CurrentHealth NetPolicy 24-056

Personal Care and Homemaker Services Referral Form

A referral and authorization form for Personal Care and Homemaker Services (PCHS) for Medi‑Cal members, including member, provider, eligibility criteria, required documents, and ADL/IADL assessment fields for initial and extension requests.

Policy Summary

PayerHealth Net

PolicyPersonal Care and Homemaker Services Referral Form

Policy CodePolicy 24-056

Change TypeInformational (no material changes)

Effective Date

Next Review Date

Key ActionComplete and submit this referral form with the Medi‑Cal Prior Authorization Request Form Outpatient either online at provider.healthnetcalifornia.com or by fax at 800‑743‑1655.

POLICY UPDATE CHANGES

No material clinical/coverage changes

FormDocument type

ADL/IADLAssessment included

IHSS (3)Eligibility pathways

Policy overview

Personal Care and Homemaker Services (PCHS) are provided for members who need assistance with Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs). The referral/authorization form is used to request authorization for PCHS and to document member eligibility, current IHSS status, and required assessments.

policy number24-056

last review2024-01-24

next review

statusCURRENT

subjectPersonal Care and Homemaker Services Referral Form

scope summaryA referral and authorization form for Personal Care and Homemaker Services (PCHS) for Medi‑Cal members, including member, provider, eligibility criteria, required documents, and ADL/IADL assessment fields for initial and extension requests.

Eligibility criteria for PCHS

Eligibility Criteria

Member must meet one of these two:

ANY of the following

Member needs assistance with ADLs and/or IADL tasks and has no other adequate support system.
ALL of the following
- ONE of
  - Member was referred for In-Home Services (IHSS) and searching for a caregiver through the Public Authority registry.
    Capture IHSS application submission date and IHSS application status (In review / Approved / Denied).
  - Member currently receives IHSS and needs additional IHSS hours. The reassessment request is pending, and a caregiver is needed for support in the meantime.
    Include reassessment request date and current IHSS hours per month.
  - 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 IHSS Notice of Action indicating a denial, if available.

PCHSPersonal Care and Homemaker Services.

ADLsActivities of Daily Living.

IADLsInstrumental Activities of Daily Living.

IHSSIn‑Home Supportive Services.

Required provider actions and documentation

Documentation Required

Submit referral and authorization

Complete and submit the referral form together with the Medi‑Cal Prior Authorization Request Form Outpatient. Submissions may be made online at provider.healthnetcalifornia.com (recommended) or by fax to 800-743-1655. Reference and attach the Medi-Cal Prior Authorization Request Form Outpatient when submitting.

Online portal: provider.healthnetcalifornia.com (recommended)
Fax: 800-743-1655
Include the Medi-Cal Prior Authorization Request Form Outpatient with the referral

Documentation Required

Required supporting documents

Attach the initial assessment documenting ADL and IADL needs with the authorization and referral forms. When applicable, include IHSS-related documents such as IHSS application details or the IHSS Notice of Action (for denials).

Initial assessment including ADLs and IADL needs
IHSS application details (when applicable)
IHSS Notice of Action if a denial has been issued

Documentation Required

Capture IHSS status details

Document the member’s IHSS status on the referral and assessment using specific dates and status indicators. Capture IHSS application and approval/reassessment details as applicable.

IHSS application submission date
IHSS application status: In review / Approved / Denied
Approved IHSS hours per month (if approved)
Reassessment request date (if reassessment pending)

Form scope and intended use

Use this form for PCHS referrals for Medi‑Cal members. It collects member and servicing provider information, documents eligibility based on ADL/IADL need or risk of hospitalization/institutionalization, and records IHSS application status or hours when applicable.

Required supporting documents include the initial assessment with ADL and IADL needs and any IHSS documentation (application submission date, application status, approved IHSS hours per month, reassessment request date, or IHSS Notice of Action for denials). The form includes fields for both initial and extension requests and prompts completion of the ADL/IADL assessment with the patient.

Key terms

Definitions:

PCHS — Personal Care and Homemaker Services.

ADLs — Activities of Daily Living.

IADLs — Instrumental Activities of Daily Living.

IHSS — In‑Home Supportive Services.

Policy Summary

PayerHealth Net

PolicyPersonal Care and Homemaker Services Referral Form

Policy CodePolicy 24-056

Change TypeInformational (no material changes)

Effective Date

Next Review Date

Key ActionComplete and submit this referral form with the Medi‑Cal Prior Authorization Request Form Outpatient either online at provider.healthnetcalifornia.com or by fax at 800‑743‑1655.

On This Page

OpenPayer

Personal Care and Homemaker Services Referral Form

Policy overview

Eligibility criteria for PCHS

Required provider actions and documentation

Form scope and intended use

Key terms

Revision history