Section 54209 - Prior Authorization(a) Adult day health care services except for the initial assessment and reassessments shall require prior authorization by the Medi-Cal Consultant. The request for authorization shall: (1) Be initiated by the center and shall include the results of an individual's multidisciplinary assessment conducted by the center within the last 30 days and the participant's plan of care.(2) Be approved and signed by a physician.(3) Include a statement describing the patient's progress toward achieving the therapeutic goals.(b) Initial authorizations and reauthorizations may be granted for up to three months. Adult day health centers which do not have a staff physician shall obtain signed approval of the treatment plan every 180 days.(c) Authorization or reauthorization may be granted only if all of the following conditions exist: (1) A medical condition that requires treatment or rehabilitative services prescribed by a physician.(2) Mental or physical impairments which handicap daily living activities but which are not of such a serious nature as to require 24-hour institutional care.(3) Reasonable expectation that preventative service will maintain or improve the present level of functioning.(4) High potential for further deterioration and probable institutionalization if adult day health care were not available.(d) In determining the need for adult day health care services, the Medi-Cal Consultant shall consider the following:(1) Medical factors including the necessity:(A) For nursing care, supervision or observation on an ongoing intermittent basis to abate health deterioration.(B) To see a physician or psychiatrist no less than every 60 days.(C) To monitor medications for response and effect on an intermittent basis.(D) For medications which cannot safely be self-administered due to physical or mental disabilities.(E) For individualized therapeutic treatment designed to restore optimal functional potential or to prevent deterioration.(2) Functional status including: Limitation in movement, with or without an assistive device such as a cane, walker, crutches, prosthesis or wheelchair, or the need for training in the use of these devices.
(B) Inability to perform toileting, bathing, eating, dressing, grooming, transferring and self-medication or the need of training and assistance in the activities of daily living.(C) Incontinency and the probable benefit from continence retraining.(D) Vision, hearing or sensory loss to some degree.(E) Dependency and the need for part-time or full-time basic supervision by persons other than day health center staff.(3) Psychosocial limitations including:(A) Inability of person or family to cope adequately with problems associated with the person's disability.(B) Need for a psychosocial environment involving peer group membership and social rehabilitation.(C) Mild or moderate confusion or depression, or tendency to wander.(D) Inappropriate affect, appearance or behavior.Cal. Code Regs. Tit. 22, § 54209
1. Amendment of subsection (b) filed 9-19-79; effective thirtieth day thereafter (Register 79, No. 38). Note: Authority cited: Chapter 1066, Statutes of 1977. Reference: Chapter 1066, Statutes of 1977.
1. Amendment of subsection (b) filed 9-19-79; effective thirtieth day thereafter (Register 79, No. 38).