regulations

HIPAA (the Privacy Rule, 45 CFR 164.506 and 164.508, for care coordination and the sharing of the care plan): Care management is a health care operation and treatment activity under which the plan and the providers may share protected health information for care coordination; a disclosure outside those purposes, or of records covered by stricter rules (substance use disorder records under Part 2, some state mental health laws), needs the member's authorization, which the enrollment captures with the consent to participate.
Medicare Advantage special needs plan and chronic care requirements (42 CFR 422.101(f)) and Medicaid managed care care coordination (42 CFR 438.208): A special needs plan must conduct a comprehensive health risk assessment of each enrollee within ninety days of enrollment and annually and develop an individualized care plan with the member's participation; a Medicaid managed care plan must make a best effort to conduct an initial screening within ninety days of enrollment and coordinate care for enrollees with special health care needs; the assessment version and timing follow the line.
NCQA population health management standards and the plan's program rules: The accreditation standards expect the plan to identify members for programs, offer participation with the right to opt out, assess and stratify, assign a care manager and document the care plan; the program rules set the eligibility criteria, the stratification and the contact frequency.

Company policies

Consent and the assessment are captured on the same contact that gets the yes, on the member's phone, never mailed after.
The assessment version and its timing follow the line of business; the questions are only the ones that apply.
Assignment is by rule on program, language and caseload; the lead decides only declines, urgent results and exceptions.
The care management system of record and the member record hold the enrollment the measures are reported from.

Controls

Eligibility and trigger prefill.
Plain-terms program explanation with consent and authorization capture.
Line-specific assessment with applicable questions only.
Risk stratification and rule-based assignment.
Decision Desk for declines, urgent results and exceptions.
System of record write and first contact scheduling.

Clocks and deadlines

Initial assessment: Within ninety days of enrollment for special needs plans and Medicaid managed care screening, with the program's shorter target.
First care manager contact: Within the program's period from assignment, scheduled at enrollment.
Reassessment: Annually for special needs plans and on the program's schedule.

Documents and checks

The trigger and the eligibility
The consent and the authorization
The completed assessment
The risk classification and the assignment
The system of record enrollment and the scheduled contact

In the Decision Trace

The eligibility and the program.
The assessment version and the stratification.
The assignment rule and any lead decision.

In the Audit Trace

The outreach or referral with time.
The consent and the assessment completion with time.
The write and the scheduled contact.

The handoff

Between the front doorand the back office.

The front door

An outreach call that texts the link, a provider's or discharge planner's referral, or the member's own request in the portal; the member completes on their phone.

The back office

The care manager opens an assigned member with the assessment and the risk level; the lead sees only exceptions.

The Decision Desk

A member who declines, an assessment answer indicating an urgent need, or an assessment the member cannot complete goes to the care management lead in the Decision Desk with the answers and only the allowed outcomes.

Proof

In scope.Proof at scale, not one process at a time.

The kind of process Callvu runs in production for customers in this industry. Ask for a reference on this exact process. The results below are the industry's published proof; each claim code links to its record on agents.callvu.com.

23 hospitals in the Ministry of Health network run on Callvu.

Across Callvu customers

More than 1,000 processes are live across Callvu customers.

Across Callvu customers

Questions

What buyers ask next,answered plainly.

What does the member consent to?

To participate in the program, which is voluntary, and to the sharing of the care plan with their providers; both are explained in plain terms and signed on their phone during the first contact.

When must the health assessment be done?

Within ninety days of enrollment for Medicare Advantage special needs plans and Medicaid managed care screening, and annually after; the program's own target is shorter and the assessment is captured on the enrollment contact.

How is the care manager chosen?

By rule on the program, the member's language, location where it matters and caseload, from the risk classification; the lead decides only exceptions.

Related processes

ID card and primary care physician changes Member appeals and grievances Member enrollment and changes HIPAA authorizations Try it in the sandbox All healthcare processes

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