23-1158 Learn More About New Post-Stabilization Authorization Requirements
Date: 10/12/23
Turn-around time for post-stabilization care requests, financial responsibility and more
California Health & Wellness Plan (CHWP) is responsible for coverage and payment of emergency services and post-stabilization care services. The hospital or facility that furnishes the services can be a participating provider, subcontractor, downstream subcontractor, or nonparticipating provider.
More information is available in the California Health and Safety Code section 1371.4 and Welfare and Institutions Code section 14454. Medi-Cal providers can also refer to All Plan Letter (APL) 23-009 (PDF), Authorizations for Post-Stabilization Care Services, effective May 3, 20231.
Request for post-stabilization authorization
When a member is stabilized after emergency services but needs continued care before safely being discharged or transferred, the health care provider must request an authorization for post-stabilization care. Requests can be made to CHWP’s Inpatient Authorization Intake Unit at 877-658-0305. Requests can also be submitted by fax or website.
The request must clearly state that the patient has been stabilized and the hospital is requesting authorization for post-stabilization care. Clinical information must be included with the contact number of the provider requesting post-stabilization care.
Notification to CHWP of emergency room treatment or admission does not satisfy the requirement. Notification of admission for inpatient care does not satisfy the requirement. Post-stabilization requirements do not apply if the member has not been stabilized after emergency services and requires medically necessary continued stabilizing care.
Response from CHWP
CHWP must approve or disapprove a request for post-stabilization care within 30 minutes. The post-stabilization care must be medically necessary for covered medical care. If the response to approve or disapprove the request is not given within 30 minutes, the post-stabilization care request is authorized. This applies to a participating provider, subcontractor, downstream subcontractor, or nonparticipating provider.
Conditions of financial responsibility
CHWP is financially responsible for post-stabilization care services that are not pre-authorized, but administered to maintain, improve, or resolve the member’s stabilized condition if CHWP:
- Does not approve or disapprove a request for post-stabilization care within 30 minutes.
- Cannot be contacted.
- Is unable to reach an agreement with the treating provider concerning the member’s care and a Plan physician is not available for consultation.
If this situation applies, the Plan must give the treating provider the opportunity to consult with a Plan physician. The treating provider may continue with care of the member until a Plan physician is reached or one of the following criteria is met:
- A Plan physician with privileges at the treating provider’s hospital assumes responsibility for the member’s care;
- A Plan physician assumes responsibility for the member’s care through transfer;
- The Plan and the treating provider reach an agreement concerning the member’s care; or
- The member is discharged.
Required documentation
All requests for authorization, and responses to requests, must be documented by the provider. The documents must include, but are not limited to:
- Date and time of the request.
- Name and contact number of the provider making the request.
- Name of the Plan’s representative responding to the request.
Additional information
Relevant sections of the provider operations manuals have been revised to reflect the information contained in this update as applicable. The provider operations manual is available in the Provider Resources section of the provider website.
Providers are encouraged to access CHWP’s provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CHWP at 877 658 0305.
1APL 23-009 – www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2023/APL23-009.pdf.
This information applies to Hospitals.