Sub Acute Services and Support

Long term care health facilities staff with a patient

Overview

Effective January 1, 2024, all MCPs will become responsible for the full LTC benefits at the following ICF (Home) types:

Adult Subacute Facility
Pediatric Subacute Facility

Per DHCS, all Medi-Cal beneficiaries residing in the above Homes are mandatorily enrolled into a Medi-Cal MCP for their Medi-Cal covered service

Sub Acute APL

Non-Emergency Medical Transportation (NEMT) for members in Long Term Care

Non-Emergency Medical Transportation (NEMT) is available for a member with a medical and/or physical condition that makes transportation by ordinary public or private transportation medically contraindicated, and transport is needed to obtain medical care. NEMT must be prescribed in writing by the member’s treating Physician, Physician Assistant or Certified Nurse Midwife and be accompanied by a completed Physician Certification Form (PCS).

For non-emergency transportation, if a member’s medical and physical condition requires any of the following, then the member requires NEMT:

Supine or prone position.
Member incapable of sitting in a private vehicle, taxicab, or other form of public transportation for the time necessary to transport to and from their appointment.
The member needs to be transported in a wheelchair or assisted to and from their residence, a vehicle, and a place of treatment because of disabling physical or mental limitation.

If a member’s medical and physical condition does not require any of the above, then the member requires Non-Medical Transportation (NMT).
For more information on Non-Emergency Medical Transportation (NEMT), please review the provider alert below.

Transportation Provider Alert

DME/Prior Authorization

For any outpatient approval – including DME – an authorization request along with necessary orders and clinical documentation would be needed.

For members transitioning to Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) from Fee-For-Service (FFS) Medi-Cal or from another Plan, incontinent supplies are not part of Continuity of Care (CoC) and will be transitioned to Western Drug immediately due to capitation. When Health Plan PA Dept receives the request from the current provider/supplier for these services, our Lead IP will transition to Western Drug per our internal process

Dental General Anesthesia:
Health Plan covers facility fees and IV sedation or general anesthesia for a member’s dental procedure with prior authorization when medically necessary and performed by a physician anesthesiologist or CRNA in the following settings:

Dental office
Hospital
Accredited Ambulatory Surgery Center and
A community clinic that:

Accepts Denti-Cal,
Is a non-profit organization and
Is recognized by the Department of Health Care Services (DHCS) as a licensed community clinic or a Federally Qualified Health Center (FQHC) or a FQHC Look-Alike

Medi-care does not cover dental general anesthesia, therefore Health Plan would cover under Medi-Cal benefit

For inpatient approvals – such as room and board – authorization form, HS 231form, TAR and face sheet for ICF will be required.

In cases where Health Plan is secondary, we will cover Medi-Cal approved benefits where it is not covered by primary insurance and when appropriate.

Case Management

Case Management Programs are available to all Health Plan members meeting eligibility for the program.

1. Complex Case Management assists members with multiple chronic conditions who need extra support to achieve optimal wellness
2.Condition Management assists members in understanding and taking care of a single chronic condition such as:

- Heart Failure
- Depression
- Asthma

Authorization Timeline

1. Auth received either by portal or fax with necessary documentation

2. Auth reviewed and processed within the following timeline:

Urgent – i.e. acute to SNF/LTC 72 hours
Standard – i.e. re-authorizations 5 days
Post Service – bedhold requests 30 days

3. Once approved approval letter sent to facility via fax

Required Documentations

Face sheet
Current MD Orders
PASRR
Discharge planning notes, if indicated by the Q section

Frequently Asked Questions:

Sub Acute FAQ

Will Subacute facilities need a new authorization for members residing in the their facilities if there is already an approved Treatment Authorization Request (TAR) on file from the Department of Health Care Services?

Yes, all patients who transition to Health Plan will need an authorization issued by Health Plan.

What if my facility patient is a Health Plan member but was not part of the data provided by DHCS?

Nursing facilities are required to follow Health Plan’s standard authorization procedures for Health Plan members who are not included in the Subacute data provided by DHCS.

How do I submit an authorization for Health Plan members?

Authorization requests must be submitted electronically through Doctor’s Referral Express, Health Plan’s the provider portal. Visit www.hpsj.com/providers to login or create a new account.

You may also submit an authorization request by secure fax to 1-209-762-4702. If submitted by fax, include the current authorization request form.

Supporting clinical documentation must be included for electronic or faxed authorization requests.

Will Health Plan honor other DHCS approved TARs (excluded from the room and board)?

Health Plan will receive TAR data from DHCS and will contact the affected facilities to verify and arrange for any new authorizations.

What do I do if a bed hold is needed?

Whenever a Health Plan member is transferred/discharged from the facility, you must notify Health Plan of the transition. For transfers to the acute hospital, submit a request for authorization of a bed hold online using Doctor’s Referral Express, www.hpsj.com/providers or by sending the authorization request form by fax to 1-209-762-4702.

How will authorization information be communicated to the facility if we do not have access to Health Plan's Provider Portal (Doctor’s Referral Express)?

The facility will receive fax notification of the authorization information.

What documentation is required for Subacute re-authorizations?

When requesting re-authorization, include the most current provider progress note validating the need for continued stay, MD orders, and PASRR for your Health Plan patient.

How far in advance can Subacute authorizations be requested?

Re-authorization can be requested 2-4 weeks prior to the current authorization expiration date date.

Which vendors are contracted for durable medical equipment (DME), lab, x-ray, oxygen, pharmacy, and podiatry?

A list of Health Plan contracted providers can be found using Health Plan’s provider search tool located at: www.hpsj.com/find-a-provider Pharmacy benefits are administrated by DHCS through Medi-Cal RX and can be found on the Medi-Cal RX website: www.medi-calrx.dhcs.ca.gov/home. View tools and resource section.

Do we need an Authorization for co-insurance when Health Plan is secondary payer?

Claims FAQs

Is it ok to bill claims on bi-weekly?

Yes, claims can be billed on a bi-weekly basis.

Does Health Plan accept claims from Office Ally for LTC?

Contact Office Ally to confirm that they can process your LTC claims for Health Plan Members.

How will our facility receive payments?

Change HealthCare (CHC) is Healt Plan’s contracted payment vendor. Claim payments are dispersed according to your current set up with CHC.

Should claims typically billed at the beginning of the month include non-covered services (NCS) such as DME equipment, transportation, etc., which are excluded from patient’s share of cost?

Non-covered services (NCS) items must be billed separately.

When billing, do we use ub04 claim form?

Yes, SNF’s should bill LTC services using a ub04 claim form.

How will our facility be reimbursed for physical therapy services?

Physical therapy services are reimbursed as part of the supplemental payment for the first 45 days of admission. After 45 days, authorization must be obtained for additional physical therapy services, and those services must be billed separately.

How should I bill for custodial vs skilled care?

We do not differentiate between the two when it comes to billing. Providers should bill the same revenue codes for all levels of care. Here are the revenue codes you should use:

0101 = All Inclusive Room and Board (bill in conjunction with accommodation code 01)
0180 = Leave of Absence – General (bill in conjunction with accommodation code 02 or 03)
0185 = Bed Hold (bill in conjunction with accommodation code 73)