CurrentmhnPolicy N/A

ICF/DD Authorization Request Form and Instructions

Governs completion and submission of authorization requests for Intermediate Care Facility/Home for the Developmentally Disabled (ICF/DD) placements for Medi‑Cal members; applies to ICF/DD facilities/homes, attending physicians, and the Medi‑Cal MCP authorization process.

Policy Summary

Payermhn

PolicyICF/DD Authorization Request Form and Instructions

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the ICF/DD Authorization Request form fields 1–11 and obtain the attending physician's signature certifying required level of care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

11numbered form fields on the authorization request

up to 3ICD diagnosis codes to list

3ICF/DD model types

4-15ICF/DD-H / ICF/DD-N bed capacity

Authorization and Coverage Criteria

Authorization requirements

Authorization request content and required certifications for coverage consideration.

ALL of the following

Member Name (field 1)
Medi‑Cal Identification Number and Eligibility (field 2)
Facility/Home Name, Address and Contact Information (field 3)
ICD Diagnosis Codes — list up to 3 codes (field 4)<= 3 codes

Policy Summary

Payermhn

PolicyICF/DD Authorization Request Form and Instructions

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the ICF/DD Authorization Request form fields 1–11 and obtain the attending physician's signature certifying required level of care.

SourceLink

On This Page

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Form Completion, Certification, and Submission

Documentation Required

Form completion — Complete the ICF/DD Authorization Request form

Complete the ICF/DD Authorization Request form fields 1–11. Include member name, Medi‑Cal ID and eligibility, facility/home name and contact, up to three ICD diagnosis codes, indicate whether the request is Initial, Transfer, Re‑admission, or Reauthorization, prescribing physician name and license number (Medi‑Cal rendering provider number), level of care requested (ICF/DD, ICF/DD‑H, or ICF/DD‑N), Admit date, From and Through dates (six‑digit format MMDDYY), and the attending physician signature.

1–11: Fill all form fields exactly as shown on the Benefits Identification Card (BIC) and facility records.
Medi‑Cal ID: Begin in the far left position; do not enter dashes, hyphens, or special characters. Enter county code and aid code just above the Medi‑Cal ID box.
ICD codes: List up to three diagnosis codes.
Dates: Use six‑digit format (e.g., November 1, 2006 = 110106).

Prior Authorization

Physician certification and submission methods

The attending physician must sign and certify the authorization request per 22 CCR § 51343(a) attesting that the Member requires the requested level of care. The ICF/DD Facility/Home initiates the request and may submit the physician signature by fax, scanning, or uploading as an attachment to the MCP.

Physician signature: Attending physician must sign and certify the request.
Submission methods: Fax, scanned copy, or uploaded attachment are acceptable for the physician's signature.

Documentation Required

Medi‑Cal ID format — Enter Medi‑Cal ID without hyphens or special characters

Enter the Medi‑Cal Identification Number exactly as it appears on the BIC without hyphens or other special characters. Include the county code and aid code in the designated area above the Medi‑Cal ID box.

Do not include dashes, hyphens, or special characters in the Medi‑Cal ID field.
Enter county code and aid code above the recipient Medi‑Cal Identification Number box.

Key Term Definitions

ICF/DD — short definition

TermIntermediate Care Facility/Home for the Developmentally Disabled (ICF/DD)

PurposeProvides authorization form and placement for individuals with intellectual and developmental disabilities (IDD) eligible for Regional Center services

Models includedICF/DD, ICF/DD-H (Habilitative), and ICF/DD-N (Nursing)

ICF/DD (Developmentally Disabled)

Facility descriptionA facility/home (up to over 60 beds) that offers 24-hour personal care, habilitation, developmental, and supportive health services for individuals with IDD whose primary need is developmental services

Nursing needsServes individuals with recurring but intermittent need for skilled nursing services (not continuous)

PopulationIndividuals with intellectual and developmental disabilities (IDD) who are eligible for Regional Center services

ICF/DD-H (Habilitative)

TypeICF/DD-H (Habilitative)

ServicesProvides 24-hour personal care, habilitation, developmental, and supportive health services for individuals with IDD

Bed capacityHome capacity of 4 to 15 beds

Nursing requirementFor individuals with intermittent recurring nursing needs but certified as not requiring continuous skilled nursing care

ICF/DD-N (Nursing)

TypeICF/DD-N (Nursing)

ServicesProvides 24-hour personal care, developmental services, and nursing supervision for individuals with IDD

Bed capacityHome capacity of 4 to 15 beds

Population servedMedically fragile persons with developmental disabilities or significant developmental delay with intermittent skilled nursing needs but not requiring continuous skilled nursing

OpenPayer

ICF/DD Authorization Request Form and Instructions

Authorization and Coverage Criteria

Diagnosis Coding and Limits

Form Completion, Certification, and Submission

Key Term Definitions