Provider Alerts

Effective January 1, 2023, Health Plan of San Joaquin (HPSJ) must authorize and cover medically necessary services provided for members residing in Skilled Nursing Facilities (SNF) under the Long-Term Care (LTC) Benefit (both freestanding and hospital-based facilities), consistent with definitions in the Medi-Cal Provider Manual and any subsequent updates.

HPSJ must ensure that Members residing in a SNF leveraging the Long-Term Care Benefit services are placed in a health care facility that provides the level of care most appropriate to the Member’s medical needs, as outlined in the MCP contract and as documented by the Member’s Provider(s). This means that, beginning January 1, 2023, Members who are admitted into a SNF with the LTC benefit will remain enrolled in managed care instead of being disenrolled from HPSJ and enrolled in Fee for Service (FFS) Medi-Cal.

Effective January 1, 2023, for members transitioning from Medi-Cal FFS to HPSJ and receiving long-term care (LTC) services:

• HPSJ will provide the SNFs with authorization for services based upon each member’s Department of Health Care Services (DHCS) – approved Treatment Authorization Request (TAR)

Members already enrolled with HPSJ and moving to LTC, will require an approved prior authorization.

Facility requests for authorization for SNF services must be submitted to HPSJ via the HPSJ provider portal at https://www.hpsj.com/providers or by sending the authorization request form by facsimile to the Utilization Management (UM) Department at (209) 762-4702. If you do not have an authorization from HPSJ for members receiving LTC services, please submit a request for authorization.

If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared.