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SAR Process Change for Providers of EPSDT Private Duty Nursing Services

December 8, 2017

Effective January 8, 2018, the Department of Health Care Services (DHCS) will implement changes in the authorization process for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Private Duty Nursing (PDN) services. As a part of this new process, DHCS will no longer issue an Eligibility Verification Request on the provider’s behalf to the local California Children’s Services (CCS) program office for eligibility verification. Additionally, DHCS will no longer issue an In-Service Request referencing the recommended service hours

Recipients Enrolled in a Medi-Cal Managed Care Health Plan (MCP)

For services to be provided to recipients enrolled in an MCP, providers should submit a Prior Authorization (PA) request to the MCP. If the requested service is not in support of a CCS-eligible condition, the MCP will review and authorize the request if medical necessity criteria are met. If the MCP determines that the requested service is in support of a CCS-eligible condition, the MCP will refer the provider to the local CCS program office. The provider will submit a Service Authorization Request (SAR) to the local CCS program office. If the local CCS program office determines that the service and recipient are CCS program-eligible, the county CCS program office will authorize a SAR for the requested service if medical necessity criteria are met. If the CCS program office denies the SAR, the service may be authorized by the MCP. The provider will need to submit a new PA request along with the CCS program denial, if available, to the MCP.

Fee-For-Service Recipients

If a recipient is not enrolled in an MCP and has a CCS-eligible condition, providers should submit a SAR to the recipient’s county CCS program office. If the recipient is eligible for PDN services, the CCS program office will authorize the SAR. If the CCS program office denies the SAR, providers should submit a Treatment Authorization Request (TAR) to DHCS along with the CCS program denial letter (Notice of Action), the plan of treatment and any other supportive clinical documentation. This documentation is necessary for TAR adjudication.

If a recipient is not enrolled in an MCP and does not have a CCS-eligible condition, providers should submit a TAR to DHCS along with the plan of treatment and any other supportive clinical documentation. This documentation is necessary for TAR adjudication.

Authorizations Currently in Process

Authorizations received prior to January 8, 2018, will continue to be adjudicated according to current practices. Authorizations received on or after January 8, 2018, will be processed as described above.

Providers may send any questions or requests for clarification by email to: PDNInquiries@dhcs.ca.gov.