- Participating Physician Groups (PPG)
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for Medi-Cal members under age 21 are based upon members' identified health care needs. Diagnostic and treatment services are provided to treat, correct or ameliorate any physical or behavioral conditions by the appropriate provider or organization. The EPSDT program allows for periodic medically necessary screening and appropriate preventive, mental health, developmental, vision, hearing, dental and specialty services. For Medi-Cal members under age 21, dental screening or assessment must be performed at every periodic assessment. EPSDT services include case management and targeted case management services designed to assist children in gaining access to necessary medical, social, education and other services, such as pediatric day health center services, cochlear implant and transportation services.
The Health Net Medi-Cal Health Services staff or delegated participating physician group (PPG) coordinates with primary care physicians (PCPs) to identify children under age 21 who would benefit from these services and assists with appointment scheduling. Health Net determines medical necessity of most EPSDT services according to criteria established by the Department of Health Care Services (DHCS). When EPSDT services are provided for the California Children's Services (CCS) program, or are specialty mental health services (which are carved-out from Health Net's coverage responsibilities), Health Net does not determine medical necessity.
The Health Net Medi-Cal Health Services staff or delegated PPG ensures that members under age 21 who qualify for EPSDT services are referred to an EPSDT services provider or to an entity that provides EPSDT services. If these referred providers render EPSDT care management services, the care manager and Health Net medical director or delegated PPG medical director determine medical necessity. If EPSDT care management services are not available from these referred providers, the health plan or delegated PPG arranges and pays for EPSDT services.
According to Department of Health Care Services (DHCS) All Plan Letter(APL) 19-010: Medi-Cal managed care health plans (MCPs) and delegated PPGs are to provide all medically necessary Medi-Cal covered services while EPSDT program eligibility is pending. The EPSDT benefit is more robust than the Medi-Cal benefit package required for adults and states may not impose limits on EPSDT services and must cover services listed in Section 1905(a) of the Social Security Act (SSA) regardless of whether or not they have been approved under a state plan amendment. Health Net or delegated PPG shall determine the medical necessity of EPSDT services using the criteria established in 42 USC Section 1396d(r) and W & I Code Section 14132(v).
Health Net's Medi-Cal Health Services staff or delegated participating physician group (PPG) works with Health Net public programs administrators to monitor the appropriate use of local government organizations, including regional centers, that provide Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services. The Health Net Medi-Cal Health Services staff or delegated PPG coordinates with the member's primary care physician (PCP) to monitor that referrals are made to the proper agencies and programs. Following review and authorization from a Health Net medical director or delegated PPG medical director, Health Net Medi-Cal Health Services staff or the PPG coordinates services with the PCP.
If EPSDT services are not available through a local government agency or organization, Health Net's Medi-Cal Health Services staff or delegated PPG issues letters of authorization and negotiated claims payment instruction to EPSDT services providers and continues to provide care coordination services, including assistance in scheduling appointments, arranging non-medical transportation and non-emergency medical transportation to and from medical appointments, and updating the care management plan. Health Net must ensure that appropriate EPSDT services are initiated in a timely manner, as soon as possible but no later than 60 calendar days following either a preventive screening or other visit that identifies a need for a follow-up. California Children's Services is (CCS) is excluded from covered services.
The member's medical record must reflect the following for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) care management services:
- Member and family education regarding EPSDT services
- Referral to EPSDT care management services
- Reason for referral
- Member or family response to referral
- Subsequent case management plan
Health Net's public programs administrators resolve disputes that arise regarding responsibility for necessary Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services. The Health Net Medi-Cal Health Services staff or delegated PPG continues to coordinate and authorize all immediate health care needs in collaboration with the primary care physician (PCP) until the matter is resolved.
Los Angeles County
In most cases, primary care physicians (PCPs) identify members in need of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services as part of regular health screening visits. It is also possible that the need for services is identified by the member, the member's parents or other family, the local Child Health and Disability Prevention (CHDP) program, or by an encounter with another health professional. Providers must direct all referrals for EPSDT services to the Health Net Medi-Cal Health Services staff or delegated PPG, and the affiliated health plans' utilization management (UM) departments for prior authorization.
The Health Net Medi-Cal Health Services staff and Health Net Medi-Cal medical directors or delegated PPG medical directors review the request and determine medical necessity for EPSDT supplemental services.
All Other Counties
In most cases, primary care physicians (PCPs) identify members in need of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services as part of regular health screening visits. The need for services may also be identified by the member, the member's parents or other family, the local Child Health and Disability Prevention (CHDP) program, or by an encounter with another health care provider. Providers must direct all referrals for EPSDT services to the Health Net Medi-Cal Health Services staff or delegated PPG.
The Health Net Medi-Cal Health Services staff and Health Net's Medi-Cal medical directors or delegated PPG medical directors review requests and determine medical necessity for EPSDT services.
PCPs and delegated PPGs are responsible for referring EPSDT-eligible members identified as needing behavioral health therapy (BHT) services, regardless of diagnosis to MHN for assessment and referral to a mental health provider. Health Net and delegated PPGs coordinate with MHN to manage the behavioral health benefits of Medi-Cal members. BHT services may include, but are not limited to:
- Applied behavioral analysis.
- Individual or family training.
- Client/parent support behavioral intervention training.
- Adaptive skills trainer by a qualified BHT provider.
The following describes the health plan’s responsibilities related to case management/care coordination services for private duty nursing (PDN) services that have been approved for Medi-Cal members under age 21 pursuant to the EPSDT benefit. The health plan, with assistance from participating provider groups (PPGs) delegated to provide utilization management for such members, is responsible for case management requirements.
PDN services are nursing services provided in a member’s home by a registered nurse (RN) or licensed vocational nurse (LVN) for a member who requires more individual and continuous care than what would be available from a visiting nurse.1
Submit prior authorization requests for PDN services as indicated:
Providers participating through PPGs
Providers participating through a PPG must contact their PPG, follow the PPG’s prior authorization process and use the PPG’s forms.
Direct Network providers
Direct Network providers must request prior authorization by completing a Request for Prior Authorization form and faxing it to the health plan Health Care Services Department at 1-800-743-1655. Providers must submit clinically relevant information for medical necessity review with the prior authorization request. The form is available in the Provider Library at providerlibrary.healthnetcalifornia.com under Forms and References.
For CCS-eligible conditions
When PDN services support a California Children's Services- (CCS-) eligible medical condition, the provider must submit a Service Authorization Request (SAR) with clinical documentation to the local CCS program office. CCS will authorize a SAR for the requested services if medical necessity criteria are met.
- PDN services require an authorization for all members under age 21.
- If the PPG is delegated for utilization management, the PPG is responsible for completing the authorization.
- If the PPG’s member is receiving PDN services through CCS, CCS is responsible for the authorization.
- Whoever completes the authorization must document all efforts to locate and collaborate with providers of PDN services and with other entities, such as CCS.
- All members under 21 receiving PDN services must be case-managed.
- Providers must submit a referral to the health plan’s Case Management Department for members under 21 receiving PDN services approved by the PPG, and for their members receiving PDN services through CCS or another entity.
- Providers can submit a referral to the health plan’s Case Management Department by completing and submitting the case management referral form via email to CASHP.ACM.CMA@healthnet.com or by fax to 1-866-581-0540. The form is available in the Provider Library at providerlibrary.healthnetcalifornia.com under Forms and References.
Department of Health Care Services (DHCS) All Plan Letter (APL) 20-012 outlines the requirements.
The health plan and PPGs delegated for utilization management are contractually obligated to provide case management/care coordination services to members. Specifically, for Medi-Cal eligible members under age 21 who have had PDN services approved, managed care health plans are required to provide case management/care coordination, as set forth in the health plan contract, and to arrange for all approved PDN services, whether or not the health plan is financially responsible for the PDN services.2
PDN case management/care coordination responsibilities
When an eligible member under age 21 is approved for PDN services and requests that the health plan or delegated PPG provide case management services for those PDN services, the health plan or delegated PPG’s obligations include, but are not limited to:
- Providing the member with information about the number of PDN hours the member is approved to receive;
- Contacting enrolled home health agencies and enrolled individual nurse providers to seek approved PDN services on behalf of the member;
- Identifying potentially eligible home health agencies and individual nurse providers and assisting them with navigating the process of enrolling to become a Medi-Cal provider; and
- Working with enrolled home health agencies and enrolled individual nurse providers to jointly provide PDN services to the member.
Note, members approved for PDN services by delegated PPGs are identified via the delegated PPG’s monthly utilization management Authorization Request (AR) source data log submission. Fifteen days post log submission, the list of approved members is provided to the health plan’s Case Management Department to monitor care coordination.
Members may choose not to use all approved PDN service hours, and health plans and delegated PPGs are permitted to respect the member’s choice. The member’s record must document instances when a member chooses not to use approved PDN services.
Compliant policies and procedures
Health plans and delegated PPGs are required to issue new or revised policies and procedures that comply with the requirements of APL 20-012. Health plans must submit copies of the new or updated policies and procedures to their Managed Care Operations Division Contract Manager for review and approval. Delegated PPGs’ policies and procedures must meet APL 20-012 requirements and either be submitted to the health plan or be made available to the health plan upon request. Such policies and procedures must be consistent with the section below about monitoring and oversight of delegated PPGs.
Notice to members
The health plan or delegated PPG is required to issue a notice to every member under the age of 21 for whom it has currently authorized PDN services on or before July 31, 2020. The notice must:
- Explain that the health plan or delegated PPG has primary responsibility for case management of PDN services.
- Describe the case management services available to the member in connection with PDN services, as set forth above.
- Explain how to access those services.
- Include a statement that the member may:
- Utilize the health plan’s existing grievance and appeal procedures to address difficulties in receiving PDN services or their dissatisfaction with their case management services;
- File a Medi-Cal fair hearing as provided by law; or
- Email DHCS directly at EPSDT@dhcs.ca.gov.
5. Include a statement that if the member has questions about their legal rights regarding PDN services, they may contact Disability Rights California at 1-888-852-9241.
Monitoring and oversight
DHCS will audit health plan compliance with the PDN services case management policy outlined in APL 20-012 and the case management requirements set forth in the health plan’s contract with DHCS. If the health plan fails to comply with the requirements of the APL or the case management requirements in the health plan’s contract, DHCS may require a corrective action plan and/or assess monetary penalties as provided for in the health plan contract and any applicable state or federal statutes and regulations.
Monitoring and oversight of delegated PPGs
The health plan’s Delegation Oversight Department will monitor and evaluate your compliance to all requirements through the health plan’s annual compliance audit in the following areas:
- Review of EPSDT policies and procedures including:
- Approval of services that are medically necessary for EPSDT eligible members.
- Communicating the approval duration/number of approved services/hours if applicable.
- Assisting the health plan Case Management Department with case management and care coordination services for EPSDT members regardless of financial responsibility for services approved. If the PPG was not the entity to approve the services, the PPG is still required to assist with the provision of case management services as needed or requested by the member.
- Refer members for whom PDN services have been approved or for whom the PPG is aware have been approved by another entity (such as CCS) to the health plan's Case Management Department to monitor care coordination.
- Review of procedures for assisting the health plan’s Case Management Department with requests for PDN services including:
- Validation that the home health agency/provider of PDN services is enrolled as a Medi-Cal provider.
- Assisting the health plan Case Management Department with contacting home health agencies and enrolled individual nurse providers on the member’s behalf.
- Arranging for all PDN service hours, as needed or requested by the member.
- Documentation of all attempts to identify PDN services for the member and the member’s refusal to use all PDN hours approved.
- Evidence that the PPG is actively assisting the health plan to increase the network of private duty nursing services by:
- Assisting eligible home health agencies/individual providers to enroll as Medi-Cal providers.
- Assisting the health plan Case Management Department with leveraging home health agencies and individual nurse providers (in combination if needed) to meet members’ needs.
- Additional activities as identified
1 For more information, refer to Department of Health Care Services (DHCS) All Plan Letter (APL) 20-012.
2 Acceptance of available PDN services is at the member’s discretion. Members are not required to use all approved PDN service hours.