CurrentmhnPolicy N/A

ICF/DD Authorization Request Form — Completion and Submission Requirements

Governs completion and submission of authorization requests to the Medi‑Cal MCP for placement or continued stay in Intermediate Care Facility/Home for the Developmentally Disabled (ICF/DD) settings; applies to ICF/DD facilities/homes, prescribing physicians, and MCP reviewers in California.

Policy Summary

Payermhn

PolicyICF/DD Authorization Request Form — Completion and Submission Requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the ICF/DD Authorization Request form with required member, facility, ICD (up to three) and physician certification information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

11form items to complete

up to 3ICD codes permitted

3ICF/DD model types

4-15 / 60+facility sizes

Authorization — Required Completion Criteria

Authorization form completion criteria

Authorization requests must include the following completed items and physician certification:

ALL of the following

Member Name: Enter the Member's full name from the Benefits Identification Card (BIC).
Medi-Cal Identification Number and Eligibility: Enter recipient ID; include county and aid codes as applicable; do not include special characters.
Facility/Home Name, Address and Contact Information: Provide physical address and submitter name, email, and telephone.
ICD Diagnosis Codes: List up to three ICD diagnosis codes.

Policy Summary

Payermhn

PolicyICF/DD Authorization Request Form — Completion and Submission Requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the ICF/DD Authorization Request form with required member, facility, ICD (up to three) and physician certification information.

SourceLink

On This Page

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Form Submission Requirements and Actions

Prior Authorization

Complete and submit the ICF/DD Authorization Request form

Complete and submit the ICF/DD Authorization Request form with all required fields: Member Name; Medi‑Cal Identification Number and Eligibility (include recipient ID, county and aid codes); Facility/Home name, address and contact information; up to three ICD diagnosis codes; authorization type (Initial, Transfer, Re‑admission, or Reauthorization); Prescribing Physician name and state license/Medi‑Cal rendering provider number; Level of Care requested (ICF/DD, ICF/DD‑H, or ICF/DD‑N); Admit Date; Period of Care (From and Through dates in six‑digit MMDDYY format); and the attending physician’s signature certifying the need for the requested level of care per 22 CCR §51343(a). The facility/home may submit the physician signature via fax, scanning, or upload.

Enter Member full name exactly as shown on Benefits Identification Card (BIC).
Provide Medi‑Cal Identification Number and eligibility details (include county and aid codes; do not include special characters).
List facility/home physical address and submitter contact (name, email, telephone).
List up to three ICD diagnosis codes.
Indicate authorization type: Initial, Transfer, Re‑admission, or Reauthorization.
Provide Prescribing Physician name and state license (Medi‑Cal rendering provider number).
Select Level of Care requested: ICF/DD, ICF/DD‑H, or ICF/DD‑N.
Enter Admit Date and Period of Care 'From' and 'Through' dates in six‑digit format (MMDDYY).
Obtain attending physician signature certifying need per 22 CCR §51343(a); signature may be faxed, scanned, or uploaded.

ICF/DD Level-of-Care Definitions

ICF/DD — definition and facility size/level summary

DefinitionICF/DD (Developmentally Disabled): facility/home (up to over 60 beds) offering 24-hour personal care, habilitation, developmental, and supportive health services for individuals with IDD whose primary need is developmental services and who have a recurring but intermittent need for skilled nursing services.

Typical services provided24-hour personal care, habilitation, developmental, and supportive health services; intermittent recurring skilled nursing when needed.

Facility sizeCapacity can be up to over 60 beds (larger facility model compared to ICF/DD-H and ICF/DD-N).

ICF/DD-H — habilitative home definition and bed-capacity details

DefinitionICF/DD-H (Habilitative): home with a capacity of 4 to 15 beds providing 24-hour personal care, habilitation, developmental, and supportive health services for up to 15 individuals with IDD.

Nursing requirementServes individuals who have intermittent recurring needs for nursing services but have been certified by a physician and surgeon as not requiring continuous skilled nursing care.

Bed capacity4–15 beds; serves 15 or fewer individuals.

ICF/DD-N — nursing home definition and nursing supervision details

DefinitionICF/DD-N (Nursing): home with a capacity of 4 to 15 beds providing 24-hour personal care, developmental services, and nursing supervision for individuals with IDD who have intermittent recurring needs for skilled nursing care.

Patient populationServes medically fragile persons with developmental disabilities or significant developmental delay who have intermittent recurring skilled nursing needs but do not require continuous skilled nursing care.

Bed capacity4–15 beds (small home model).

OpenPayer

ICF/DD Authorization Request Form — Completion and Submission Requirements

Authorization — Required Completion Criteria

ICD Diagnosis and Code Limits

Form Submission Requirements and Actions

ICF/DD Level-of-Care Definitions