California Code of Regulations
Title 9 - Rehabilitative and Developmental Services
Division 1 - Department of Mental Health
Chapter 11 - Medi-Cal Specialty Mental Health Services
Subchapter 2 - Medi-Cal Psychiatric Inpatient Hospital Services
Article 2 - Provision of Services
Section 1820.220 - MHP Payment Authorization by a Point of Authorization

Universal Citation: 9 CA Code of Regs 1820.220

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) A hospital shall submit a separate written request for MHP payment authorization of psychiatric inpatient hospital services to the Point of Authorization of the beneficiary's MHP for each of the following:

(1) The planned admission of a beneficiary.

(2) Ninety-nine calendar days of continuous service to a beneficiary, if the hospital stay exceeds that period of time.

(3) Upon discharge.

(4) Services that qualify for Medical Assistance Pending Fair Hearing (Aid Paid Pending).

(5) Administrative day services that are requested for a beneficiary.

(b) A hospital shall submit the request for MHP payment authorization for psychiatric inpatient hospital services to the Point of Authorization of the beneficiary's MHP not later than:

(1) Prior to a planned admission.

(2) Within 14 calendar days after:

(A) Ninety-nine calendar days of continuous service to a beneficiary if the hospital stay exceeds that period of time.

(B) Discharge.

(c) Except as approved by the Department pursuant to Section 1810.438, a written request for MHP payment authorization to the Point of Authorization shall be in the form of:

(1) A Treatment Authorization Request (TAR) for Fee-for-Service/Medi-Cal hospitals; or

(2) As specified by the MHP for Short-Doyle/Medi-Cal hospitals.

(d) The Point of Authorization staff that approve or deny payment shall be licensed mental health or waivered/registered professionals of the beneficiary's MHP.

(e) Except as approved by the Department pursuant to Section 1810.438, approval or disapproval for each MHP payment authorization shall be documented by the Point of Authorization in writing:

(1) On the same TAR on which the Fee-for-Service/ Medi-Cal hospital requested MHP payment authorization or

(2) In an MHP payment authorization log maintained by the MHP for Short-Doyle/Medi-Cal hospitals.

(f) In accordance with title 42 CFR section 438.210(b)(2)(ii), the MHP shall consult with a hospital requesting authorization when appropriate.

(g) The MHP shall document that all adverse decisions regarding hospital requests for MHP payment authorization based on medical necessity criteria or the criteria for emergency admission were reviewed and approved:

(1) by a physician, or

(2) at the discretion of the MHP, by a psychologist for patients admitted by a psychologist and who received services under the psychologist's scope of practice.

(h) A request for an MHP payment authorization may be denied by a Point of Authorization if the request is not submitted in accordance with timelines in this Subchapter or does not meet medical necessity reimbursement criteria in Section 1820.205 or emergency psychiatric condition criteria in Section 1820.225(b) on an emergency admission or if the hospital has failed to meet any other mandatory requirements of the contract negotiated between the hospital and the MHP.

(i) A Point of Authorization shall approve or deny the request for MHP payment authorization within 14 calendar days of the receipt of the request and, for a request from a Fee-for-Service Medi-Cal hospital, shall submit the TAR to the fiscal intermediary within 14 calendar days of approval or denial. The MHP shall consider a possible extension in accordance with timelines of title 42 CFR section 438.210(d)(1). If the MHP extends the timeframe, the MHP shall provide the beneficiary with written notice of the decision on the date the decision to extend is made. The notice to the beneficiary shall advise the beneficiary of the reason for the decision and the beneficiary's right to file a grievance if the beneficiary disagrees with the decision. The Point of Authorization shall provide for an expedited review of an MHP payment authorization request in accordance with title 42, Code of Federal Regulations, Section 438.210(d)(2), when the MHP determines or the hospital certifies that following the 14 calendar day time frame would seriously jeopardize the beneficiary's life, health or ability to attain, maintain or regain maximum function.

(j) Point of Authorization staff may authorize payments for up to seven calendar days in advance of service provision.

(k) In accordance with title 42 CFR section 438.210(c), the MHP shall notify the requesting provider of any decision to deny an MHP payment authorization request, or to authorize a service in an amount, duration or scope that is less than requested. The notice to the provider need not be in writing.

(l) Approval of the MHP payment authorization by a Point of Authorization requires that:

(1) Planned admission requests for an MHP's payment authorization shall be approved when written documentation provided indicates that the beneficiary meets medical necessity criteria for reimbursement of psychiatric inpatient hospital services, as specified in Section 1820.205, any other requirements of this Subchapter that apply to the admission, and any mandatory requirements of the contract negotiated between the hospital and the MHP. The request shall be submitted and approved prior to admission.

(2) Emergency admissions shall not be subject to prior MHP payment authorization.

(3) A request for MHP payment authorization for continued stay services shall be submitted to the Point of Authorization as follows:

(A) A contract hospital's request shall be submitted within the timelines specified in the contract. If the contract does not specify timelines, the contract hospital shall be subject to the same timeline requirements as the non-contract hospitals.

(B) A non-contract hospital's request shall be submitted to the Point of Authorization not later than:

1. Within 14 calendar days after the beneficiary is discharged from the hospital, or

2. Within 14 calendar days after a beneficiary has received 99 continuous calendar days of psychiatric inpatient hospital services.

(4) Requests for MHP payment authorization for continued stay services shall be approved if written documentation has been provided to the MHP indicating that the beneficiary met the medical necessity reimbursement criteria for acute psychiatric inpatient hospital services for each day of service in addition to requirements for timeliness of notification and any mandatory requirements of the contract negotiated between the hospital and the MHP.

(5) Requests for MHP payment authorization for administrative day services shall be approved by an MHP when the following conditions are met in addition to requirements for timeliness of notification and any mandatory requirements of the contract negotiated between the hospital and the MHP:

(A) During the hospital stay, a beneficiary previously has met medical necessity criteria for reimbursement of acute psychiatric inpatient hospital services.

(B) There is no appropriate, non-acute residential treatment facility in a reasonable geographic area and a hospital documents contacts with a minimum of five appropriate, non-acute residential treatment facilities per week subject to the following requirements:

1. Point of Authorization staff may waive the requirements of five contacts per week if there are fewer than five appropriate, non-acute residential treatment facilities available as placement options for the beneficiary. In no case shall there be less than one contact per week.

2. The lack of placement options at appropriate, non-acute residential treatment facilities and the contacts made at appropriate facilities shall be documented to include but not be limited to:

a. The status of the placement option.

b. Date of the contact.

c. Signature of the person making the contact.

(C) An MHP may submit a request to the Department for approval to use an alternative to the procedures described in Subsection (j)(5)(B). The Department shall approve the request if the MHP establishes to the satisfaction of the Department that the alternative ensures that placement options for beneficiaries who are receiving administrative days are being considered in a timely manner.

(D) For beneficiaries also eligible under Medicare (Part A) who have received acute psychiatric inpatient hospital services which were approved for Medicare (Part A) coverage, the hospital has notified the Point of Authorization within 24 hours or as specified in the contract, prior to beginning administrative day services.

(6) Medical Assistance Pending Fair Hearing Decision requests for MHP payment authorization by a hospital shall be approved by an MHP when necessary documentation, as specified in Section 1850.215, is submitted.

1. New section filed 10-31-97 as an emergency; operative 11-1-97 (Register 97, No. 44). A Certificate of Compliance must be transmitted to OAL by 3-2-98 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 3-2-98 as an emergency; operative 3-2-98 (Register 98, No. 10). A Certificate of Compliance must be transmitted to OAL by 6-30-98 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 6-17-98 as an emergency; operative 6-30-98 (Register 98, No. 25). Pursuant to Chapter 324 (Statutes of 1998) Item 4440-103-0001(4), a Certificate of Compliance must be transmitted to OAL by 7-1-99 or emergency language will be repealed by operation of law on the following day.
4. Editorial correction of HISTORY 3 (Register 98, No. 39).
5. Editorial correction extending Certificate of Compliance date to 7-1-2001 pursuant to Chapter 50 (Statutes of 1999) Item 4440-103-0001(4) (Register 99, No. 33). Notwithstanding any other provision of law, emergency regulations adopted pursuant to Welfare and Institutions Code section 14680 to implement the second phase of mental health managed care as provided in this part shall remain in effect until permanent regulations are adopted, or June 30, 2006, whichever occurs first.
6. Editorial correction of HISTORY 5 (Register 2000, No. 42).
7. Editorial correction of HISTORY 5 and repealer and new section filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).
8. New subsections (f) and (k), subsection relettering and amendment of newly designated subsection (i) filed 10-18-2010; operative 11-17-2010 (Register 2010, No. 43).

Note: Authority cited: Section 14680, Welfare and Institutions Code. Reference: Sections 5777, 5778 and 14684, Welfare and Institutions Code; and Title 42, Code of Federal Regulations, Section 438.210.

Disclaimer: These regulations may not be the most recent version. California may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.