Specialty Authorizations

Unique authorization rules apply for certain types of healthcare services, products, and providers.

All services requiring prior authorization must be authorized before providing the service, with the exception of services that are necessary on an emergent or truly urgent basis.

For authorization requests submitted prior to the date of service, expect a response from HPSM within:

  • 72 hours for urgent or expedited authorization requests
  • Five business days for routine authorization requests

Incontinence Supplies

HPSM requires prior authorization for some incontinence supply services: for details, see our Incontinence Supply Policy. You can also look up the CPT code of an incontinence supply or service by checking HPSM’s Prior Authorization Required (PAR) List on our Authorizations webpage. Authorizations require a diagnosis code. For a list of incontinence diagnosis codes, click here.

Caring for Homebound HPSM Members

How should a provider request home care visits?

  1. Visit HPSM members to start care and conduct an assessment within 48 hours of receiving a physician’s order.
  2. After the start of care visit has been conducted, compose a care plan for the entire 60 day certification period. See example below.
    • The care plan should contain any services already delivered (at least the start of care visit, but possibly more) and those future services that will be required.
    • Services delivered within the initial 10 calendar day period (counting from start of care visit date of service) will be authorized.
    • Any services delivered from calendar day 11 to day 60 of the certification period will be subject to full utilization review and potentially denied if not deemed medically necessary by HPSM staff.
  3. Fax the request form to HPSM within 10 days from start of care: failure to do so risks denial of some or all services (including those already delivered).

Fax should include the following documents:

Care Plan Example

 Day 1: Physician order receivedDay 2: Start of care (SN visit) Day 4: Subsequent visit (OT visit) Day 6: Subsequent visits (PT/SN visits)
Day 7: Authorization submittedDay 8: Additional visit (SN) Day 10: Any visits after day 10 subject to review (and possible denial)Day 60: Certification period ends. Last day of required care plan.
  1. Physician order received: Monday (day one)
  2. Start of Care SN visit: Tuesday (day two)
  3. Subsequent visits occurring prior to submission of authorization request: Thursday for OT (day four), Saturday for PT & SN (day six)
  4. Submission of authorization: Sunday (day seven)
  5. Additional visit: Monday for SN (day eight)
  6. Guaranteed approved visits: 5 (Tuesday, Thursday, Saturday x2, Monday)
  7. Visits subject to review and potential denial: any occurring after calendar day ten (the following Wednesday)

HPSM retrospectively reviews visit requests during the initial 10 day period looking for patterns of unnecessary or excessive requests for services within that period. Any observed patterns of this nature will put provider at risk for denial of future requests.

As always, HPSM reserves the right to deny any claims for services delivered after the initial 10 day period if abuse, fraud or waste is suspected.

Non-Emergency Medical Transportation

HPSM requires prior authorization of NEMT services in all cases except for hospital to nursing facility (modifier HN), hospital to custodial facility (modifier HE), hospital to residence (HR), or hospital to hospital (modifier HH) rides. Non-Emergency Medical Transport (NEMT) services include ambulance, litter/gurney van and wheelchair van medical transportation for non-emergency care. Download the NEMT Prior Authorization Form. A few key things to keep in mind:

  • The provider rendering care for the member will need to complete the prior authorization form and physician certification statement (PCS) and submit to HPSM. These have been combined into a single form for ease of use.
  • The treating physician can submit a request for NEMT services for a period of up to 12 months if recurring transportation is needed to support the member’s treatment plan.
  • Retro-active authorization for NEMT services is allowed. Keep in mind that retro-active authorization requests are subject to denial e.g., for lack of medical necessity. Requests received retro-actively will be processed within 30 business days. Requests received prior to service are processed within our standard turn-around times (see above).
  • For all NEMT authorization requests, providers must report an origin and destination modifier for each transport segment, or else the authorization will be rejected. A modifier is not required for mileage on the authorization form. For example, for a round trip between a patient’s Residence (Modifier = R) and a Physician Office (Modifier = P), the authorization form should include three lines:
Procedure CodeModifierUnits of Service
A0130RP# of trips for leg 1 (if the authorization is for multiple trips)
A0130PR# of trips for leg 2 (if the authorization is for multiple trips)
A0380 Total mileage for all trip legs

For all NEMT transportation and mileage claims, providers must report an origin and destination modifier for both the transport codes and the mileage. Using the above example, two claims would be submitted to HPSM:

Claim 1

Procedure CodeModifierUnits of Service
A0130RP# of trips for leg 1 (if the authorization is for multiple trips)
A0380RPTotal mileage for leg 1

Claim 2

Procedure CodeModifierUnits of Service
A0130PR# of trips for leg 2 (if the authorization is for multiple trips)
A0380PRTotal mileage for leg 2

Claims submitted without the required modifiers (or where the submitted modifiers do not match the authorized modifier on the transport code) are subject to denial.

Please see our NEMT Authorization FAQs for a list of all NEMT modifiers and answers to other frequently-asked questions.

Nutritional Supplements for Medical Conditions

The Nutritional Supplements for Medical Conditions Formulary contains nutritional products which are covered by Medi-Cal if certain conditions are met. These include infant formulas, oral nutritional supplements, and enteral nutritional supplements. Providers must submit a Prescription Drug Prior Authorization Request Form and members must meet the criteria as outlined in the Nutritional Supplements for Medical Conditions Policy.

DME (Durable Medical Equipment)

For some types of DME, such as customized wheelchairs, HPSM contracts with a third party organization to conduct additional home-based reviews of members’ need. This organization is called DME Consultants. When relevant, DME Consultants visit members at home to assess what they require, and whether other services or items may be needed. They provide an in-depth assessment to HPSM which assists in care coordination for our members.

Non-contracted providers

An HPSM-contracted PCP may ask you to provide service for a patient. If you agree, you must get prior authorization before providing any non-emergency services for HPSM members.