Tentative Launch Date: Winter 2025
Type: Medicaid- Food as Medicine
State(s): California
CenCal Health provides comprehensive health coverage to residents of Santa Barbara County and San Luis Obispo County in California. CenCal Health also collaborates with organizations like Foodsmart to address social determinants of health while increasing patients' access to healthcare.
We are partnering with CenCal to provide Nutrition counseling in addition to managing the food benefit. Our partnership launched in November 2025 to help administer both the nutrition counseling and the food benefits, which include a risk assessment to determine whether Foodsmart will recommend food as a temporary clinical intervention.
RD Requirements:
Health Plan Credentialing | State Medicaid Enrollment | Foodsmart Credentialing Requirements |
CenCal workramp trainings must be completed |
| Medallion Credentialing Application, Copies of CDR, license in home state and where pt resides, CV |
RD Responsibilities
Eligibility: RDs are NOT required to determine if a member qualifies for food. The Risk Assessment logic automatically recommends food based on reported qualifying medical conditions.
Submission Policy: The Risk Assessment must be completed during the initial visit. Because the form cannot be edited or updated once submitted, accuracy and completeness are vital.
Important: If a member lacks the information required to complete the assessment at the first visit, please advise them to request a reauthorization or email cencalauth@foodsmart.com.
CenCal RD Network Roster Updates
The CenCal network roster is currently managed to ensure operational stability and clinical quality. While we have a process for adding RDs back to the network, we are managing this transition in phases to maintain streamlined operations.
Next Steps: Once we are ready to expand the roster, we will reach out to eligible RDs in our log with the specific steps required to get back on the roster (e.g., completing the mandatory Workramp competency check).
Please note: Re-entry is based on clinical documentation performance and current network capacity.
Benefits Overview:
Video Required
| # of Allowed Visits
| # of Allowed Units per Visit
| Schedule Cadence
| Billing Codes |
No | 3 visits every 3 months | 4 | Every ~4 weeks
Visits should be spaced out monthly, as that would align with 3 visits for each 12 week food authorization | Initial: 97802 Follow Up: 97803 |
Nutriquiz Required | SNAP Required?
| Risk Assessment Required? |
Yes | Recommended if patient does not already have SNAP | See below for updated risk assessment information
**You cannot edit the Risk Assessment once it’s been submitted, so accuracy and completeness are essential. |
Food Benefits:
Foodsmart Bucks | Foodboxes/MTM | Food Selection Instructions |
No | Food is authorized in 12- week durations!
Food will be authorized for 4-week approvals when: (1) there is not sufficient clinical information to approve the auth or (2) the member's diagnosis does not match the clinical evidence provided (e.g., member self reports high cholesterol but reports lab values not indicating high cholesterol but with lab values that indicate a different condition such as Hyperlipidemia).
** No lifetime max has been set up yet RDs are forbidden from calling Cencal regarding a member's denial. Members can reach out to Cencal if they want to appeal.
Estimated turnaround time after RA is submitted is 2-4 weeks.
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*RDs should not contact CenCal directly regarding member benefit denials. If you believe a denial was issued in error, please submit a Food Support Ticket on FNN with new supporting documentation. The Food Ops team will review the information to determine if the authorization request should be resubmitted.
Helpful RD Scripting Before Risk Assessment:
“Your insurance plan provides nutrition services that are administered by Foodsmart, which includes nutrition counseling. You have been referred to Foodsmart for an assessment to determine which nutrition services would be appropriate.
During the assessment, I am going to ask you questions about your clinical history. Please share as much information as possible which includes any medical conditions you are managing, any recent labs you have completed with your doctor, and any recent hospitalizations.
Based on the information you provide today, Foodsmart will make a recommendation that could include food support provided through one of CenCal plan's contracted food vendors.
Please note that receiving food is temporary and it will not be recommended to assist with food insecurity alone. Food is only recommended if the food would help you manage your chronic conditions, and you might not continue receiving food just because you were previously receiving food.
Regardless of whether your plan ultimately approves you to receive food, you do have access to nutrition counseling to help you achieve your nutrition goals.”
Risk Assessment
The Risk Assessment serves a clinical tool to determine intervention intensity by measuring the severity of a member’s chronic condition. While CenCal recognizes the impact of food insecurity, this specific eligibility program is rooted in the "Food as Medicine" model, designed to directly improve clinical health outcomes, and food insecurity is not relevant in their eligibility considerations.
Risk Level | Criteria | Will Foodsmart recommend food for member and, if yes, how much? | What is sent to CenCal after RA is completed | When should follow-up MNT visit be scheduled? | When should member complete their next risk assessment to determine if Foodsmart will continue recommending food? |
Low Risk | Member has only 1 or fewer of the DHCS qualifying conditions | No | Nothing | 4 weeks from assessment | N/A |
Medium Risk | Member has 2 or more DHCS qualifying conditions OR has congestive heart failure OR has uncontrolled diabetes (A1c >= 9.0%) | Yes, for 12 weeks | RA and FFD chart | 4 weeks from assessment | 9 weeks from previous assessment |
High Risk | Member meets Medium Risk criteria AND had a recent hospitalization within the past 90 days due to a DHCS qualifying condition | Yes, for 12 weeks | RA and FFD chart | 4 weeks from assessment | 9 weeks from previous assessment |
A notification will appear at the top of the FFD alerting RDs when a risk assessment is required.
Guide your member through the risk assessment and answer all required questions that are labeled with an *
Thoroughly complete any preferences, recommendations, and notes for the food vendor for the members.
List of DHCS qualifying conditions:
Anemia
Anxiety disorders
Asthma
Atherosclerosis
Bipolar disorder
Cancer
Celiac disease
Chronic kidney disease stage 3
chronic kidney disease stage 4
Congestive heart failure (stage C or D)
COPD
Crohns disease
Dementia alzheimers
Diverticular disease
Dyslipidemia
Elevated lead levels
End stage renal disease
Fatty liver
Gastritis
Gastroenterities and colitis
Gastroesophageal reflux disease (gerd)
Gastrointestinal hemorrhage
Gestational diabetes
Heart disease
High cholesterol
High risk perinatal conditions
HIV
Hypertension / high blood pressure (or elevated bp/medication)
Hypertensive heart disease with heart failure
Hypertensive heart disease without heart failure
IBS (irritable bowel syndrome)
Liver disease
Major depressive disorder
Nutritional marasmus
Obesity
Peptic ulcer without hemorrhage or perforation
Schizophrenia
Stroke
Thyroid issues
Type 1 diabetes
Type 2 diabetes
Ulcerative colitis
Unspecified protein calorie malnutrition
If the member does not have one of these DHCS qualifying conditions select "No Medical Conditions."
Save time by typing the first letter of the condition. This will instantly narrow down the choices.
Clinical Grid for Risk Assessment
For each medical condition selected in the risk assessment, it will display the related primary labs, secondary labs, and symptoms.
If a lab or symptom is shared across multiple selected conditions, the RD can update it once, and the latest value will sync everywhere on the form.
Medical Condition | Lab 1 | Lab 2 | Symptoms |
Type 1 Diabetes
(Requires 1 Lab) | HbA1c (≥ 7.0%) | Fasting Glucose (Marker), Post-Meal Glucose (Marker) |
|
Type 2 Diabetes
(Requires 1 Lab) | HbA1c (≥ 7.0%) | Fasting Glucose (Marker), Post-Meal Glucose (Marker) |
|
Gestational Diabetes
(Requires 1 Lab) | HbA1c (≥ 6.5%) | Fasting Glucose (Marker), Post-Meal Glucose (Marker) |
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Hypertension (High BP)
(Requires 1 Lab) | BP (≥ 130/80) | N/A |
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Hypertensive Heart Dis. (no HF)
(Requires 1 Lab) | BP (≥ 130/80) | N/A |
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Hypertensive Heart Dis. (w/ HF)
(Requires 1 Lab) | BP (≥ 130/80) | Sodium (Marker) |
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CKD Stage 3
(Requires 1 Lab) | eGFR (Marker) | Creatinine (Marker) |
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CKD Stage 4
(Requires 1 Lab) | eGFR (Marker) | Phosphorus (Marker) |
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End Stage Renal (ESRD)
(Requires 1 Lab) | eGFR (Marker) | Phosphorus (Marker) |
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Obesity
(Requires 1 Lab) | BMI (≥ 30.0) | Weight (Marker) |
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High Cholesterol / Dyslipidemia
(Requires 1 Lab) | LDL (≥ 130) | Triglycerides (Marker), Total Chol (Marker) |
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Anemia
(Requires 1 Lab) | Hemoglobin (Marker) | Hematocrit (Marker) |
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ASCVD/Cardiovascular Disorders
(Requires 1 Lab) | LDL (≥ 130) | Total Chol (Marker) |
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Congestive Heart Failure (C/D)
1 Lab OR (BMI + 1 Symptom) | BNP (Marker) | Weight (Marker) | Shortness of Breath, Edema (water retention) |
Malnutrition
1 Lab OR (BMI + 1 Symptom) | % Weight Loss (Marker) | Albumin (Marker) | Unintentional weight loss |
Crohn’s Disease
1 Lab OR (BMI + 1 Symptom) | CRP (Marker) | Albumin (Marker) | Abdominal pain, Diarrhea |
Ulcerative Colitis
1 Lab OR (BMI + 1 Symptom) | CRP (Marker) | Albumin (Marker) | Rectal bleeding, Abdominal pain |
Celiac Disease
1 Lab OR (BMI + 1 Symptom) | tTG-IgA (Marker) | Weight (Marker) | Steatorrhea (fatty stools), Bloating, Diarrhea |
Cancer
1 Lab OR (BMI + 1 Symptom) | % Weight Loss (Marker) | Albumin (Marker) | Unintentional weight loss, Oral pain |
HIV
1 Lab OR (BMI + 1 Symptom) | CD4 Count (Marker) | Albumin (Marker) | Unintentional weight loss, Fatigue |
Stroke (CVA/TIA)
1 Lab OR (BMI + 1 Symptom) | LDL (Marker) | BP (Marker) | Fatigue, Brain Fog |
COPD
1 Lab OR (BMI + 1 Symptom) | O2 Sat (Marker) | Weight (Marker) | Shortness of Breath, Fatigue |
Asthma
1 Lab OR (BMI + 1 Symptom) | Pulse Ox (O2) (Marker) | Peak Flow (Marker) | Shortness of Breath, Fatigue, Chest Pain |
Liver Disease (NAFLD, NASH, Cholestatic, ESLD, Cirrhosis)
1 Lab OR (BMI + 1 Symptom) | ALT/AST (Marker) | Bilirubin (Marker) | Nausea, Abdominal pain, Edema (water retention) |
Thyroid Issues
1 Lab OR (BMI + 1 Symptom) | TSH (Marker) | Weight (Marker) | Fatigue, Sudden weight gain |
High Risk Perinatal
1 Lab OR (BMI + 1 Symptom) | BP (Marker) | Glucose (Marker) | Inappropriate gestational weight gain |
Elevated Lead Levels
1 Lab OR (BMI + 1 Symptom) | Blood Lead (Marker) | Hemoglobin (Marker) | Abdominal pain, Constipation, Loss of appetite, Fatigue, Irritable |
GERD / Gastritis
(Symptom-Based) | N/A | N/A | Heartburn, Reflux, Nausea |
Gastrointestinal Disorder (IBS / IBD / Short Bowel / Diverticular Disease / Gastroparesis)
(Symptom-Based) | N/A | N/A | Abdominal pain, Bloating, Constipation |
Peptic Ulcer
(Symptom-Based) | N/A | N/A | Abdominal pain, Nausea, Vomiting |
Major Depressive Disorder
(Symptom-Based) | N/A | N/A | Fatigue, Loss of appetite, Reduced energy |
Anxiety Disorders
(Symptom-Based) | N/A | N/A | Irritable, Fatigue, Brain Fog |
Schizophrenia / Bipolar
(Symptom-Based) | N/A | N/A | Fatigue, Disordered Eating, Irritable |
Dementia / Alzheimer’s
(Symptom-Based) | N/A | N/A | Brain Fog, Loss of appetite, Fatigue |
What happens if your member has no labs/symptoms that are requested under the medical conditions?
Click the box “Requested data not available"
You will see the alert below
The member will not be eligible for food benefits unless the required labs and/or symptoms are provided either in the current visit or another visit.
The risk assessment will be available for retaking on the next visit, if the member brings their needed labs, to reassess food benefit eligibility.
After completing the risk assessment, please read the following script to the member based on their Risk Level from the assessment.
Medium and High Risk
Based on the assessment, Foodsmart will be submitting a recommendation for food benefits with additional nutrition counseling. Your health plan will review this recommendation and determine eligibility. This could take up to 2 weeks. If approved, the food vendor will contact the member to coordinate food delivery. You should work with your primary care provider or specialist to manage your chronic condition since additional labs and clinical notes will be needed in 10 weeks during your reassessment.
Low Risk
Based on the screening information provided, you does not qualify for the criteria needed for Medically Tailored Meals. As of July 2025, Medically Tailored Meals is a short-term health support program for members with specific medical conditions that can improve with medically tailored food. It is not meant to be a long-term or ongoing food assistance program. Regardless, the RD can continue to provide nutrition education and help connect member to longer-term food assistance resources, such as SNAP or local food banks.
If a member is identified as a low risk, their information will NOT be sent to CenCal. If the member prefers to have their information sent, members may email cencalauth@foodsmart.com. However, we do not encourage this as their request will likely be denied because they don’t meet the clinical criteria. Please try to refocus the member on the benefit of MNT/nutrition counseling, which is still provided to them at no cost
If the member does email cencalauth@foodsmart.com, we will manually send the results of the RA and their chart note for consideration to CenCal, even though it’s likely to be denied.
Documenting Clinical Necessity in FFD
For a medical nutrition therapy (MNT) visit to be reimbursed or for a food authorization to be approved by CenCal, documentation MUST explicitly demonstrate clinical necessity. Because RDs are delivering a Medically Tailored Meal (MTM) intervention, the FFD chart must support and reflect a medical service based on clinical necessity.
1. The Evidence-Based Requirement
RDs documentation must prove that the member requires medically tailored meals or groceries to either stabilize a chronic condition or show measurable clinical improvement.
2. Required Clinical Data Points
To support a specific diagnosis, the FFD Chart must include:
Clinical Evidence: Self-reported lab values (e.g., A1c, GFR, Blood Pressure).
Medication Reconciliation: Documentation of current medications, dosage, and adherence, particularly those affected by nutrition.
Symptomatology: Current physical manifestations of the condition.
Interventions: Specific MNT actions taken during the session.
SMART Goals: Member-centered goals that are Specific, Measurable, Achievable, Relevant, and Time-bound.
CenCal denies food authorizations because documentation is too vague or geared towards food insecurity as opposed to clinically oriented towards managing a chronic condition.
Documentation Best Practices
To avoid claim denials, ensure the narrative in your "FFD Chart" aligns with the "Risk Assessment" logic. If the member's condition is severe enough to trigger a food recommendation, the clinical notes should reflect that severity through the data points mentioned above.
SMART Goal Clinical Framework
This SMART Goal Framework is designed to help you bridge the gap between a member's personal motivation and the clinical documentation required for food authorization. By focusing on behavior-based interventions, you provide CenCal plan with a clear path to medical necessity.
Collaborate with the member to define objectives that focus on the specific behaviors impacting their health outcomes. Define exactly what the member will do (the intervention) to achieve the desired change.
Translating Member Statements to SMART Clinical Goals
FFD Smart Goals is the clinical document of the 'Food as Medicine' program. It is essential that your SMART goals are clearly written and provide clinical justification for food support, specifically detailing how the intervention addresses the member’s medical conditions and behavioral goals. Use the "Strong" examples below to guide your documentation in the FFD Chart.
Member Statement (Weak) | Clinical SMART Goal (Strong) | Why it Works |
"I want to eat healthier." | "The member will consume 3 servings of non-starchy vegetables per day, 5 days per week, to improve glycemic control." | Focuses on a specific behavior that impacts blood sugar. |
"I need to lose weight." | "The member will reduce daily caloric intake by 500 kcal and walk 20 minutes per day to manage BMI and joint pain." | Links the intervention to symptom management (joint pain). |
"I'll try to use less salt." | "The member will limit sodium intake to less than 2,300 mg per day by using herbs instead of salt for 6 out of 7 dinners." | Defines the exact intervention (using herbs) to reach the target. |
RD Documentation Checklist for Medically Tailored Meals
Use this checklist during every visit especially the Initial to ensure the Risk Assessment (RA) provides the strongest clinical justification for Medically Tailored Meals (MTM).
1. Clinical Evidence & Lab Values
[ ] Capture Member-Reported Labs: While missing labs won't automatically disqualify a member, providing them significantly strengthens the case for "unmanaged" conditions.
[ ] If the member doesn't have labs handy, document what they do have (e.g. height, weight, and symptoms) and a plan for them to bring results to the next visit to support future reauthorizations.
2. Symptomatology & Medications
[ ] Link Symptoms to Diagnosis: Document all current symptoms, specifically highlighting those that correlate with their qualifying diagnosis (e.g., Diabetes or CHF).
[ ] Identify Clinical Justification: Note any symptoms that demonstrate the member is struggling to manage their condition through diet alone, necessitating MTM support.
[ ] Reconcile Medications: List all current medications and dosages to illustrate the intensity of the medical intervention required.
3. SMART Goals & Interventions
[ ] Prioritize SMART Goals: The absence of documented SMART goals is a primary reason for food authorization denials. Work with the member to set at least one specific, measurable goal..
Additional Labs that have been added to FFD Chart
Category | Lab Value | Standard Unit (US) |
Protein & Inflammatory Status | Albumin | g/dL |
| Prealbumin | mg/dL |
| Total Protein | g/dL |
| C-Reactive Protein (CRP) | mg/L |
| Transferrin | mg/dL |
Glycemic Control & Metabolism | Fasting Glucose | mg/dL |
| Fasting Insulin | uIU/mL |
| C-Peptide | ng/mL |
Hematology & Anemia Markers | Hemoglobin (Hgb) | g/dL |
| Hematocrit (Hct) | % |
| Ferritin | ng/mL |
| Serum Iron | mcg/dL |
| TIBC | mcg/dL |
| MCV | fL |
Micronutrients | Vitamin D (25-hydroxy) | ng/mL |
| Vitamin B12 | pg/mL |
| Folate | ng/mL |
| Methylmalonic Acid (MMA) | nmol/L |
| Homocysteine | umol/L |
| Zinc | mcg/dL |
Electrolytes & Renal Markers | Sodium | mEq/L |
| Potassium | mEq/L |
| Phosphorus | mg/dL |
| Magnesium | mg/dL |
| Blood Urea Nitrogen (BUN) | mg/dL |
| Creatinine | mg/dL |
Thyroid | TSH | mIU/L |
| Free T4 (Free Thyroxine) | pmol/L |
| Free T3 (Free Triiodothyronine) | pmol/L |
| Total T4 | nmol/L |
| Total T3 | nmol/L |
Check Box: Member states they do not have updated labs for this visit
Standardized Scripting for Effective Risk Assessment Communication in FFD
Scripting after performing the Risk Assessment to communicate to the members what next steps will be is provided within the Risk Assessment in FFD when you view the member’s results.
This standardized scripting is designed to pivot the conversation from "food delivery" to "clinical treatment." Use these talking points to ensure members understand that food is a medical tool and that their health plan requires specific data for approval.
RD Terminology Guide
Avoid Using | Use Instead | Why? |
"Denial" / "Denied" | "The health plan did not approve the recommendation." | We are providers, not the health plan. |
"Low/High Risk" | "Eligible" or "Not Eligible" | Provides clarity on service access without labeling the member. |
"I am giving you food." | "I am recommending food support based on this assessment." | Sets realistic expectations for the health plan's final review. |
"Required for compliance" | "Consistent partnership" or "Collaborative effort" | Promotes a positive, supportive relationship. |
Cencal Vendors
For Medically Tailored Meals (MTM): We partner exclusively with Homestyle Direct. They provide fully prepared, clinician-approved meals that are ready to heat and eat.
For Medically Tailored Groceries (MTG): We partner exclusively with Bento. They provide credits for specific healthy grocery items that members can select.
"Gold Standard" Charting Examples for Cencal
Example 1:
Member Baseline: A1C: 8.4% (Latest lab from 02/15/26)
Clinical Linkage: High-fiber intake is required to slow glucose absorption and stabilize blood sugar, addressing the member's uncontrolled T2DM and helping to manage co-morbid Dyslipidemia.
SMART Goal:
Specific: Replace processed carbohydrate snacks with 1 serving of fresh fruit/veg to stabilize Fasting Blood Glucose <130 mg/dL.
Measurable: Patient will track daily morning glucose readings and report to RD.
Achievable: Addresses physical barriers (member uses a walker/gets dizzy) by utilizing home-delivered grocery boxes.
Relevant: Lowering daily fasting glucose is a necessary clinical step to reduce A1C to <7.0% at the next 3-month draw.
Time-Bound: Achieve consistent fasting readings <130 mg/dL by the March 10 follow-up visit.
Example 2:
Member Baseline: Weight: 240 lbs | Height: 5'10" (BMI: 34.4)
Clinical Linkage: Connects high-fiber intake and physical activity to energy levels and the management of Obesity and Major Depressive Disorder.
SMART Goal:
Specific: Add 2 non-starchy vegetables, 2 high-fiber fruits, and 1 whole grain food per day to support 1–2 lb weight loss/week.
Measurable: 90% adherence (approx. 6 days/week); patient will track on her food log app.
Achievable: Confirmed member has a refrigerator for safe grocery storage.
Relevant: Achieve 5% total weight loss (approx. 12 lbs) to improve metabolic health and energy.
Time-Bound: Achieve 80% goal attainment by next month’s follow-up.
Example 3:
Member Baseline: A1C: 7.6%
Clinical Linkage: Addresses "denture-friendly" options (canned, mashed, or blended) to ensure the clinical intervention is accessible despite physical dental limitations.
SMART Goal:
Specific: Add 1 soft fruit or cooked vegetable to meals to improve glycemic stability and reduce fasting BG to <130 mg/dL.
Measurable: At least 1 serving daily recorded in a paper log.
Achievable: Uses denture-friendly, easy-to-chew options included in Bento boxes.
Relevant: Supports blood glucose control and digestive health for chronic disease management.
Time-Bound: Continue daily through the 5-week follow-up period.
Example 4:
Member Baseline: BP: 154/92 mmHg
Clinical Linkage: Focuses on reducing sodium intake to manage fluid retention and decrease cardiac strain. Lowering systemic blood pressure through sodium restriction is medically necessary to prevent fluid volume overload.
SMART Goal:
Specific: Limit daily sodium intake to <2,000 mg to support a target reduction of systolic BP by 5–10 mmHg.
Measurable: Patient will track daily sodium (mg) using a food log and record BP readings 3x/week.
Achievable: Member is receiving low-sodium Medically Tailored Meals (MTM) to simplify adherence.
Relevant: Sodium restriction is medically necessary to stabilize fluid volume and move toward a long-term BP goal of <130/80.
Time-Bound: Achieve a consistent downward trend (target <145/85) by the 4-week follow-up.
Example 5:
Member Baseline: Weight: 325 lbs | Height: 5'10" (BMI: 46.6)
Clinical Linkage: Specifically addresses "sugar withdrawal" symptoms after cutting soda, providing behavioral support to maintain clinical progress in obesity management.
SMART Goal:
Specific: Replace soda with water at every meal to support 5% total weight loss (approx. 16 lbs).
Measurable: Track 100% adherence (0 sodas per day) in the Foodsmart app.
Achievable: Member has a refillable water bottle for consistent access.
Relevant: Direct reduction of sugar/carbohydrate intake to support weight reduction and metabolic health.
Time-Bound: Achieve 100% adherence to soda replacement by the 4-week follow-up visit.
Physician Review for CenCal
For CenCal we are having our ClinOps team review your charts before they can be sent to CenCal.
When you go to submit your chart you will now see an option to “Send to physician for review” and will not be able to select “Finalize and submit to billing”.
Once you send this to our team, they will either submit the claim on your behalf or provide feedback on something that needs to be fixed in your chart.
If changes are needed, you will see a task show up with comments. You will then be able to fix the chart and re-submit in the same way.
Sample Visit Topics:
This program has medically tailored meals. For the patient to receive meals you must complete the risk assessment during the visit with the patient.
Visit Number | Topics | Must Complete |
1 | Get to Know, NutriQuiz (baseline measurements + reminder to get lab work done), Food Insecurity Screening, Introduction to Prenatal Nutrition | Risk Assessment and Nutriquiz |
| Medium Risk Patient: MTM Delivery High Risk Patient: MTM Delivery |
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2 | SNAP application (if applicable | SNAP Application if needed. |
| Medium Risk Patient: MTM Delivery High Risk Patient: MTM Delivery |
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3 | MNT Foodsmart Program | Nutriquiz and MTM Reassessment |
| Medium Risk Patient: MTM Delivery High Risk Patient: MTM Delivery |
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Cencal FAQs:
Is not having the labs going to disqualify them from qualifying for food support, even if we asked for them?
Not having labs will not “disqualify” a member, but having lab values will greatly enhance the justification behind a food support recommendation. It is highly encouraged for members to provide labs as this can display whether or not a condition is “unmanaged”
Do patients need to be sure of their labs or is a guess or estimate sufficient?
A guestimate is okay since the lab fields are documented as patient reported
Encourage the patient to bring lab values to the next visit (for RD to include in the next RA), since the lab values may be a consideration on if they qualify for food support
Will the changes in FFD appear in all charts or just CenCal charts?
Only CenCal for the outlined additions
BMI and wt graph additions are in all charts
What are the next steps in the appeal process after this email is sent, will the RD be notified of any additional documentation needed?
Yes, the RD will be notified directly if any additional documentation is needed.
Are there any guidelines for asking the members symptoms? Should we ask for all symptoms or just those that may be related to their DX?
Ask for and document all symptoms the member may be experiencing, especially the symptoms that you feel are related to their qualifying diagnosis.
You should also document any symptoms that you feel contribute to the clinical justification for MTM food support.
Is NQ still required for CenCal? RDs are finding not enough time to do both RA and NQ at the initial.
NQ can be bumped to the 2nd visit, prioritize collecting an RA at the initial if you do not have time for both.
Are members informed in advance of their initial appointment of what information they need to report, such as lab values?
Yes, Member Support has been reminded to communicate this to the members when scheduling.
If the patient is not open to making SMART goals or having a nutrition intervention, should we tell them this will affect whether they qualify to receive food?
The lack of documented SMART goals will most likely impact if the member qualifies for food. Encourage the member that they need to set SMART goals.
If patient refuses, you can document in intervention “pt denies setting smart goals but would like to xyz (eat more vegetables, eat out less, etc)”
What should I do when pt is denied benefits and doesn’t want to proceed with the visit?
We suggest the RD wait until the end of the visit, not the beginning of the visit, to disclose our recommendation based on their results/risk level.
The RD should not use the word “deny”. Remind the patient that foodsmart does not “deny” and that their health plan will make this final decision based on all the notes from the completed visit.
Are there any updates in regards to Bento telling members that their authorization ends within 6 weeks?
This occurred because all members were conditionally approved for a window of food support, giving Foodsmart time to reassess the member with the new RA. The member will need to complete a new RA to assess if they will receive continued food support after that 6 week conditional period ends.
Does the RD still need to add justification in the "Recommendations to Food Vendor” section on the Risk Assessment?
No, with the updates to the RA the justification will come from the documented information within the RA and chart note.
SMART goals must be discussed with members and documented in FFD.
Does all of the information from the assessment copy over into our notes (sx, dx, meds, etc), or do we need to document everything twice?
The duplicate fields were removed from the RA, so you should only need to document things once. The fields from the RA do not populate into the chart.
Do pts know that the program is not for food insecurity and is more temporary than how they received them before?
CenCal is working on communication to members to help explain the program. Foodsmart is also reinforcing the goals of the program - that the program is about food as a clinical intervention - in our support, outreach, and marketing communications.
Can engineering consider making some drop downs in the lab section of FFD? I don't see an option when the FFD note is open to enlarge the chart section of the screen.
We don’t have this today, but we’re working on some larger changes to FFD that should make the UI much better/easier to navigate. We will take this as feedback for the changes.
Pts from December filled out an RA and many were denied. RD is unable to redo RA as it isn’t showing active, are RDs able to redo an RA for those that were previously denied?
CenCal approved conditional meal support for the short term, giving us time to redo an RA with our new version. This will be submitted with the new chart to CenCal for consideration of food support.
We should direct members to CenCal, specifically their member portal, for the status of their food authorization.
When does the RA repopulate for pts who completed appointments in December?
Some members did not have sufficient clinical documentation for CenCal to make a determination, including patients assessed to be low, medium, or high. Many were sent conditional temporary food support for this gap time.
A new Risk Assessment should be completed when indicated in FFD as active.
Should we do risk assessments every follow up?
No, the RA will activate 10 weeks after the last one was completed.
Right now, we need a new RA done for all members since the old version did not have what CenCal needed.
Follow FFD for when to complete another RA for these members.
For the members that were temporarily approved for a shorter 6 week period, my worry is that they didn't have the qualifications for eligibility to begin with and are going to be denied again. What language should we use to explain this if this were to happen?
This program is meant to provide a temporary clinical intervention for members who have multiple chronic conditions that are unmanaged. Food might not be the appropriate clinical intervention for members with stable chronic conditions.
Complete the visit and new risk assessment, as CenCal will be the one to determine if they are truly eligible. We've aligned with Cencal on if food would be an appropriate intervention, so aim to complete the visit and see what CenCal decides.
Can we be allowed to see last Risk Assessment answers? (Last clinical note/recommendation to Cencal, last vendor used (members forget often), etc. etc)
We don’t have this capability at this time, but possibly in the future!
What happens for charting purposes if a pt completes the RA, but does not want to create smart goals? Do we continue with the chart but put N/A for smart goals and explain that pt was not interested in the end?
Always encourage these members to document SMART goals as it will be a large consideration in food support
If patient refuses, you can document this in the intervention section by saying something like “Patient denied setting smart goals and states ‘they would like to work on improving their general dietary patterns’”(or whatever the member states regarding goals).
Given the visit cadence, should we tell the member that a monthly check-in is required for compliance to keep food benefits going?
We would advise the RD not to use the work “required for compliance”, but rather encourage the member to come to their visit every month since the program is meant to promote consistent partnership between the RD, member, and food support as a collaborative effort.
Are we able to remove CenCal members from the on demand cue to allow a full hour for the session?
We likely won’t do this, as it would result in fewer on demand visits to go around.
Are we able to diagnose malnutrition based on clinical criteria?
We can make a nutritional diagnosis malnutrition by identifying specific clinical criteria (weight loss, low intake, muscle/fat loss) within our PES statements
While we can diagnose and are often the first to identify malnutrition, a medical provider must have diagnosed it to add to the list of medical conditions. What can be helpful if someone is unsure or doesn't have access to what they have been diagnosed with (after visit summaries, mychart, etc) is to ask and speak directly to their PCP. I have also been able to help a member request our documentation to provide to their doctor to be able to have them formally agree and acknowledge our nutritional diagnosis. (Thank you to Maria Cammarota for this extensive answer!)
For clarity and to communicate this to members when they ask: Why can’t CenCal complete an approval for food benefits directly themselves? Several members have stated that having FS appointments to complete the authorization is a long way around for a decision-making process that is ultimately not within our control or up to us.
When a member asks why Foodsmart is part of the food box program, it can be helpful to explain that many reasons why CenCal has partnered with Foodsmart is to give members access to a nutrition specialist like "myself". Through this partnership, nutrition therapy becomes a targeted “food as medicine” approach—making sure the food you receive actively supports your health, helps manage existing conditions, and prevents symptoms from getting worse. Together, we work with you on personalized meal planning, behavior-based nutrition coaching, and health-informed guidance to help prevent or manage chronic conditions such as diabetes and heart disease, reduce healthcare costs, and improve overall well-being.
Is CenCal FNN summary document 100% up to date with these changes?
Yes
What part of the chart is shared with CenCal to document other nutrition factors that indicate additional need for food outside DHCS conditions, so they can view member’s disease burden and have a full clinical picture to review when they make their decisions?
Intervention Notes
SMART Goals
Labs Attestation
SNAP/EBT Assistance Interest
Symptoms
Medications Specific Name
All Risk Assessment fields
Is there an appropriate PROBLEM list for PES listed somewhere?
Could we walk through writing a smart goal with the guidelines/prompts that are in FFD? What is the best way to write PES and SMART goals to best tie them to MTM?
Make sure SMART goals are behavior-based and centered on improving their chronic condition. For example, for a member with T2DM instead of saying “increase daily consumption of fruit” you might say “replace 3 high carb meals per week with a low glycemic index MTM meal” or “replace one serving of carbs at each dinner with a serving of non-starchy vegetables.”
For PES statements, some examples are “Inadequate nutrient intake related to limited ability to plan, shop for, and prepare meals consistent with medical nutrition therapy recommendations as evidenced by [diagnosis], [lab values/clinical indicators], and reliance on inconsistent or nutritionally inadequate meals; medically tailored meals are indicated to support disease management and meet individualized nutrition needs.”
Is Bento the only Vendor for CenCal members?
For MTM, Homestyle Direct is the only vendor
For MTG, Bento is the only vendor
Do the members' visits restart with 3 total for 2026? So if they started in Dec 2025, they have 3 for this year?
The member gets 1 visit per month for 3 months, then they reset. So essentially they will get 12 per year, ideally 1 every 3-4 weeks.
If they started in December 2025, they now have 12 visits (1 per month) for 2026.
Can we request that the assigned vendor and their contact information be listed on members’ charts? That way, we will quickly be able to direct a member to contact the appropriate company/agent for more information.
We are not able to display the member’s assigned food vendor in FFD at this time, but this is being discussed as a valuable possible addition to FFD.
Please see the following link of Overview of Health Plans for info on all health plans.