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 1820.225 - MHP Payment Authorization for Emergency Admissions by a Point of Authorization

Universal Citation: 9 CA Code of Regs 1820.225

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

(a) The MHP shall not require a hospital to obtain prior MHP payment authorization for an emergency admission, whether voluntary or involuntary.

(b) The hospital providing emergency psychiatric inpatient hospital services shall assure that the beneficiary meets the criteria for medical necessity in Section 1820.205, and due to a mental disorder, is:

(1) A current danger to self or others, or

(2) Immediately unable to provide for, or utilize, food, shelter or clothing.

(c) The hospital providing emergency psychiatric inpatient hospital services shall notify the MHP of the county of the beneficiary within ten calendar days of the time of presentation for emergency services, or within the timelines specified in the contract, if a time requirement is included as a term of the contract between the hospital and MHP.

(1) If the hospital cannot determine the MHP of the beneficiary, the hospital shall notify the MHP of the county where the hospital is located, within ten calendar days of the date of presentation for emergency services.

(2) The MHP for the county where the hospital is located shall assist the hospital to determine the MHP of the beneficiary. The hospital shall notify the MHP of the beneficiary within ten calendar days of the date of presentation for emergency services of determination of the appropriate MHP.

(d) Requests for MHP payment authorization for an emergency admission shall be approved by an MHP when:

(1) A hospital notified the Point of Authorization within ten calendar days of the date of presentation for emergency services or within the time required by contract, if a time requirement is included as a term of the contract between the hospital and MHP.

(2) Written documentation has been provided to the MHP that certifies that a beneficiary met the criteria in Subsection (b) at the time of admission.

(3) Written documentation has been provided to the MHP that certifies a beneficiary met the criteria in Subsection (b) for the day of admission.

(4) A non-contract hospital includes documentation that the beneficiary could not be safely transferred to a contract hospital or a hospital owned or operated by the MHP of the beneficiary, if the transfer was requested by the MHP.

(5) Any mandatory requirements of the contract negotiated between the hospital and the MHP are met.

(e) 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.

(f) After an emergency admission, the MHP of the beneficiary may:

(1) Transfer the beneficiary from a non-contract to a contract hospital or a hospital owned or operated by the MHP of the beneficiary as soon the patient is stable. An acute patient shall be considered stable when no deterioration of the patient's condition is likely, within reasonable medical probability, to result from or occur during the transfer of the patient from the hospital.

(2) Choose to authorize continued stay with a non-contract hospital.

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

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 (e) and (g), subsection relettering and amendment of NOTE 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, Sections 438.114(d)(ii) and 438.210.

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