Specialty Provider Authorizations

Incontinence Supplies

The incontinence supply formulary contains products eligible for reimbursement when billing for contracted incontinence supply billing codes for Medi-Cal fee-for-service outpatient recipients. Incontinence supply formulary products are updated on a regular basis. Please visit this page for the latest version of the formulary

Incontinence Supply Formulary:    PDF    Excel
Last Updated 11/01/2018

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:

Expect a response from HPSM regarding authorization request within:

  • Three business days for urgent or expedited authorization requests
  • Five business days for routine authorization requests

Example 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-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.
  • The PCP will request your services by submitting a Referral Authorization Form (RAF) to HPSM.
  • If HPSM approves the PCP’s request, an authorized RAF will be faxed to your office. Once you receive this, contact the member to schedule an appointment.