California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51343 - Intermediate Care Facility Services for the Developmentally Disabled

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Intermediate
					 care facility services for the developmentally disabled are covered subject to
					 prior authorization by the Department. Authorizations may be granted for up to
					 six months. The authorization request shall be initiated by the facility. The
					 attending physician shall sign the authorization request and shall certify to
					 the Department that the beneficiary requires this level of care.
Each authorization request and reauthorization request
						submitted shall have attached certification documentation as required by the
						Department of Developmental Services. Such documentation shall be completed by
						regional center personnel.
(b) The request for reauthorization shall be
					 received by the appropriate Medi-Cal consultant on or before the first working
					 day following the expiration of a current authorization. When the request is
					 received by the Medi-Cal consultant later than the first working day after the
					 previously authorized period has expired, one day of authorization shall be
					 denied for each day the reauthorization request is late.
(c) The Medi-Cal consultant shall deny any
					 authorization request, reauthorization request, or shall cancel any
					 authorization in effect when services or placement are not appropriate to the
					 health needs of the patient. In the case of denial of a reauthorization request
					 or cancellation of authorization, the facility shall be notified by the most
					 expeditious means and payment may be made for up to 15 days following the date
					 of giving notice.
(d) The attending
					 physician shall recertify, at least every 60 days, the patient's need for
					 continued care in accordance with the procedures specified by the Director. The
					 attending physician shall comply with this requirement prior to the 60-day
					 period for which the patient is being recertified. The facility shall present
					 proof of this recertification at the time of billing for services
					 rendered.
(e) Prior to the transfer
					 of a beneficiary between facilities, a new initial Treatment Authorization
					 Request shall be initiated by the receiving facility and signed by the
					 attending physician. No transfer shall be made unless approved in advance by
					 the Medi-Cal consultant for the district where the receiving facility is
					 located.
(f) Medi-Cal beneficiaries
					 in the facility shall be visited by their attending physicians no less often
					 than every 60 days. An alternative schedule of visits may be proposed subject
					 to approval by the Medi-Cal consultant. An alternative schedule of visits shall
					 not result in more than three months elapsing between physician
					 visits.
(g) There shall be a
					 written plan of care for each beneficiary. The plan of care shall be reviewed
					 and evaluated by a physician and other personnel involved in the care of the
					 individual every 90 days. The plan of care shall meet the requirements of
					 42 CFR
					 456.380.
(h) Each beneficiary shall receive a
					 comprehensive medical, social and psychological evaluation prior to admission.
					 Psychological evaluations shall be performed within a time period not exceeding
					 three months before admission and shall meet the requirements of
					 42 CFR
					 456.370 (a) (1)
					 (i).
(i) Each beneficiary shall receive a complete
					 dental examination within one month following admission unless such an
					 examination was done within six months of admission, and the results are
					 received and reviewed by the facilities and are entered into the resident's
					 record. Each beneficiary shall be reexamined at specific intervals in
					 accordance with his or her needs.
(j) Each beneficiary shall receive an annual
					 physical examination that includes:
(1)
					 Examination of vision and hearing.
(2) Routine screening laboratory examinations
					 as determined necessary by the physician and special studies when the index of
					 suspicion is high.