Intermediate Care Facilities (ICF) - Health Plan of San Joaquin

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:

Intermediate Care Facility for the Developmentally Disabled (ICF/DD)
Intermediate Care Facility for the Developmentally Disabled-Habilitative (ICF/DD-H)
Intermediate Care Facility for the Developmentally Disabled-Nursing (ICF/DD-N)

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

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 HPSJ 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 HPSJ 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:
HPSJ 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 HPSJ 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 HPSJ 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 HPSJ 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

Docs needed for ICF Authorizations

Face sheet
Current MD Orders
HS 231

Frequently Asked Questions:

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

Yes. All members in the ICF will require authorization issued by HPSJ. However, HPSJ will honor any TARS currently active at the time of transition up until the expiration date or 1 year, whichever is soonest.

How do I submit an authorization for HPSJ members?

Authorization requests must be submitted electronically through Doctor’s Referral Express, HPSJ’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 (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.

What do I do if a bedhold or LOA is needed?

Whenever an HPSJ member is transferred/discharged from the facility you must notify HPSJ 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 (209) 762-4702.

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

The facility will receive fax notification of the authorization information.

How far in advance can re-authorizations be requested?

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

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

A list of HPSJ contracted providers can be found using HPSJ’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.

What documents are needed for an authorization?

Facility Facesheet, MD orders, HS 231, TAR – if applicable.

Will HPSJ honor DHCS approved TARs?

TARs will honored until the expiration date or 1 year whichever is soonest. In cases where the expiration date is further out than 1 year please re-submit the TAR with the re-authorization request.