22-684 Nonparticipating Hospital Post-Stabilization Notification

Date: 08/26/22

This information applies to Hospitals. 

ATTENTION!

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 California Health & Wellness Plan (CHWP), once a patient who is an enrollee of the health care service plan is stabilized 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 a CHWP Medi-Cal plan. The request for authorization is required once the patient is stabilized following emergency treatment, the hospital seeks authorization for post-stabilization care, and the services of the hospital are not subject to a written Provider Participation Agreement (PPA) between the hospital and CHWP.

A request for authorization must be made via telephone to CHWP’s Hospital Notification Unit; call 877-658-0305, and use options 3, 6, 2, and 1. Under Health and Safety Code section 1262.8(a)(3), a hospital is required to provide CHWP with the treating physician and surgeon’s diagnosis and any other relevant information reasonably necessary for CHWP 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 CHWP telephone or fax number, or the patient’s independent practice association (IPA), to request authorization to provide post-stabilization care does not satisfy the requirements of the above laws. Do not contact the patient’s IPA or any other CHWP telephone or fax number to request CHWP’s authorization for post-stabilization care.

See below for an addendum explaining a temporary suspension of certain prior authorization requirements due to COVID-19.

CHWP 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 CHWP does not have a record of the hospital’s required telephone call to the Inpatient Authorization Intake Unit requesting post-stabilization authorization or a record that CHWP provided the hospital with an express authorization for such services.

If a patient’s CHWP identification (ID) card indicates the member is under age 21, and services are related to a California Children’s Services (CCS)-eligible condition, the hospital should call CHWP’s Inpatient Authorization Intake Unit at 877-658-0305, and use options 3, 6, 2, and 1 and then 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 member must transfer to a CCS-approved facility. CHWP cooperates with hospitals that seek CCS authorization for treatment but does not provide authorization for services for which CCS is financially responsible.

Below is CHWP’s 24-hour, Inpatient Authorization Intake Unit contact number to be used by nonparticipating hospitals to notify CHWP once a CHWP member is stabilized, and to initiate a request for authorization of additional services.

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

California Health & Wellness Plan Inpatient Authorization Intake Unit Contact Information

Please use the telephone number below to notify California Health & Wellness Plan (CHWP) of stabilized patients and to request authorization for additional services. Failure to contact CHWP Inpatient Authorization Intake Unit may result in CHWP’s contesting or denying claims for reimbursement. A hospital’s contact with any other CHWP department or the enrollee’s independent practice association (IPA) to request authorization to provide post-stabilization care does not satisfy the requirements of applicable laws. Do not contact the patient’s IPA or other CHWP department to request CHWP’s authorization for post-stabilization care.

Inpatient Authorization Intake Unit Telephone Number
Health plan	Telephone number
California Health & Wellness Plan*	877-658-0305, options 3, 6, 2, and 1 Follow the prompts to reach the Inpatient Authorization Intake Unit

*If the member is under age 21, and services are related to a California Children’s Services (CCS)-eligible condition, the hospital should call the CHWP Inpatient Authorization Intake Unit 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 member must transfer to a CCS-approved facility. CHWP cooperates with hospitals that seek CCS authorization for treatment, but does not provide authorization for services for which CCS is financially responsible.

Addendum:

Due to the COVID-19 state of emergency, prior authorization for post-stabilization care and the CHWP’s Hospital Notification Unit (HNU) 800 number are temporarily suspended. While the prior authorization requirement is presumed to be met, the requirement to timely notify CHWP of admission remains.

During the suspension, CHWP contracted hospitals, skilled nursing facilities, long-term care facilities, and long-term acute care hospitals should submit inpatient admission notifications by fax to 855-556-7907.