Provider Alerts

Effective January 1, 2023, Health Plan of San Joaquin (HPSJ) is responsible for the Long-Term Care (LTC) benefit. HPSJ will authorize and cover medically necessary services provided in Skilled Nursing Facilities (SNF) (including a distinct part or unit of a hospital)
for LTC members residing in or obtaining care in a Skilled Nursing Facility (SNF).

Benefit Requirements

As part of Basic Population Health Management (BPHM), HPSJ must ensure members are engaged with their assigned Primary Care Providers (PCPs), including arranging transportation. HPSJ must provide Non-Emergency Medical Transportation (NEMT) and Non-Medical Transportation to Members, including those residing in a SNF, in accordance with APL 22-008, Non-Emergency Medical and Non-Medical Transportation Services and Related Travel Expenses, or any superseding APL. This includes providing NEMT services if the Member is being transferred from an emergency room or acute care hospital to a SNF, without prior authorization. For covered services requiring recurring appointments, HPSJ must provide authorization for NEMT for the duration of the recurring appointments, not to exceed 12 months. The Member must have an approved Physician Certification Statement (PCS) form authorizing NEMT by the Provider.

The Preadmission Screening and Resident Review

To prevent an individual’s inappropriate nursing facility admission and retention of individuals, federal law requires proper screening and evaluation before such placement. The Preadmission Screening and Resident Review (PASRR) requirements are applicable for all Medicaid-certified nursing facilities for all admissions (regardless of payer source). The PASRR process is required to ensure that individuals who may be admitted into a nursing facility for a long-term stay be preliminarily assessed for serious mental illness and/or intellectual/development disability or related conditions. HPSJ is required to work with DHCS and Network Providers, including discharging facilities or admitting nursing facilities, to obtain documentation validating PASRR process completions. Further implementation guidance is forthcoming.

Long-Term Services and Supports Liaison

HPSJ must identify an individual or set of individuals as part of their Provider Relations or related functions to serve as the liaison for Long-Term Services and Supports (LTSS) Providers. The HPSJ Provider Rep assigned to LTSS will service as the LTSS Liaison. The LTSS Liaison will receive all inquiries from LTSS providers and engage subject matter experts within the appropriate business unit for questions and/or clarifications.

Included are HPSJ Authorization and Claim FAQs. These can also be found at the following link: https://www.hpsj.com/long-term-care-snf-faqs/

Additional information from DHCS on the LTC Carve-In can be found at the following link: https://www.dhcs.ca.gov/provgovpart/Documents/LTC-SNF-Carve-In-FAQs.pdf as well as https://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2 023/APL23-004.pdf.

Additional information regarding the PASRR process can be found at:
https://www.dhcs.ca.gov/services/MH/Pages/PASRR.aspx

Please continue to page three through five to access the Long-Term Care benefits for HPSJ Members (effective 1/1/23) FAQs.

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If you have questions or need assistance, please call our Provider Services team at (209) 942-6340. You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan of San Joaquin and our services is always available on our website https://www.hpsj.com/.

Long Term Care benefits for HPSJ Members (effective 1/1/23)
Skilled Nursing Facility Authorizations FAQs

Q: 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?

A: Yes, all patients in a SNF who transition to HPSJ will need an authorization issued by
HPSJ.

Q: How can our nursing facility obtain an authorization from HPSJ for LTC services?

A: 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.

Q: What if my facility patient is an HPSJ Member but was not part of the data provided by DHCS?

A: 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.

Q: How do I submit an authorization for HPSJ members?

A: 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:

https://www.hpsj.com/wp-content/uploads/2022/09/Medical-Authorization-9_2022-updated_fillable.pdf

Supporting clinical documentation must be included for electronic or faxed authorization requests.

Q: What other steps can I take to help my HPSJ patients prepare for the transition?

A: 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.

Q: Will HPSJ honor other DHCS approved TARs (excluded from the room and board)?

A: HPSJ will receive TAR data from DHCS and will contact the affected facilities to verify and arrange for any new authorizations.

Q: What do I do if a bed hold is needed?

A: 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.

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

A: The facility will receive fax notification of the authorization information.

Q: What documentation is required for LTC re-authorizations?

A: 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.

Q: How far in advance can LTC re-authorizations be requested?
A: Re-authorization can be requested 2-4 weeks prior to the current authorization expiration date.

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

A: 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.

Q: 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?

A: Under skilled stay, Medicare B members will require auth for room & board. When transitioning to LTC, all members will require authorization.

Q: Do we need an authorization for co-insurance when HPSJ is secondary payer?

A: No

Claims FAQs

Q. Is it ok to bill claims on bi-weekly?

A. Yes, claims can be billed on a bi-weekly basis.

Q. Does HPSJ accept claims from Office Ally for LTC?

A. Contact Office Ally to confirm that they can process your LTC claims for HPSJ Members.

Q. How will our facility receive payments?

A. Change HealthCare (CHC) is HPSJ’s contracted payment vendor. Claim payments are dispersed according to your current set up with CHC.

Q. 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?

A. Non-covered services (NCS) items must be billed separately.

Q. When billing, do we use ub04 claim form?

A. Yes, SNF’s should bill LTC services using a ub04 claim form.

Q. How will our facility be reimbursed for physical therapy services?

A. 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.

Q. How should I bill for custodial vs skilled care?

A. 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)