Long-Term Care

Provider Type

  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Health Net must authorize long-term care (LTC) services when a member has a medical condition that requires LTC. LTC includes both skilled nursing care and non-skilled custodial care, specific to out of-home protective living arrangements with 24-hour supervised or observation care on an ongoing intermittent basis to abate deterioration.

LTC is care provided in a skilled nursing facility (SNF), intermediate care facility or subacute care facility. Additionally, it is an inpatient care level for members who meet medical necessity at the following care levels as defined in the Manual of Criteria for Medi-Cal Authorization:

  1. A skilled nursing facility admission for members accessing Medi-Cal nursing facility Level A or B benefit level.
  2. An intermediate care facility admission for members accessing Medi-Cal nursing facility Level A benefits.
  3. A subacute care facility admission for members accessing Medi-Cal covered subacute care services.

Members in need of LTC services are placed in facilities providing the level of care commensurate with their medical needs.

Coordination of Care

The PCP continues to provide care during the transition to LTC, and coordinates with the LTC attending physician to ensure continuity of care. This includes forwarding all pertinent records to the new PCP when identified and available to consult. For coordination of benefit questions, providers may contact the Health Net Public Programs Department.

Additional communication requirements for appropriate and timely concurrent review, claims submission and claims adjudication include:

  1. Hand-off communications - Upon authorizing LTC services, Health Net and the participating physician group (PPG), communicate about the member's LTC admission
  2. Level of care communications - Health Net and the PPG communicate regarding the member's level of care or transition from Medicare-based skilled nursing services to Medi-Cal-based LTC benefits.

Referrals and Authorizations

Providers must supply both the completed Health Net Long-Term Care Authorization Notification Form as well as any supporting clinical information, such as the Pre-Admission Screening and Resident Review (PASRR), Minimum Data Set (MDS), approved Treatment Authorization Request (TAR) or Last Covered Date for Services letter (LCD) through the assigned PPG, as applicable, to the Health Net Long-Term Care Intake Line by fax. Health Net continues to honor any currently active TAR approved authorizations.

For new admission authorization/notification requests, once a decision is made, Health Net notifies the provider by telephone or fax. Other ancillary services may require prior authorization and are not included in the nursing facility room rate. Providers must obtain prior authorization prior to providing such services.

Providers may contact the Health Net Long-Term Care Intake Line with all questions regarding LTC referrals and authorizations, or to check the status of a request.

Claims and Payment

The Coordinated Care Initiative (CCI) integrates care and services for long term care services. Cal MediConnect members are provided long-term support and services benefits including LTC nursing facility services. Providers can refer to the Cal Duals website at www.calduals.org for enrollment charts and timelines, including enrollment data by county to confirm transition dates. Additionally, providers must verify eligibility to be certain claims are appropriately directed. Providers may submit claims directly to the Health Net Cal MediConnect Claims Department.