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/Medi-Cal for Kids & Teens services according to criteria established by the Department of Health Care Services (DHCS). When EPSDT/Medi-Cal for Kids & Teens 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/Medi-Cal for Kids & Teens services are referred to an EPSDT/Medi-Cal for Kids & Teens services provider or to an entity that provides EPSDT/Medi-Cal for Kids & Teens services. If these referred providers render EPSDT/Medi-Cal for Kids & Teens care management services, the care manager and Health Net medical director or delegated PPG medical director determine medical necessity. If EPSDT/Medi-Cal for Kids & Teens care management services are not available from these referred providers, the health plan or delegated PPG arranges and pays for EPSDT/Medi-Cal for Kids & Teens 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/Medi-Cal for Kids & Teens program eligibility is pending. The EPSDT/Medi-Cal for Kids & Teens benefit is more robust than the Medi-Cal benefit package required for adults and states may not impose limits on EPSDT/Medi-Cal for Kids & Teens 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/Medi-Cal for Kids & Teens 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)/Medi-Cal for Kids & Teens 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/Medi-Cal for Kids & Teens 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/Medi-Cal for Kids & Teens 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/Medi-Cal for Kids & Teens 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)/Medi-Cal for Kids & Teens care management services:

Health Net's public programs administrators resolve disputes that arise regarding responsibility for necessary Early and Periodic Screening, Diagnosis and Treatment (EPSDT)/Medi-Cal for Kids & Teens 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.

In most cases, primary care physicians (PCPs) identify members in need of Early and Periodic Screening, Diagnosis and Treatment (EPSDT)/Medi-Cal for Kids & Teens 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, or by an encounter with another health professional. Providers must direct all referrals for EPSDT/Medi-Cal for Kids & Teens 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/Medi-Cal for Kids & Teens supplemental services.

In most cases, primary care physicians (PCPs) identify members in need of Early and Periodic Screening, Diagnosis and Treatment (EPSDT)/Medi-Cal for Kids & Teens 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, or by an encounter with another health care provider. Providers must direct all referrals for EPSDT/Medi-Cal for Kids & Teens 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/Medi-Cal for Kids & Teens services.

Referral Coordination

PCPs and delegated PPGs are responsible for referring EPSDT/Medi-Cal for Kids & Teens-eligible members identified as needing behavioral health therapy (BHT) services, regardless of diagnosis to Health Net Behavioral Health Services for assessment and referral to a mental health provider. Health Net Behavioral Health Services and delegated PPGs coordinate the management of behavioral health benefits of Medi-Cal members. BHT services may include, but are not limited to:

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 a PPG must contact their PPG, follow the PPG’s prior authorization process and use the PPG’s forms.

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.

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.

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

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:

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.

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.

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:

      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.

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.

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:

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.