22-683 Nonparticipating Hospital Post-Stabilization Notification

Date: 08/26/22

This information applies to Hospitals. 

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

ATTENTION: ANNUAL NOTICE REQUIREMENT

Prior authorization for post-stabilization care is currently suspended, per the Addendum below. CalViva Health will notify the nonparticipating facilities once the suspension is lifted. Nonparticipating hospitals must follow the processes outlined in this letter when obtaining prior authorization for post-stabilization care pursuant to AB 1203.

Pursuant to California Health and Safety Code sections 1262.8 and 1371.4 (AB 1203), a nonparticipating hospital is required to obtain authorization for post-stabilization care from a health care service plan (such as CalViva Health – a health care service plan providing Medi-Cal managed care coverage in Fresno, Kings and Madera counties) once a patient who is an enrollee of the health care service plan is stabilized¹ after presenting with an emergency medical condition. Authorization is required for both outpatient and inpatient post-stabilization care.

This request for authorization requirement applies only to a hospital whose patient is an enrollee of CalViva Health. The request for authorization is required once the patient is stabilized following emergency treatment and the hospital seeks authorization for post-stabilization care, and the services of the hospital are not subject to a written Provider Participation Agreement between the hospital and Health Net*, on behalf of CalViva Health, for the applicable enrollee’s plan.

A request for authorization must be made via phone to the CalViva Health Hospital Notification Unit (HNU) at 800-995-7890, option 2. Under Health and Safety Code section 1262.8(b)(3), a hospital is required to provide CalViva Health with the treating physician and surgeon’s diagnosis and any other relevant information reasonably necessary for CalViva Health to make a decision to authorize post-stabilization care or to assume management of the patient’s care by prompt transfer. A hospital’s contact with any other CalViva Health phone or fax number, or the patient’s participating physician group (PPG), to request authorization to provide post-stabilization care does not satisfy the requirements of the above laws. Do not contact the patient’s PPG or any other CalViva Health phone or fax number to request CalViva Health’s authorization for post-stabilization care.

CalViva Health may contest or deny claims for post-stabilization care following treatment in the emergency department or following an admission through a hospital’s emergency department where CalViva Health does not have a record of the hospital’s required phone call to 800-995-7890, option 2. Calls received after hours will be handled by CalViva Health’s Provider Services Center. In the instance that post stabilization is authorized by CalViva Health, the hospital will be provided a number for the authorization of initial post-stabilization services. Within one day of the initial call to CalViva Health, the hospital is required to fax the medical records necessary for CalViva Health to determine medical necessity for the continued care and stay.

If a patient’s CalViva Health identification (ID) card indicates enrollment through Medi-Cal, the enrollee is under age 21, and services are related to a California Children’s Services (CCS)-eligible condition, the hospital should call CalViva Health’s HNU at 800-995-7890, option 2. Then the hospital should immediately seek authorization for treatment from CCS by faxing a Service Authorization Request (SAR) with medical records to the local county CCS office. If your facility is not CCS-approved, the enrollee must transfer to a CCS-approved facility. CalViva Health cooperates with hospitals that seek CCS authorization for treatment but does not provide authorization for services for which CCS is financially responsible.

The CalViva Health 24-hour HNU contact number below is to be used by nonparticipating hospitals to notify CalViva Health once a patient who is enrolled in a CalViva Health Medi-Cal plan is stabilized, and to initiate a request for authorization of additional services.

_ _ _ _ _ _ _ _ _ _SAVE and Post this contact information _ _ _ _ _ _ _ _ _

CalViva Hospital Notification Unit Contact Information

Please use the phone number below to notify CalViva Health of stabilized patients and to request authorization for additional services. Failure to contact CalViva Health may result in CalViva Health’s contesting or denying claims for reimbursement. A hospital’s contact with any other CalViva Health phone or fax number or the enrollee’s participating physician group (PPG) to request authorization to provide post-stabilization care does not satisfy the requirements of applicable laws. Do not contact the patient’s PPG or other CalViva Health phone or fax numbers to request CalViva Health’s authorization for post-stabilization care.

Hospital Notification Unit Phone Number
Health plan	Phone number
CalViva Health*	800-995-7890, option 2

*If a patient’s CalViva Health identification (ID) card indicates enrollment through Medi-Cal, the enrollee is under age 21, and services are related to a California Children’s Services (CCS)-eligible condition, the hospital should call the CalViva Health HNU contact number and then immediately seek authorization from CCS by faxing a Service Authorization Request (SAR) with medical records to the local county CCS office. If your facility is not CCS-approved, the enrollee must transfer to a CCS-approved facility. CalViva Health cooperates with hospitals that seek CCS authorization for treatment, but does not provide authorization for services for which CCS is financially responsible.

Addendum:

During the COVID-19 state of emergency, the requirement for prior authorization for post-stabilization care and the CalViva Health Hospital Notification Unit (HNU) 800 number are temporarily suspended. While the AB 1203 prior authorization requirement is presumed to be met, the requirement to notify CalViva Health of the admission along with relevant information that is reasonably necessary for CalViva Health to review the inpatient admission and ongoing treatment, still remains.

During the suspension, CalViva Health nonparticipating or noncontracted hospitals, should submit inpatient admission notifications by fax to 800-676-7969.

If additional information is required, call the Provider Services Center at 888-893-1569. The Provider Services Center will escalate any inquiries directly to the HNU, as needed.

You will be notified when the HNU 800 number and the requirement for prior authorization for post-stabilization care is again active. Until then, please fax your inpatient notifications to 800-676-7969.

¹A patient is “stabilized” or “stabilization” has occurred when, in the opinion of the treating provider, the patient’s medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from, or occur during, the release or transfer of the patient.