PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY/ PROCEDURE
Policy/Procedure Number: MCUP3039 (previously UP100339)
Policy/Procedure Title: Special Case Managed Members
Lead Department: Health Services
☒External Policy
☐ Internal Policy
Next Review Date: 03/18/2016
Last Review Date: 03/18/2015
Original Date: 04/25/1994
Applies to:
☒ Medi-Cal
☐ Healthy Kids
☐ Employees
Reviewing
Entities:
☒ IQI
☐P&T
☒ QUAC
☐ OPERATIONS
☐ EXECUTIVE
☐ COMPLIANCE
☐ DEPARTMENT
☐ BOARD
☐ COMPLIANCE
☐ FINANCE
☐ PAC
☐ CREDENTIALING
☐ DEPT. DIRECTOR/OFFICER
Approving
Entities:
☒ CEO
☐ COO
Approval Signature: Robert Moore, MD, MPH
Approval Date: 03/18/2015
I.
RELATED POLICIES:
A. MCUP3041 - TAR Review Process
B. MPCP2002 - California Children’s Services (CCS)
C. MCUP3104 - Major Organ Transplants
D. MCUP3020 - Hospice Service Guidelines
E. MCUP3103 - Coordination of Care for Members in Foster Care
F. MCUP3033 - Out of Area Emergency Admissions
G. MCUP3051 - Long Term Care Admissions
II.
IMPACTED DEPTS:
A. Health Services
B. Member Services
C. Claims
III.
DEFINITIONS: N/A
IV.
ATTACHMENTS: N/A
V.
PURPOSE:
To define criteria for members who meet special case managed status.
VI.
POLICY / PROCEDURE:
A. Introduction:
Special case managed members are those whose service needs are such that inclusion in the PHC
capitated case management system would be inappropriate. Assignment to special case managed status
may be based on the members' medical condition, prime insurance, demographics or administrative
eligibility status. To maximize the patient-provider relationship and to coordinate care, California
Children Services (CCS) special case managed members are encouraged to select and identify an entry
point provider, who is termed an "alternate provider". Services for special case managed members will
be paid on a fee-for-service basis based upon prevailing PHC rates. The TAR system will be in place for
all PHC services that require the use of a TAR. For CCS members, authorization for services to the CCS
condition will be done by CCS staff at the County. CCS in Sonoma, Mendocino, Lake, Lassen, Del
Norte, Modoc, Shasta, Siskiyou, Humboldt and Trinity Counties is carved out of PHC.
Generally, members become eligible for special case managed status either due to a specific clinical
condition or due to a specific administrative service category.
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Policy/Procedure Number: MCUP3039 (previously
UP100339)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 03/18/2016
Last Review Date: 03/18/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Special Case Managed Members
Original Date: 04/25/1994
Applies to:
☒ Medi-Cal
Default1
New Member
Default2
Member no
longer eligible
for a HS special
member
designation.
Members that no
longer have
prime insurance
status (HP 12,
20, 21, 24)
OBRA/Aliens
Default4
HP 1
HP 2
HEALTHCCS
HP 3
HP 4
California
Children
Services (CCS)
CCS Carved out
Counties
Acquired
Immune
Deficiency
Syndrome
(AIDS)
Upon becoming eligible to PHC, new members will have up to 30 days to select
a PCP. During the interim, the member will not be assigned to a PCP or a case
managed pool unless the member has selected a PCP in advance.
Members that no longer qualify for Health Services special member status such
as CCS, LTC or continuity of care are placed in Default 2 for one month if the
member cannot be relinked, family linked or assigned based on claims data.
Members that no longer qualify for prime insurance coverage status are placed
in Default 4 for one month if the member cannot be relinked, family linked or
assigned based on claims data.
The member is assigned the first day of the month the member becomes eligible
for limited services (OBRA) related to pregnancy and/or emergency treatment.
Members have aid code 58, 5F, 5G, 5N, C1, C2, C3, C4, C5, C6, C7, C8, C9,
D1, D8 or D9. The member is removed on the first day of the month following
loss of OBRA status. OBRA aid codes apply to Solano, Napa and Yolo
Counties only.
Solano, Napa, Yolo and Marin County Members approved for CCS by the
county CCS office and placed into this HP effective the day of CCS eligibility.
CCS services in these counties are carved into PHC.
Sonoma, Mendocino, Lake, Lassen, Del Norte, Modoc, Shasta, Siskiyou,
Humboldt and Trinity County Members approved by CCS. CCS services in
these counties are carved out of PHC.
Members approved when the 2008 CDC criteria for AIDS is met. Effective date
is the day of PHC notification.
For Kaiser members, PHC does not remove from Kaiser assignment,
however, a change in affiliation is made. The affiliation will change on the
first day of the month if PHC is notified by the 15th day of the previous
month. If PHC is notified after the 15th day of the month the affiliation will
commence on the first day of the month after the next month.
Exception: Kaiser prime members that meet the HIV criteria are not moved
to the Kaiser HIV affiliation until the member’s Kaiser prime insurance is
no longer active. Assignment to the Kaiser HIV affiliation would occur the
month following PHC’s notification of the termination of the Kaiser prime
insurance.
Not in use for the
Medi-Cal
program.
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Policy/Procedure Number: MCUP3039 (previously
UP100339)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 03/18/2016
Last Review Date: 03/18/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Special Case Managed Members
Original Date: 04/25/1994
Applies to:
HP 5
☒ Medi-Cal
Continuity of
Care
CONTINUITY of CARE:
The PHC Medical Director has the discretion to place members, with complex
medical conditions, into special member status because of the member’s need
for continuity of care. Criteria for inclusion as a special member, for continuity
of care, is based upon:
1. The member’s eligibility to PHC should be relatively recent.
2. The member requires ongoing care from out-of-area specialist(s) for
appropriate management of his (her) complex medical conditions and
discontinuation of this care from the out-of-area specialist(s) would be
detrimental for the member’s health.
3. Referrals to specialty care by an in-plan PCP does not meet the member’s
health care needs.
4. The out-of-area specialist accepts the additional responsibility of Primary
Care Provider.
5. Transgender member or member with gender dysphoria requiring primary
care with clinician with expertise in this area.
6. The member’s need for special member status under Health Plan 5 is
generally required for 12 months or less.
7. Member will be removed when the member’s needs for continuity of care
have been met.
Sonoma Members Approved for House Calls
Sonoma Members approved for House Calls (a St. Joseph’s System Provider
Group) House Calls is a provider group that provides care for home bound
patients.
TRANSPLANTS
SOLID ORGAN TRANSPLANTS:
Member is approved upon notification from a Medi-Cal designated transplant
facility that the member has completed the evaluation process and is currently
listed and waiting a solid organ transplant. Exception: See HP 38. Members on
dialysis awaiting a kidney will stay in HP 38 until transplanted. Heart
transplant recipients are granted HP 5 for plan lifetime.
BONE MARROW TRANSPLANT:
Member is approved upon notification from a Medi-Cal designated transplant
facility that the member has completed the evaluation process, a donor match
has been found and is currently listed and waiting transplant.
Member becomes eligible for assignment to a PCP one year after receiving the
transplant but may qualify for continued HP 5 based on continuity of care criteria
above.
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Policy/Procedure Number: MCUP3039 (previously
UP100339)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 03/18/2016
Last Review Date: 03/18/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Special Case Managed Members
Original Date: 04/25/1994
Applies to:
HP 6
☒ Medi-Cal
Hospice
HP 7
Foster Care (FC)
and special
needs,
Development
Delay Services
(DDS) children.
HP 8
Out of Area
HP 9
Long Term Care
(LTC)
AND
Long Term Care
Psychiatric
Patients
HP 10
Retroactive
Members
HP 11
Deceased
Members are approved the day the member signs the hospice election form and
continues in this category as long as their care is provided by a hospice program.
CMS notifies Member Services of PA members that have Hospice. MS staff
places the Hospice coding on the member’s PA record and moves the member
to HP 6 on the member’s Medi-Cal record.
All foster care (FC) and Development members in or out of county that have
one of the following aid codes: 03,04, 06, 07, 40, 42, 43, 45, 46, 49, 4A, 4F,
4G, 4H, 4K, 4L, 4M, 4N, 4S, 4T, 4W, 5K, 6W, or 6V. Solano, Napa or Yolo
county FC members assigned to PCP prior to September 1, 2011 remain
assigned to a PCP and have the option to move to a special member status.
Members are approved the day the member establishes residence out-of-county
for a 3 month period. If the member is an inpatient in an out-of-county hospital,
the member is eligible the day the member moved out of county.
LTC:
Member approved the day of admission to SNF or LTC facility.
Kaiser members, assignment remains to Kaiser for the month of admission and
the following month. If at the end of this time frame the member remains in
SNF and meets PHC criteria for LTC, the member will then be taken out of
Kaiser cap and placed into this category.
Kaiser members with Kaiser prime insurance are not moved to HP 9.
 Kaiser Commercial members are moved to HP 24 the 3rd month
following admission.
 Kaiser Senior Advantage members are placed in HP 24 3rd month
following admission if member is not at a skilled level of care.
 Kaiser Senior Advantage members receiving skilled level of care are
placed in HP 24 on the 101 day of placement or any time after the 3rd
month of placement that they no longer qualify for a skilled level of
care.
LTC Psychiatric:
The member is approved on the date the member is admitted to a long term care
psychiatric facility. The member is removed on the first day of the month
following discharge and is re-linked to the previously assigned PCP at this time.
The member is approved the first day of the month, the member becomes
retroactively eligible with PHC. The member is removed and assigned to a PCP
on the first day of the month after the retroactive period.
The member is approved on the date of death plus one day.
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Policy/Procedure Number: MCUP3039 (previously
UP100339)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 03/18/2016
Last Review Date: 03/18/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Special Case Managed Members
Original Date: 04/25/1994
Applies to:
☒ Medi-Cal
HP 12
Tricare/Champus
HP 13
Newborn
(mother not
capitated)
ADMINISTRAT
IVE
HP 14
HP 15
HP 16
HP 17
HP 18
NO LONGER IN
USE as of 9/1/03
Napa State and
Sonoma
Developmental
Ctr. 1500 Arnold
Dr.
Not in use
Native American
Indians
The member is approved on the first day of the month that PHC is notified that
the member is Tricare/Champus eligible. The member is removed from HP 12
on the first day of the month following the date the member’s Tricare/Champus
eligibility ends.
The member is approved on the date of birth. The member is removed on the
first day of the third month following the date of birth.
Members placed in HP 14 for any of the reasons below:
 Have a Pope Valley or a Sea Ranch address or
 Qualify for special member status due to a state fair hearing decision,
or
 County expansion
 Members that exceed a 30 mile radius from the nearest PCP
The member is approved on the date of admission to Napa State Hospital. The
member is removed on the first day of the month following discharge from Napa
State Hospital.
Members with the Sonoma Developmental address are automatically placed.
Members are moved to HP 16 the date they are discharged.
The member is approved when confirmed as a qualified Native American Indian
and the member chooses not to be assigned to a contracted PCP site.
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Policy/Procedure Number: MCUP3039 (previously
UP100339)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 03/18/2016
Last Review Date: 03/18/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Special Case Managed Members
Original Date: 04/25/1994
Applies to:
HP 19
☒ Medi-Cal
General Member
Service
AND
Prenatal Care
28+ weeks
GMS
The member is approved on the first day of the month of assignment to this
category, at the discretion of the PHC Member Services Director, under the
following circumstances:
1. The member has an appointment with a physician for primary care
services other than the member’s assigned PCP, and
2. The member was assigned to a PCP inappropriately due to an error in the
assignment process.
3. Other criteria making special member status appropriate (must be
approved by the PHC Member Services Director and the Chief Medical
Officer or physician designee.)
The member is removed when the member no longer qualifies, based on the
criteria listed above.
Prenatal Care
The member is approved the first of the month that PHC is notified of eligibility
with PHC under the following conditions:
1. The member is 28 weeks pregnant or more on the date of eligibility with
PHC,
2. The member has been regularly cared for by an obstetrical provider prior
to eligibility with PHC, and;
3. The member wishes to continue her care and requests during her pregnancy
to continue with her established obstetrical provider for the duration of her
pregnancy. The member is removed on the first day of the month following
60 days from the delivery date.
HP 20
Sonoma, Marin
and Mendocino
Medi-Medi
members
HP 21
Health Insurance
Payment
Program (HIPP)
HP 22
Genetically
Handicapped
Persons Program
(GHPP)
NO LONGER IN
USE as of 9/1/03
HP 23
If the member is not made HP 19, the member would be required to change OB
providers due to PCP and hospital linkages.
Effective the date member has Medicare Part A or Part B or both Part A and Part
B status.
Moved out of HP 20 the day they no longer have any Medicare status.
Exception: Sonoma and Marin Medi Medi members that have Kaiser prime are
capped to Kaiser.
The member is approved on the first day of the month of notification that the
member is eligible for HIPP and the Health Services Department determines that
the member’s medical condition warrants continued eligibility for this program.
If the member is in HP 21, the member’s health insurance premium is paid by
PHC. The HS Director monitors HP 21 members periodically. The member is
removed on the first day of the month after the member no longer meets criteria
for eligibility.
The member is approved on the date PHC is notified from the state that the
member has been included on the GHPP list. The member is removed on the
first day of the month that the member is no longer eligible for GHPP.
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Policy/Procedure Number: MCUP3039 (previously
UP100339)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 03/18/2016
Last Review Date: 03/18/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Special Case Managed Members
Original Date: 04/25/1994
Applies to:
☒ Medi-Cal
HP 24
Other Insurance
The member is approved on the first of the month of notification or identification
that the member has other health insurance. The member is removed on the first
day of the month that the other insurance ends. In this situation, since PHC is
the “payor of last resort”, the other insurance is always the primary payor.
HP 25
PA LOSS OF
MEDI-Cal grace
period
HP 26
Unmet Share of
Cost
HP 27
Long Term Care
Resident with aid
code 53 55, D2
through D7 aid
codes.
PA members that no longer have PHC and no share of cost Medi-Cal, the
member’s Medi-Cal record is placed in HP 25 for 2 months following the loss
of Medi-Cal eligibility. Coverage during this period is limited to those medical
benefits covered under the crossover benefit.
The member is placed in HP 26 when the member has an unmet share of cost
and does not have a second aid code of 44, 48, 74, 7C, 7H or 76. When the
member is in HP 26, the member is not eligible for services under PHC and PHC
is not financially responsible for this member. When the member has met the
share of cost, the member is removed from HP 26 and becomes eligible for HP
10 (retroactive eligibility).
The member is approved on the day the member is admitted to a long term care
facility. The member is removed on the first day of the month that the member
is discharged from the LTC facility or the member no longer has aid code 53.
HP 28
HP 29
Long Term Care
aid code not in
LTC (13, 23, 63)
Duplicates
HP 30
Aid code 81, 86
&87 without
Share of Cost
HP 31
Not used
HP 32
Holderman
Patients
HP 33
HP 34
HP 35
Aid codes 55 and D2-D7 limited to LTC, ER, and pregnancy related services.
These aid codes apply to Solano, Napa and Yolo County members.
Member with long term care (LTC) aid code, but not in LTC facility.
Members that have Kaiser prime are placed in HP 24.
The member is approved on the day the member becomes eligible under more
than one name or membership number. PHC pays for services under the valid
member number.
The member is approved on the first day of the month PHC is notified that the
member is eligible with aid code 81 or 86 and the member has no share of cost
responsibility. The member is removed the first day of the month PHC is
notified the member is no longer eligible for aid code 81, 86 or 87 without share
of cost.
The member is approved on the date of admission to Holderman facility. The
member is removed on the first day of the month following discharge from the
Holderman facility.
A member is placed in HP 33 when the member has an unmet share of cost
(SOC) and a second aid code of 44 or 48. The member is transferred from HP
33 to HP 10 when the SOC is met.
A member is placed in HP 34 when the member has an unmet SOC and a second
aid code 74. The member is transferred from HP 34 to HP 10 when the SOC is
met.
A member is placed in HP 35 when the member has an unmet SOC and a second
aid code 7C. The member is transferred from HP 35 to HP 10 when the SOC is
met.
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Policy/Procedure Number: MCUP3039 (previously
UP100339)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 03/18/2016
Last Review Date: 03/18/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Special Case Managed Members
Original Date: 04/25/1994
Applies to:
☒ Medi-Cal
HP 36
HP 37
HP 38
End Stage Renal
Disease
HP 39
Breast / Cervical
Cancer
A member is placed in HP 36 when the member has an unmet SOC and a second
aid code 7H. The member is transferred from HP 36 to HP 10 when the SOC is
met.
A member is placed in HP 37 when the member has an unmet SOC and a second
aid code 76. The member is transferred from HP 36 to HP 10 when the SOC is
met.
Members approved when the Medicare definition for ESRD is met. Effective
date is the actual date of the first outpatient hemo/ peritoneal dialysis treatment.
Exception: See HP 9
A member is placed in HP 39 when the member has
 Aid code OT, OR (has other insurance with deductible greater than
$750), or OU or
 Has 0P, 0N, or 0M with a secondary aid code.
B. Other Considerations
1. When conversion to special case managed status is approved, it will be done so for a time-limited or
condition-limited (e.g., pregnancy) interval. After the interval has elapsed, the case will be
reconsidered, and the member removed from special case managed status if circumstances
warranting this status no longer exist.
2. The Medical Director may review other cases where the circumstances of the clinical condition may
warrant consideration of the status change by the Plan. The Chief Medical Officer or Physician
Designee will consult with other specialty physicians as needed to complete the review.
3. Members or their physicians may request consideration for special case managed status. Member
requests will be processed through Member Services and reviewed by the Health Services staff.
Physicians must complete a Special Case Management Provider Request for Status Change form on
behalf of their members. The HS staff will contact the providers as necessary to obtain medical
documentation. Each case will be reviewed by the Chief Medical Director or Physician Designee3.
Members may appeal the decision by the process in “Member Grievances”.
4. Appeals submitted only for determination regarding HP 5 Continuity of Care status will go through
the physician review process.
5. The Health Services staff will notify the provider and the member of the decision. If the request is
denied, the reasons will be outlined in the letter to the provider. If the request is approved, an
alternate provider will be identified and notified concerning the PHC procedures for obtaining TAR
services. The member will be encouraged to obtain all care from the alternate provider.
6. The Health Services Department will encourage all special members to utilize the PHC network.
7. The special member will receive a letter with their new ID card from the Member Services
Department. The Member I.D. Card will reflect Partnership HealthPlan of California as PCP and an
alternate provider, if indicated.
8. Agencies/facilities will continue to provide the direct case management activities as mandated by
state, federal and regulatory agencies.
VII.
REFERENCES:
N/A
VIII.
DISTRIBUTION:
A. PHC Department Directors
B. PHC Provider Manual
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Policy/Procedure Number: MCUP3039 (previously
UP100339)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 03/18/2016
Last Review Date: 03/18/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Special Case Managed Members
Original Date: 04/25/1994
Applies to:
☒ Medi-Cal
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services
X.
REVISION DATES:
Medi-Cal 03/01/95; 10/10/97 (name change only); 6/14/00; 8/15/00; 11/20/00; 03/07/01; 10/17/01;
11/11/03; 03/10/04; 02/08/05; 10/10/06; 11/19/08; 08/18/10, 06/19/13; 03/18/1
PREVIOUSLY APPLIED TO:
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