Provider News
Medi-Cal Nursing Facility Services Benefit Transferred to HPSM
We are pleased to announce that we will begin managing skilled and custodial nursing facility services for our
Medi-Cal members starting Feb. 1, 2010. Management of these services for Health Plan of San Mateo’s (HPSM)
Medi-Cal patients is being transferred from the Medi-Cal fee-for-service (FFS) system to HPSM. This will
enable us to provide services in a much more coordinated and integrated manner across different levels of care.
Administrative Functions
- Facility contracting. We will enter into contracts with nursing facilities to provide services
to our Medi-Cal members. Services will include the full scope of services covered under FFS Medi-Cal.
- Prior authorization and utilization review. We will conduct prior authorization review as well
as concurrent and retrospective utilization review with our contracted facilities. We will adhere to FFS Medi-Cal
guidelines in managing these reviews. For members already residing in nursing facilities as of Feb. 1, 2010,
we will honor authorizations that have been granted through Dec. 31, 2010. However, providers need to submit authorization
requests for new stays beginning on Feb. 1 or later, as well as renewals for stays continuing beyond December 2010.
- Claims processing and payment. We will manage claims processing and payment.
Providers can refer to section 3 of the HPSM Provider Manual for rules regarding claims.
What Does This Mean for Providers?
- For nursing facilities: Payment for room and board and authorization of new admissions will be managed by HPSM.
- For all other providers: HPSM will continue to authorize and pay for services and visits to members in nursing
care facilities. These added functions will enable HPSM to work more closely with you to ensure that our members and your patients
receive the most appropriate care.
- If you have any questions about these changes, please contact HPSM Provider Services at
650-616-2106,
Monday through Thursday, 8:00 a.m. to 5:00 p.m., and Friday, 1:00 p.m. to 5:00 p.m.