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 Health Plan of San Joaquin (“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

Docs needed for ICF Authorizations

Face sheet
Current MD Orders
HS 231

ICF/DD Authorization Request Form

Frequently Asked Questions:

What's the time frame for authorization approval?

Authorization approvals can be given for a period of up to 2 years.

How and when to communicate when there’s a leave of absence. Advance notices require?

Leave of Absence can be communicated in advance or after LOA has occurred. Notification should be done by phone, provider portal, secure email, or fax.

How do I communicate that a bed hold is needed during an inpatient stay? When should I communicate the need for a bed hold?

When a bed hold is needed, documentation can be sent via fax or provider portal. Bed hold is only authorized for up to 7 days per episode. The need for a bed hold should be communicated as soon as possible.

What is the requirement when submitting an authorization request?

Documentation needed for an authorization request is as follows: Face sheet and the HS 231.

What will be the TAR/authorizations process when 01/01/2024 comes along?

Authorization will need to be requested from HPSJ. Documentation needed is the Face sheet and the HS 231. Please note that the Authorization process will be replacing the TAR process.

Will HPSJ advocate for unsafe discharges?

Discharges to the ICF should not be accepted if there is not an authorization in place. Member or Member’s representative is encouraged to use the Appeals and Grievance’s Process. If an HPSJ nurse is reviewing the authorization request and feels something is unsafe for our member, we have an internal reporting process that is followed.

How often will ICFs need to submit an authorization?

When possible, authorization should be requested prior to Member’s admitting to the facility.

Will members still participate in the adult day program, if so, will this be through the MCP?

Members that are participating in Day Programs should continue to participate as appropriate. However according to the APL the Plan does not incur the cost of the program or the transportation to and from.

Do we report to HPSJ when we have beds available?

At this time we do not require a census of available beds to be provided to us on a regular basis. However, there may be instances where HPSJ would reach out to see bed availability in an effort to assist with Discharge of a member from a higher level of care, or for a member who wanted to change facilities.

Can ICF Care Takers file grievances on the members’ behalf?

Member or Member’s representative is encouraged to use the Appeals and Grievance’s Process.

Can auths be valid for two years other than 1 year?

ICF authorizations can be approved, if appropriate, for up to 2 years.

Can an auth be paused after the seven-day bed hold if needed?

Unfortunately, once the 7 day bed hold has elapsed and member has not returned, we are unable to keep an authorization open. If the member needs to re-admit after the 7 day bed hold a new authorization will need to be requested.

Will ICFs be paid from the time the hospital discharges a client to the ICF if the auth is no longer valid because the member has been out of the home past seven days?

Verifying and obtaining authorization will now need to be part of the ICF’s admission process. However, in cases where it is appropriate, a concurrent authorization or a retrospective authorization can be requested.

How often will we need to submit an authorization?

When possible, authorization should be requested prior to Member’s admitting to the facility. For the re-authorization process, a new authorization should be requested no later than 14 days prior to current authorization expiration or as early as 30 days prior to current authorization expiration.

2023 ICF Claims FAQ

What are HPSJ’s claims processing turnaround times?

Average processing turnaround time for clean claim submission is 8 to 14 days.

What are HPSJ’s PDR processing turnaround times?

Average processing turnaround time for a properly submitted PDR is 26-27 days.

How do ICFs bill a client that will be on a leave of absence for residence?

Facilities must bill indicating the Revenue Code that is applicable to the specific accommodation services, in conjunction with the accommodation code as this drives the appropriate payment rate for a facility based on the California Medi-Cal rate for the facility.