Need to Submit an Authorization?
Need to Submit an Authorization?
Medi-Cal covered long-term care services include placement in the following types of facilities:
Effective January 1, 2024, or as authorized by the Department of Health Care Services, HPSJ will cover the following additional types of facilities:
The Preadmission Screening Resident Review (PASRR) is a federal requirement (Code of Federal Regulation (CFR), Title 43, Sections 483.100-138) for all members initially entering a SNF to determine if they have a possible Serious Mental Illness (SMI)or have an Intellectual Disability/Development Disability/Related Conditions (IDD/DD/RC). The Federal regulation indicates that a PASRR is required for all members who apply for admission into a Medi-Cal certified Skilled Nursing Facility (SNF), regardless of the individual’s insurance type or payment source. This requirement also applies to members who already reside in a Medi-Cal certified SNF.
PASRR Responsibilities:
General Acute Care Hospital (GACH):
Skilled Nursing Facilites (SNF):
Skilled Nursing Facilities (SNF) – Alerts (hpsj.com)
Priority | Turn-Around Time | Example Scenarios |
---|---|---|
Urgent | 72 Hours | Acute to SNF/LTC |
Standard | 5 Business Days | Re-authorizations |
Post Service | 30 Calendar Days | Retrospective bed hold requests. |
3. The facility will receive an initial notification within 24 hours of the decision via fax or phone for all decisions. The facility will also receive a Notice of Action (NOA) by mail , in addition to the initial notification for adverse determinations within 2 business days of the decision.
Non-Emergency Medical Transportation (NEMT) for members in Long Term Care
For non-emergency transportation, if a member’s medical and physical condition requires any of the following, then the member requires NEMT:
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.
Skilled Nursing Facility Authorizations FAQ
You may also submit an authorization request by secure fax to (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.
Claims FAQs
Please access DRE here https://www.hpsj.com/providers/
Access HPSJ’s Provider Network/search for providers: Find a Provider (hpsj.com)
Looking for Skilled Nursing Providers in HPSJ’s network? (HPSJ Provider Area)
HPSJ’s Medi-Cal EOC: Medi-Cal Evidence of Coverage – Health Plan of San Joaquin (hpsj.com)
All Provider alerts: Stay up to date on updates from HPSJ! Health Plan of San Joaquin Provider Alerts (hpsj.com)
HPSJ PCS Form: Forms & Documents for HPSJ Providers
HPSJ authorization form: Click Here
Read more about Continuity of Care: Continuity of Care Information for Providers – HPSJ
Posted on April 28th, 2023 and last modified on October 18th, 2023.
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