CurrentmhnPolicy N/A

Recuperative care (medical respite) referral

This form governs referral, eligibility, documentation, and authorization submission for recuperative (medical respite) care for Medi-Cal enrollees served by CalViva Health in specified California counties. It affects providers making referrals and Community Supports (CS) organizations arranging short-term residential recovery services for individuals experiencing or at risk of homelessness.

Policy Summary

Payermhn

PolicyRecuperative care (medical respite) referral

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the Recuperative Care Referral Form with the CalViva Health Prior Authorization Request Form - Outpatient and include required clinical documentation (history & physical and discharge summary dated within 30 days).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsmaximum recuperative care duration (rolling 12 mo)

30 daysdischarge summary recency

Fresno, Kings, Maderaservice counties

HUD 91.5homelessness definition

Coverage & Eligibility Criteria

Eligibility

Covered when ALL of the following are met

Recuperative care eligibility: Member requires a period of recovery to heal from an injury or illness

Both criteria must be checked on the form

Recuperative care eligibility: Member is experiencing or at risk of homelessness as defined by HUD Section 91.5 with the policy-specific modifications

See policy for modifications to HUD definition (institutional exit, 30‑day imminent loss, income requirement removed)

Duration / global cap

Coverage limited by global cap

Global cap check:

Policy Summary

Payermhn

PolicyRecuperative care (medical respite) referral

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Duration Limits & Documentation Timing

inv-04: Maximum duration

Maximum durationRecuperative Care cannot exceed a duration of six months per rolling 12-month period (global cap applies across Short-Term Post-Hospitalization Housing, Recuperative Care, and Transitional Rent).

Authorization lengthMay be authorized for a shorter period based on individual needs.

Global cap consequenceIf the member has already used the six-month global cap in the rolling 12-month period, the member is not eligible for recuperative care.

inv-05: Discharge summary recency

Required recencyDischarge summary must be dated within 30 days of submission.

Applicable documentsDischarge summary requirement applies to medical facility and behavioral health treatment facility discharges (includes ED, mental health facility, skilled nursing facility).

Submission impactDischarge summaries older than 30 days may trigger denial or delay of authorization.

Referral Submission & Required Documentation

Prior Authorization

Form and submission elements

Complete and submit the Recuperative Care Referral Form with the CalViva Health - Prior Authorization Request Form - Outpatient online (recommended) at provider.healthnetcalifornia.com or by fax at 800-743-1655. The request form is available at https://bit.ly/HN-prior-auth. Select Initial authorization or Authorization extension and confirm member consent/attestations and CS provider attestation on the form. Required form fields include member information (name, phone, Medi‑Cal ID, DOB, preferred language, address, contact person and phone, ECM provider if applicable), Community Supports provider information (organization, Tax ID, NPI, staff name/title/contact, facility name/address), and referring entity information (name, address, phone, email, fax; checkbox if same as CS provider).

Complete and submit with the CalViva Health Prior Authorization Request Form - Outpatient (online recommended) or fax 800-743-1655.
Form must indicate Initial authorization or Authorization extension.
Member consent/attestation and CS provider attestation checkboxes are required on the referral form.
Required form fields: member info, CS provider info, referring entity, consent/attestations, signatures where applicable.

Documentation Required

Required clinical documentation

For individuals recovering from physical illness or injury: attach History and Physical AND a Discharge Summary from the medical facility (including ED, mental health facility, SNF) dated within 30 days of submission. For individuals recovering from a behavioral health condition: attach History and Physical that documents diagnoses, high‑risk diagnoses, medications, comorbid medical/substance use issues and relevant psychosocial risk factors, AND a Discharge Summary from the behavioral health treatment facility (including ED, mental health facility, SNF) dated within 30 days of submission.

History and Physical (required).
Discharge summary from treating facility (required) — must be dated within 30 days of submission.
Behavioral health referrals: History and Physical must include number of diagnoses, specific high‑risk diagnoses, number of medications, comorbid medical and substance use issues, and relevant psychosocial risk factors.

Denial Risk

Global cap exceeded

Recuperative Care cannot exceed six months per rolling 12‑month period and is subject to the six‑month global cap on room and board services. If the member has already used the six‑month global cap in the rolling 12‑month period, they are not eligible for recuperative care.

Ask and document: Has the member already used their six‑month global cap per rolling 12‑month period? (Yes/No).
If Yes, the member is not eligible for recuperative care.

Denial Risk

Documentation missing or outdated

Do not submit the referral without the required attachments. Missing required clinical documents or a discharge summary dated more than 30 days prior to submission may result in denial of authorization. Ensure all documents are legible, signed where applicable, and dated within the required timeframes before sending.

Missing required documents = denial risk.
Discharge summary must be dated within 30 days of submission — older summaries may lead to denial.
Ensure documentation is legible and signed where applicable.

Key Definitions

inv-13: Recuperative care / medical respite

DefinitionRecuperative care (medical respite) is a short-term residential setting for individuals experiencing or at risk of homelessness to recover from injury, illness, or behavioral health conditions that are significant enough to result in ED visits, hospital admissions, or other institutional care.

PurposeProvides clinical recovery supports and housing navigation during a period of recuperation.

SettingShort-term residential recovery (medical respite) provided by Community Supports (CS) organizations as arranged via referral and prior authorization.

inv-14: Homeless / at risk of homelessness (policy-specific)

Base definitionMembers must meet the U.S. Housing and Urban Development (HUD) definition of homeless or at risk of homelessness per 24 CFR 91.5, with policy-specific modifications.

Modification — institutional exitsIf exiting an institution, individuals are considered homeless if they were homeless immediately prior to entering that institutional stay or become homeless during that stay, regardless of length of institutionalization.

Modification — imminent loss timeframeThe timeframe for imminent loss of housing is extended to 30 days (from HUD's 14 days/21 days).

Modification — income requirement removedFor the 'at risk of homelessness' definition, the HUD annual income requirement (below 30% of area median) does not apply under this policy.

OpenPayer

Recuperative care (medical respite) referral

Coverage & Eligibility Criteria

Duration Limits & Documentation Timing

Referral Submission & Required Documentation

Policy Background

Key Definitions