Authorization of HRIF Services
- As part of the NICU discharge planning process, the NICU must identify and refer to the CCS Program infants identified as potentially eligible for the HRIF Program. Refer to NICU Program Responsibilities for NICU referral and SAR submission information. The approved SARs for HRIF services will be sent to the HRIF Coordinator who is responsible for distributing copies of the authorization to all relevant HRIF team members and consultants responsible for the infant’s follow- up care.
- The HRIF Program will receive an authorization of services for SCG 06 for each infant or child determined eligible for the HRIF Program.
- SCG 06 contains billable codes for diagnostic services provided by medical and other allied health professionals. The provider group entitled “Other Allied Health Professionals” includes pediatric nurse specialists, nurse specialists, psychologists, social workers, physical therapists, occupational therapists, and audiologists
SCG 06 allows HRIF Program providers to render limited core diagnostic services only for a CCS Program client without the submission of a separate request for each service required. No additional codes are approved for HRIF diagnostic services.
- Refer to the CCS Program website for HRIF SCG 06 codes and descriptions http://www.dhcs.ca.gov/services/ccs/cmsnet/Pages/SARTools.aspx.
- Refer to the Medi-Cal Provider Manual for the most current code list and billing guidelines: http://files.medi-cal.ca.govpublications/masters- mtp/part2/calchildser_m00i00o03o04o07o09o11a02a04a05a06a07a08p0 0v00.doc.
- Refer to the superseded HRIF N.L. 09-0606 for historical code descriptions for provider type and type of service http://www.dhcs.ca.gov/services/ccs/Documents/ccsnl090606.pdf.
NOTE: On July 1, 2013, the Department implemented new pricing methodology based on “Diagnosis Related Groups” (DRGs) for reimbursement of inpatient stays at private hospitals for both CCS Program and Medi-Cal. DRG inpatient reimbursement methodology does not affect CCS Program eligibility or service authorization for outpatient services. This includes and applies to HRIF diagnostic services.
- At the time of the referral for HRIF authorization, an authorization for two home assessments by the HHA nurse, preferably experienced in evaluating the maternal/infant environment, may be separately authorized if needed.
- The HRIF Program must inform the CCS county program which HHA is to be authorized for skilled nursing home assessment(s).
- The authorization will be for up to two home assessments during the first year.
- These visits are only to assess the home environment. They are not to be used as the venue for the provision of HRIF diagnostic services.
- Additional home assessments by a HRIF HHA nurse requires medical necessity justification from the HRIF Program physician.
When a CCS Program-eligible medical condition is discovered as part of the HRIF diagnostic assessments, the HRIF Coordinator is responsible for referring the client to the local county CCS program or State SCD Office. The program eligibility, including financial eligibility, will be determined by the local CCS program staff for treatment of the CCS Program-eligible medical condition.
If found to be eligible for the CCS Program, treatment services for the child will be separately authorized to the most appropriate CCS Program-approved provider. HRIF services (SCG 06) will continue to be authorized up to the child’s third birthday. An overview of CCS Program-eligible conditions can be found on the CCS Program website at http://www.dhcs.ca.gov/services/ccs/Pages/medicaleligibility.aspx.
- When the CCS HRIF Program staff identifies the HRIF client as having other health coverage (OHC), i.e., commercial third party health insurance or Health Maintenance Organization (HMO), the HRIF staff must bill the OHC prior to billing the CCS Program. A denial of benefits or Explanation of Benefits (EOB) must be attached to each claim. CCS Program/Medi-Cal is the payor of last resort.
- The State SCD Office expects HRIF clients identified as high-risk and authorized for HRIF diagnostic services to receive these services. HRIF programs that do not provide diagnostic services as authorized because the client has OHC with an unmet deductible or co-payment must notify the client's CCS Program county nurse case manager.
- The local CCS county program county or State SCD Office staff will contact the State HRIF Program manager to report any unresolved issues of a CCS Program HRIF client who is unable to access authorized services to assure HRIF-eligible clients receive services.
Provision of HRIF diagnostic services may be terminated prior to the child’s third birthday if the HRIF Program indicates that the child no longer has high risk for neurodevelopmental concerns and HRIF services are no longer required. This may occur when the child is found to be doing well on neurodevelopmental examination and testing.
NOTE: If an infant who has been discharged from HRIF Program services, is later identified, prior to the third birthday, as being at risk for neurodevelopmental issues, that child may be reinstated into the HRIF Program.