CurrentHealth NetPolicy N/A

PERSONAL CARE AND HOMEMAKER SERVICES AUTHORIZATION FORM

Authorization form to request personal care and homemaker services (PCHS) for Medi‑Cal/CHPIV members via Health Net/CHPIV, capturing member details, eligibility checkboxes, functional ADL/IADL assessments, provider and referral information, and requested hours. Intended to accompany authorization requests per the Personal Care and Homemaker Services Authorization Guide.

Policy Summary

PayerHealth Net

PolicyPERSONAL CARE AND HOMEMAKER SERVICES AUTHORIZATION FORM

Policy CodePolicy N/A

Change TypeInformational form (no material changes)

Effective Date

Next Review Date

Key ActionComplete the authorization form fields including member info, requested PCHS hours, ADL/IADL assessment, and IHSS application/status details as applicable.

SourceLink

POLICY UPDATE CHANGES

No material changes — this is an authorization form; no policy coverage changes provided.

1Form purpose (authorization request)

3Primary eligibility pathways listed

20+ADL/IADL items on assessment

Policy overview

Authorization form to request Personal Care and Homemaker Services (PCHS) for Medi‑Cal/CHPIV members in Imperial County. The form documents member and referral details, community supports provider information, caregiver preferences, and the requested number of PCHS hours per day and per month.

Used to assess functional need via a structured ADL/IADL assessment completed with the patient (covering bathing, dressing, mobility, medication management, meal prep, transportation, and other items), to record IHSS application/status (including IHSS hours, reassessment dates, or denial Notice of Action), and to indicate eligibility pathways for PCHS authorization.

PayerHealth Net

PolicyPERSONAL CARE AND HOMEMAKER SERVICES AUTHORIZATION FORM

Policy NumberN/A

StatusCURRENT

Effective Date

Scope summaryAuthorization form to request personal care and homemaker services (PCHS) for Medi‑Cal/CHPIV members via Health Net/CHPIV, capturing member details, eligibility checkboxes, functional ADL/IADL assessments, provider and referral information, and requested hours.

Key ActionAuthorization request

Eligibility criteria for PCHS requests

Eligibility criteria

Member must meet one of the following:

AND meet one of the following

ANY of the following
- Member at risk for hospitalization, or institutionalization in a nursing facility.
- Member has functional deficits and no other adequate support system.
- Member approved for In-Home Supportive Services (IHSS). Eligibility criteria can be found at: www.cdss.ca.gov/In-Home-Supportive-Services.
ANY of the following
- Member was referred for IHSS and searching for a caregiver through the Public Authority registry.
- Member currently receives IHSS and needs additional IHSS hours. The reassessment request is pending, and a caregiver is needed for support in the meantime.
  Reassessment request date and current IHSS hours per month to be provided.
- Member is not eligible for IHSS and needs services to help avoid a short-term stay in a skilled nursing facility (not to exceed 60 days).
  Provide the IHSS Notice of Action indicating a denial, if available.

ref

title

ref|error

title|error

b1_0

ADL / IADL assessment and supports

Activities of Daily Living / Instrumental Activities of Daily Living assessment

Complete assessment with patient; indicate need (Yes/No/N/A) for each listed ADL/IADL

ALL of the following

Taking a bath or shower — Yes/No/N/A
Going up stairs — Yes/No/N/A
Eating — Yes/No/N/A
Getting dressed — Yes/No/N/A
Brushing teeth, brushing hair, shaving — Yes/No/N/A
Making meals or cooking — Yes/No/N/A
Getting out of a bed or a chair — Yes/No/N/A
Shopping and getting food — Yes/No/N/A
Using the toilet — Yes/No/N/A
Walking — Yes/No/N/A
Washing dishes or clothes — Yes/No/N/A
Writing checks or keeping track of money — Yes/No/N/A
Getting a ride to the doctor or to see your friends — Yes/No/N/A
Doing house or yard work — Yes/No/N/A
Managing medications — Yes/No/N/A
Driving or using public transportation — Yes/No/N/A
Going out to visit family or friends — Yes/No/N/A
Using the phone — Yes/No/N/A
Keeping track of appointments — Yes/No/N/A

Falls/fear/family concerns

Falls in last month — Yes/No
Afraid of falling — Yes/No
Friends/family express concerns about ability to care for self — Yes/No

Assistive devices / supports

Glasses — Use/Need
Cane — Use/Need
Walker — Use/Need
Hearing device — Use/Need
TTY (visual support) — Use/Need
Crutches — Use/Need
Grab bars — Use/Need

Medical supplies / advanced needs

Urinary catheter — Use/Need
IV infusions for meds — Use/Need
Incontinence supplies — Use/Need
Trach/suction supplies — Use/Need
Lift device (for transferring) — Use/Need
Other — Use/Need (free text)

What providers must do

Documentation Required

Complete authorization form fields

Providers must complete member information, community supports provider info, referral info, eligibility checkboxes, requested PCHS hours per day/month, ADL/IADL assessment responses, and IHSS application/status details as applicable.

Member information
Community supports provider information
Referral information
Eligibility checkboxes
Requested PCHS hours per day and per month
ADL/IADL assessment responses
IHSS application/status details

Prior Authorization

Authorization required for PCHS

This form is used to request initial or extension authorization for personal care and homemaker services; include IHSS Notice of Action when member is not eligible for IHSS and services are requested to avoid a short-term skilled nursing facility (SNF) stay (not to exceed 60 days).

Include IHSS Notice of Action when member is not eligible for IHSS
Request services to avoid a short-term SNF stay (<= 60 days)

Documentation Required

IHSS documentation

When applicable, document IHSS application submission date, application status, IHSS hours per month, reassessment request date, or provide IHSS denial Notice of Action.

IHSS application submission date
IHSS application status (in review / approved / denied)
IHSS hours per month (if approved)
Reassessment request date (if pending)
IHSS denial Notice of Action (if denied)

Definitions

PCHSPersonal Care and Homemaker Services.

IHSSIn-Home Supportive Services.

CHPIVCommunity Health Plan of Imperial Valley, Local Health Authority in Imperial County.

Form used locally in Imperial County through Community Health Plan of Imperial Valley (CHPIV) and its contracted administrator Health Net Community Solutions to request PCHS for Medi‑Cal enrollees; documents eligibility checkboxes (risk of hospitalization/institutionalization, functional deficits, IHSS approval), IHSS application/status details, and requested PCHS hours.

Policy Summary

PayerHealth Net

PolicyPERSONAL CARE AND HOMEMAKER SERVICES AUTHORIZATION FORM

Policy CodePolicy N/A

Change TypeInformational form (no material changes)

Effective Date

Next Review Date

Key ActionComplete the authorization form fields including member info, requested PCHS hours, ADL/IADL assessment, and IHSS application/status details as applicable.

SourceLink

On This Page

OpenPayer

PERSONAL CARE AND HOMEMAKER SERVICES AUTHORIZATION FORM

Policy overview

Eligibility criteria for PCHS requests

Requested service quantity

ADL / IADL assessment and supports

What providers must do

Definitions

Document revision history