APL 24-012 – Single Point of Contact for Hospitals to Request Authorization for Poststabilization Care

July 2, 2024 9:00 am Published by

FROM THE OFFICE OF THE CALIFORNIA DEPARTMENT OF MANAGED HEALTH CARE:

ALL PLAN LETTER

DATE: June 25, 2024

TO: All Full-Service Health Care Service Plans1

FROM: Sarah Ream, Chief Counsel

SUBJECT: APL 24-012 – Single Point of Contact for Hospitals to Request Authorization for Poststabilization Care

This All Plan Letter (APL) reminds plans they may not require a hospital to make more than one telephone call to request authorization to provide poststabilization care to plan enrollees.

I. Plans must provide hospitals with one telephone number to serve as the point of contact for 24-hour access for poststabilization authorization requests.

Per Health and Safety Code section 1371.4, full-service health plans must “provide 24-hour access for enrollees and providers, including, but not limited to, noncontracting hospitals, to obtain timely authorization for medically necessary care, for circumstances where the enrollee has received emergency services and care is stabilized, but the treating provider believes that the enrollee may not be discharged safely.” Plans must “provide all noncontracting hospitals in the state with specific contact information” so the hospital can contact the plan for poststabilization authorization.2 Plans must also provide the contact information to the Department of Managed Health Care (DMHC); the DMHC then posts the information to its public website.3

If a hospital calls a health plan’s designated 24-hour access telephone number, the plan has 30 minutes to either authorize poststabilization care or inform the hospital that the plan will arrange for a prompt transfer of the enrollee to another hospital. If the plan fails to do so, any necessary poststabilization care the hospital delivers to the enrollee is deemed authorized.4

II. To obtain authorization for poststabilization care, plans may not require a hospital to make multiple telephone calls or to contact the plan in any way other than the plan’s designated phone number.

Section 1371.4 specifically prohibits a plan from requiring a hospital to make more than one telephone call to obtain prior authorization for poststabilization services. Likewise, sections 1371.4 and 1262.8 do not allow a plan to require a hospital to contact the plan in some way other than the 24-hour contact number the plan designated in advance.

Section 1371.4 (e) allows a plan to delegate responsibility for staffing the plan’s 24-hour contact phone number. However, delegating that responsibility does not negate the requirement that the plan have a uniform point of contact for hospitals, nor the requirement that the plan (or its delegate) respond within 30 minutes to a hospital’s request for authorization for poststabilization care.

If you have questions regarding this APL, please contact your health plan’s assigned reviewer in the DMHC’s Office of Plan Licensing.

1 This APL does not apply to Medicare Advantage products or specialized health care service plans. The APL does apply to restricted and limited licensees to the extent the plan has been delegated responsibility for hospital services.

2 Health and Safety Code section 1262.8(j).

3 Health and Safety Code section 1262.8(k).

4 California Code of Regulations, title 28, section 1300.71.4(b).

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