LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 801.07 Payment for Outside County Services
 
  PROCEDURES
  1. Out-of-county mental health inpatient services provided in either a FFS, SD/MD, or Los Angeles County Department of Mental Health (DMH) Medical Director designated hospital will be paid if they meet the Medi-Cal medical necessity criteria. The host county must notify DMH within 24 hours of admission except for a Friday, Saturday, Sunday, or holiday when the notification of the hospitalization must be made the following business day. Failure to notify the Medical Director or the Medical Director designee will result in the denial of the claim.
     
  2. DMH review to determine if the Los Angeles County (LAC) patient meets the medical necessity criteria will be conducted retrospectively to the actual psychiatric hospitalization. The following are necessary for this review: 
     
    1. Documentation that the admission of the patient to the appropriately licensed out-of-county psychiatric inpatient facility was accomplished by a doctor with admitting privileges at that psychiatric inpatient facility, who determined that that level of care was necessary. (The clinical need for inpatient service is not always fully congruent with Medi-Cal medical necessity.)
       
    2. Documentation that appropriate treatment and discharge planning, commensurate with this level of care, was provided to the patient during the course of the patient’s stay.
       
    3. Lockouts, overrides, computer edits, and other limitations shall be followed according to the regulations of the LAC/State Department of Mental Health Manual on the Rehabilitation Option and Targeted Case Management.
       
    4. On or before 14 calendar days after discharge, the out-of-county psychiatric inpatient facility shall send the complete documentation of Medi-Cal medical necessity for the patient’s stay to:

      Los Angeles County Department of Mental Health
      Office of the Medical Director
      550 S. Vermont Ave., 12th Floor
      Los Angeles, CA 90020
       
      1. Based on the documentation, a copy of the Management Information System (MIS) Client Face Sheet (DMH 224) will be completed on each patient by the DMH Office of Standards and Records and submitted to MIS Division for retroactive data entry into the MIS under a designated out-of-county provider/reporting unit code.
         
  3. In the event that medical transportation services required for continuous inpatient treatment elsewhere have been documented, payment for the transportation services will be made only if there is appropriate documentation of medical necessity for the patient’s continued psychiatric inpatient treatment. However, reimbursement for modes of transportation used exceeding the standards provided in 22 CCR § 51323 shall be limited to reasonable charges.
     
    1. Reasonable charge is the lower of the prevailing rate or the rates in the Medi-Cal Allied Health Services Provider Manual, Medical transportation – Maximum Allowances (HCPCS Codes).
       
  4. Claiming for the costs incurred for the hospitalization of the client will require the following list of documents from the out-of-county provider:
     
    1. A formal request for payment of specific services.
       
    2. Medical record of the patient for the billed services. Such medical record must support Medi-Cal medical necessity.
       
    3. Client invoice detailing the costs for the provided service. Mail invoice to:

      Los Angeles County Department of Mental Health
      Accounting Division
      550 S. Vermont Ave., 8th Floor
      Los Angeles, CA 90020
      Attn: Medi-Cal Unit
       
    4. Accounting Division will process the invoice for payment to outside counties.