Need to Submit an Authorization?

Happy nurse holding hands of elderly patient sitting side by side at home, laughing.

Types of Long-Term Care Facilities:

Medi-Cal covered long-term care services include placement in the following types of facilities:

  • Nursing Facility Level A (NF-A) and Level B (NF-B)

Effective January 1, 2024, or as authorized by the Department of Health Care Services, HPSJ will cover the following additional types of facilities:

  • Subacute Care Facilities – both adult and pediatric facilities
  • Intermediate Care Facilities for the Developmentally Disabled (ICF/DD)
    ICF/DD All Plan Letter
  • Intermediate Care Facilities for the Developmentally Disabled Habilitative (DD-DH)
  • Intermediate Care Facilities for the Developmentally Disabled Nursing (DD-N)

Long Term Care Benefit Overview

  • HPSJ covers long-term care benefits for members who qualify.
  • Long term care services require authorization based on medical necessity.
  • For those members that LTC services are deemed medically necessary, HPSJ will assist members and their providers in locating in a health care facility that provides the level of care most appropriate to member’s medical needs.
  • HPSJ offers support to members transitioning through various levels of care.

The Preadmission Screening Resident Review (PASRR)

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):

  • required to perform the Preadmission Screening Resident Review (PASRR) on any member being discharged to a SNF.

Skilled Nursing Facilites (SNF):

  • required to perform the PASRR when a member is being admitted directly from the community.
  • required to initiate Resident Review (RR) by submitting Level 1 Screening only when there is a significant change in the member’s physical or mental condition.

Skilled Nursing Facilities (SNF) – Alerts (

Authorization Timeline Process for Facilities 

  1. The authorization request will be reviewed and processed within the specified timelines
  2. 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. 
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.

Required Documentations 

  • Facesheet 
  • Current MDS 
  • Current MD Orders 
  • PASRR 
  • Discharge planning notes, if indicated by the Q section 

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:

  1. Supine or prone position.
  2. 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.
  3. 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.

Frequently Asked Questions:

Skilled Nursing Facility Authorizations FAQ

Will Skilled Nursing Facilities (SNF) need a new authorization for LTC members residing in their facilities if there is already an approved Treatment Authorization Request (TAR) on file from Department of Health Care Services?
Yes, all patients in a SNF who transition to HPSJ will need an authorization issued by HPSJ.
How can our nursing facility obtain an authorization from HPSJ for LTC services?
DHCS provided HPSJ with data that includes HPSJ members who are receiving LTC services. HPSJ will proactively contact each nursing facility to validate the information. Upon working with the facility to verify the information from DHCS, HPSJ will issue new authorizations for HPSJ members in your care.
What if my facility patient is an HPSJ Member but was not part of the data provided by DHCS?
Nursing facilities are required to follow HPSJ’s standard authorization procedures for HPSJ members who are not included in the SNF data provided by DHCS.
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 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 other steps can I take to help my HPSJ patients prepare for the transition?
HPSJ will contact you to provide the list of HPSJ members receiving care from your facility. Be prepared to review the list as soon as you receive it:

  1. Ensure that all LTC patients transitioning to HPSJ are on the list.
  2. If someone on the list is no longer a resident, please indicate the date of discharge.
  3. If a resident is not on the list, submit an authorization request for that member to HPSJ.
Will HPSJ honor other DHCS approved TARs (excluded from the room and board)?
HPSJ 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 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, 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.
What documentation is required for LTC re-authorizations?
When requesting re-authorization, include the most current provider progress note validating the need for continued stay, as well as the MDS for your HPSJ patient.
How far in advance can LTC 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), lab, x-ray, oxygen, pharmacy, and podiatry?
A list of HPSJ contracted providers can be found using HPSJ’s provider search tool located at: Pharmacy benefits are administrated by DHCS through Medi-Cal RX and can be found on the Medi-Cal RX website: View tools and resource section.
When a resident admits under Medicare in our facility, as I understood we do not request HPSJ Auth until they transition to General care and will be staying Long Term. Is this correct?
Under skilled stay, Medicare B members will require auth for room & board. When transitioning to LTC, all members will require authorization.
Do we need an Authorization for co-insurance when HPSJ 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 HPSJ accept claims from Office Ally for LTC?
Contact Office Ally to confirm that they can process your LTC claims for HPSJ Members.
How will our facility receive payments?
Change HealthCare (CHC) is HPSJ’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)

Help and Resources:

Please access DRE here

Access HPSJ’s Provider Network/search for providers: Find a Provider (

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 (

All Provider alerts: Stay up to date on updates from HPSJ! Health Plan of San Joaquin Provider Alerts (

HPSJ PCS Form: Forms & Documents for HPSJ Providers

Non-Contracted Providers

HPSJ authorization form: Click Here

Read more about Continuity of Care: Continuity of Care Information for Providers – HPSJ

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Posted on April 28th, 2023 and last modified on October 18th, 2023.