– Prior Authorization Request Form – ICF Form

State of California – Health and Human Services Agency Department of Health Care Services MCP ICF/DD Authorization Request (10/23) Page 1 of 3 Health Net Community Solutions, Inc. Medi-Cal Managed Care Plan (MCP) Intermediate Care Facility/Home for the Developmentally Disabled (ICF/DD) Authorization Request

1. Member Name _
2. Medi-Cal Identification Number and Eligibility _
3. Facility/Home Name, Address and Contact Information _
4. International Classification of Diseases (ICD) Diagnoses Codes _
5. Initial, Transfer, Re-admission, or Reauthorization _
6. Prescribing Physician Name and License Number _
7. Level of Care Requested (ICF/DD, ICF/DD-H or ICF/DD-N) _
8. The “Admit” Date _
9. The “From” Date _
10. The “Through” Date _
11. Physician Signature _

MCP ICF/DD Authorization Request (10/23)

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Explanation of Form Items

1. Member Name. Enter the Member’s full name from the Benefits Identification Card (BIC).
2. Medi-Cal Identification Number and Eligibility. When entering the recipient identification number from the Benefits Identification Card (BIC), begin in the farthest left position of the field. Do not enter any characters (dashes, hyphens, special characters, etc.) in the remaining blank positions of the Medi‑Cal ID field. The county code and aid code must be entered just above the recipient Medi-Cal Identification Number box.
3. Facility/Home Address and Contact Information. Enter the facility/home’s physical address and the name, email, and telephone contact information for the individual submitting the re- quest.
4. ICD Diagnosis Codes. List the ICD diagnosis codes for the Member, up to three.
5. New, Transfer, or Readmission Authorization. Note if the authorization is for a new Member, a transfer to another ICF/DD Facility/Home, or for a readmission.
6. Prescribing Physician Name and License Number. Enter the full name and license number for the physician authorizing the service from the Facility/Home. The state license number is the Medi-Cal rendering provider number.
7. Enter Level of Care — ICF-DD, ICF/DD-H, or ICF/DD-N, as defined below: Intermediate Care Facility/Home for the Developmentally Disabled (ICF/DD, ICF/DD-H, and ICF/DD-N). These three models are offered, as appropriate, to individuals with intellectual and developmental disabilities (IDD) who are eligible for Regional Center services as administered by the Department of Developmental Services. The models offer specialized living arrangements and are briefly defined as follows: • ICF/DD (Developmentally Disabled): “Intermediate care facility/home / developmentally disabled” is a facility/home (up to over 60 beds) that offers 24-hour personal care, habilitation, developmental, and supportive health services for individuals with IDD whose primary need is for developmental services and who have a recurring but intermit- tent need for skilled nursing services. • ICF/DD-H (Habilitative): “Intermediate care facility/home / developmentally disabled ha
   bilitativeis a home with a capacity of 4 to 15 beds that provides 24-hour personal care, habilitation, developmental, and supportive health services for 15 or fewer individuals with IDD who have intermittent recurring needs for nursing services, but have been certified by a physician and surgeon as not requiring availability of continuous skilled nursing care. • ICF/DD-N (Nursing): “Intermediate care facility/home / developmentally disabled-
   nursing" is a home with a capacity of 4 to 15 beds that provides 24-hour personal care, developmental services, and nursing supervision for individuals with IDD who have intermittent recurring needs for skilled nursing care but have been certified by a physician and surgeon as not requiring continuous skilled nursing care. The facility shall serve medically fragile persons who have developmental disabilities or demonstrate significant developmental delay that may lead to a developmental disability if not treated.
8. Admit Date This Service. Enter the recipient’s admission date to the facility/home in six-digit format (for example, November 1, 2006 = 110106).

MCP ICF/DD Authorization Request (10/23)

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9. Period Of Care Requested. Enter the “From Date” and the “Through Date” requested for authorization in six-digit format (for example, November 1, 2006 = 110106). This applies to numbers 9-10.
10. Physician Signature. The authorization request must be initiated by the ICF/DD Facility/
    Home. Per 22 CCR section 51343(a), the ICF/DD Facility/Home’s attending physician must sign the authorization request and certify to the MCP that the Member requires this level of care. ICF/DD Facility/Homes may submit the physician’s signature through fax, scanning, or uploading as an attachment.