22-105 Temporary Changes to Prior Authorization Requirements Due to COVID-19 Surge

Date: 01/26/22

This information applies to Participating Physician Groups (PPGs) and Hospitals.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.

Refer to updated requirements that clarify CalViva Health’s COVID-19 practices to help reduce administrative burden for hospitals

Health Net, on behalf of CalViva Health, and its delegated participating physician groups (PPGs), have waived select prior authorization requirements for hospitals that qualify as a surge hospital, based on the criteria below. The waiver is for the duration of the COVID-19 public health emergency by the federal government.

Surge criteria

Hospitals qualify when they experience any one of the impacts below:

• Less than 10% intensive care unit (ICU) capacity or less than 15% overall inpatient capacity.
• A critical decrease in either ICU capacity or the number of inpatient acute beds.
• A need to use:
  • Alternative spaces for inpatient surge capacity (i.e., cafeteria, hallway and/or conference room).
  • Tents or other outside structures for inpatient surge capacity.
• Staffing shortage.

Prior authorization waived for emergency department/inpatient hospital transfers and discharges

For hospitals that meet the surge criteria noted above, prior authorization is waived for:

• Patients transferred or discharged from acute inpatient hospitals to:
  • Acute rehabilitation.
  • Home health.
  • Long-term acute care.
  • Other lower level of care (excludes congregate living health facilities, which are not covered by Health Net).
  • Skilled nursing facilities.
  • Swing beds.
• Non-urgent transportation to lower levels of care, including:
  • Ambulance.
  • Gurney vans.
• Routine durable medical equipment (DME) needed to safely discharge patients, including:
  • Manual wheelchairs.
  • Oxygen supplies.
  • Respiratory and continuous positive airway pressure (CPAP) devices for acute treatment of COVID-19.
  • Semi-electric hospital beds.
  • Walkers.
  • Wound care supplies.

Note: Electric wheelchairs continue to require prior authorization and are not waived.

No daily concurrent review required

For hospitals that are impacted by a surge, daily concurrent review is not required for patients admitted to the ICU. Updates are only required every five days.

Continue to notify Health Net of inpatient admissions

Hospitals should continue to notify the Hospital Notification Unit as soon as possible of any hospital admission to help coordinate patient care and facilitate timely payment. Send hospital admissions via fax at 800-676-7969, or by calling 800-995-7890.

Additional information

Providers are encouraged to access the provider portal online at provider.healthnetcalifornia.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.