CurrentmhnPolicy N/A

Day Habilitation Referral Form

Form and instructions to refer Medi-Cal members for Day Habilitation Programs to assist with self-help, socialization, and adaptive skills; used by providers contracting with Health Net/CHPIV for Medi-Cal enrollees in Imperial County.

Policy Summary

Payermhn

PolicyDay Habilitation Referral Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

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.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medi-Calpayer program referenced

Imperial Countycoverage area

24 monthsexit timeframe

online or faxsubmission

days/hoursservice quantity fields

Eligibility and Coverage Criteria

Eligibility criteria

Eligibility criteria for Day Habilitation referral (one of the following must be met):

ANY of the following

Experiencing homelessness
Exited homelessness and entered housing in the last 24 months.
At risk of homelessness or institutionalization whose housing stability could be improved through participation in a Day Habilitation Program.

ALL of the following

Individual experiencing or at risk of homelessness is defined per HUD with three modifications as detailed in Appendix C in the CS Policy Guide Volume 2.

Policy Summary

Payermhn

PolicyDay Habilitation Referral Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

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.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Submission and Prior Authorization Instructions

Prior Authorization

Pair this referral with the Medi‑Cal Prior Authorization Request (online or fax)

Complete and submit this Day Habilitation referral form together with the Medi‑Cal - Prior Authorization Request Form - Outpatient. Submit the prior authorization either online at provider.healthnetcalifornia.com (recommended) or by fax to 800-743-1655.

Include this referral form as an attachment to the Medi‑Cal Prior Authorization Request.
Use the online submission portal at provider.healthnetcalifornia.com (recommended) or fax to 800-743-1655.

Program Definitions and Special Eligibility Notes

Day Habilitation Programs — description

Purpose of Day HabilitationAssist the member in acquiring, retaining, and improving self-help, socialization and adaptive skills necessary to successfully reside in the person's natural environment.

ScopeServices intended to support daily living skills, community integration, and adaptive functioning in the member's natural environment.

Reference guidanceRefer to the Day Habilitation Authorization Guide for more information.

Homelessness-related eligibility

Experiencing homelessnessMember is currently experiencing homelessness (meets this eligibility criterion).

Exited homelessness within 24 monthsMember exited homelessness and entered housing in the last 24 months (eligible).

At risk of homelessness or institutionalizationMember is at risk of homelessness or institutionalization and participation in Day Habilitation could improve housing stability.

OpenPayer

Day Habilitation Referral Form

Eligibility and Coverage Criteria

Billing and Service Quantity

Submission and Prior Authorization Instructions

Program Definitions and Special Eligibility Notes