A&I Audit Descriptions

Audits & Investigations - Descriptions of Audit Types

Providers subject to audit include acute care inpatient hospitals, long-term care facilities (such as skilled nursing and intermediate care), Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC), home offices related to the above categories of providers, and public health programs such as Maternal Child Health and Office of AIDS.

(Click on type for descriptions)		2005	2006	2007	2008
Types of Audits		Reports for Fiscal Periods Ended
1)	Acute Hospital Cost Reports	click here	pending	pending	pending
2)	Acute Psychiatric Costs	pending
3)	Adult Day Health Care	pending
4)	Billing	pending
5)	County Medical Services Program	pending
6)	Emergency Preparedness	pending
7)	Federally Qualified Health Centers	pending
8)	Home Office-All Long Term Care Provider Types	pending
9)	Home Office Cost Report	pending
10)	In-Home Support Services	pending
11)	Intermediate Care Facility	pending
12)	Intermediate Care Developmentally Disabled	pending
13)	Intermediate Care Developmentally Disabled Habilitative	pending
14)	Intermediate Care Developmentally Disabled Nursing	pending
15)	Local Education Assistance	pending
16)	Long Term Care	pending
17)	Maternal, Child, and Adolescent Health	pending
18)	Medi-Cal Administrative Activities	pending
19)	Nursing Facility	pending
20)	Office of AIDS	pending
21)	Rate Development Branch Worksheet	pending
22)	Rural Health Clinics	pending
23)	State Hospital	pending
24)	Subacute Freestanding	pending
25)	Targeted Case Management	pending

Acute Hospital - A medical institution which is licensed to provide 24-hour inpatient services for the diagnosis, acute care, and treatment of patients. Such services may include emergency medical surgery, maternity, x-ray, etc.

Acute Psychiatric Costs - Psychiatric Acute Care is the provision of nursing care to adult patients admitted for diagnosis as well as treatment on the basis of physicians' orders and approved nursing care plans. This cost center is staffed with nursing personnel specially trained to care for the mentally ill, mentally disordered, or other mentally incompetent persons.

Adult Day Health Care - Adult day health care means an organized day program of therapeutic, social and health activities and services, provided to elderly persons or other persons with physical or mental impairments for the purpose of restoring or maintaining optimal capacity for self-care.

Billing - COMING SOON


County Medical Service Program - COMING SOON


Emergency Preparedness - COMING SOON


Federally Qualified Health Centers - A freestanding FQHC clinic is a primary outpatient care, non-profit, community based or public organization. FQHC's are licensed as primary care clinics (or are exempt) in accordance with Health & Safety Code, Sections 1204 & 1206. The freestanding clinic is not related to a hospital and operates independently having its own governance and professional supervision (Vol. 1, Sec. 3117, Medicare & Medicaid Guide). It must have approval by Public Health Service as an FQHC either via the section 329 (community clinic), 330 (migrant farmworkers), 340 (healthcare for the homeless), 340a (public housing project) grants or have received "look alike" status from the Public Health Service. There is no limit on reimbursable cost per visit.


Home Office-All Long Term Care Provider Types - A home office is an organization that controls through ownership, lease or any other device, two or more health care facilities. The organization may include other business entities and/or organizations which are engaged in activities not directly related to patient care. Home offices are also referred to as chain operations, with the various subsidiaries as members of the chain.

The office of the controlling organization. This office generally incurs costs and provides services to or on behalf of the individual health facility.

Home Office Cost Report - COMING SOON

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In-Home Support Services - COMING SOON


Intermediate Care Facility -"Intermediate Care Facility" means a health facility, or a distinct part of a hospital or skilled nursing facility, which provides the following basic services: Inpatient care to patients who have need for skilled nursing supervision and need supportive care, but who do not require continuous nursing care.

A health facility which provides inpatient care to patients who have need for skilled nursing supervision and supportive care, but who do not require continuous nursing care.

Intermediate Care Developmentally Disabled - Intermediate Care Facility for the developmentally disabled means a health facility which provides care and support services to developmentally disabled clients whose primary need is for developmental services and who have a recurring but intermittent need for skilled nursing services.


Intermediate Care Developmentally Disabled Habilitative - The primary purpose of an ICF/DDH facility is to furnish 24-hour personal care, developmental, training, and habilitative and supportive health services in a facility with 15 beds or less to residents with a developmental disability. A developmental disability is a disability which originates before age 18 and is a permanent and substantial handicap as defined in the Welfare and Institutions (W & I) Code, Section 4512. ICF/DDH facilities provide these services to developmentally disabled beneficiaries in the least restrictive community type setting.


Intermediate Care Developmentally Disabled Nursing -The primary purpose of an ICF/DDN facility is to furnish 24-hour nursing supervision, personal care, training and habilitative services in a facility with 4-15 beds to medically fragile developmentally disabled beneficiaries, or to beneficiaries who demonstrate a significant developmental delay that may lead to a developmental disability if not treated. Such beneficiaries shall have been certified by a physician as not requiring continuous skilled nursing care. ICF/DDN facilities provide services to the medically fragile developmentally disabled beneficiaries in the least restrictive community setting.

Local Education Assistance - "Local educational agency" means the governing body of any school district or community college district, the county office of education, a state special school, a California State University campus, or a University of California campus.

Long Term Care - Nursing and personal care services provided over an extended period to persons who require convalescence at a level which is less than that normally provided in acute facilities and/or who are chronically ill, aged, or disabled. Inpatient facilities which provide long term care, such as nursing homes and convalescent hospitals, are categorized for licensing purposes as either skilled nursing facilities or intermediate care facilities.

Maternal, Child and Adolescent Health - The Maternal and Child Health Program (MCH), established on the state level in 1973, is funded by a Federal Title V Block Grant as well as by Federal Medicaid funds (Title XIX), state General Fund, and the state Cigarette and Tobacco Products Surtax Fund. The mission of the MCH Branch is to assure that infants, children, adolescents, and pregnant women in California receive a variety of services to protect and improve their health. To accomplish its goals, the Branch maintains partnerships, contracts, and agreements with state federal and local agencies in both the public and private sectors.

The Maternal and Child Health Program (MCH) administers a variety of programs to assure that infants, children, adolescents, and pregnant women in California receive a variety of services to protect and improve their health. As part of this effort, the MCH Branch also administers a Battered Women Shelter Program (BWSP). The BWSP was enacted in 1994 through Assembly Bill 801 and is supported by the state General Fund. The purpose of the BWSP is to provide services and prevention programs throughout California to assist battered women and their children.

Medical Administrative Activities - COMING SOON

Nursing Facility - A health facility or a distinct part of a hospital which provides skilled nursing care and supportive care to patients whose primary need is for nursing care on an extended basis. It provides 24-hour inpatient care that includes at a minimum, medical, nursing, dietary, pharmaceutical services and an activity program. The facility must have effective arrangements, confirmed in writing, through which services required by the patients but not regularly provided within the facility, can be obtained promptly when needed.



Office of AIDS - The AIDS Drug Assistance Program (ADAP) provides drugs related to the treatment of HIV and AIDS for clients who are not otherwise covered by private insurance, Medi-Cal, or any other third party payor, and cannot afford the cost of these drugs themselves. The drugs are provided on a sliding scale based on specific financial eligibility requirements.

The HIV CARE Program is responsible for assuring the provisions of humane, cost-effective, and appropriate health and social service resources for persons with HIV along the entire continuum of care. The HIV CARE Branch, with state and federal funding, administers several statewide programs that provide care and treatment, and support services to people with HIV. These services span the entire disease spectrum from initial HIV detection through hospice care and death.

Rate Development Branch Worksheet - Title 22, California Code of Regulations (CCR), Section 51536 states, "Reimbursement for hospital inpatient services provided to Medi-Cal program beneficiaries shall be the lesser of the following for each hospital: (1) Customary Charges; (2) Allowable costs determined in accordance with applicable Medicare standards and principles of reimbursement; (3) All-inclusive rate per discharge." Customary charges are the fees that a hospital normally charges the general public; allowable costs are costs which are reimbursable in accordance with Federal and State laws/regulations. Allowable costs are determined based on annual audit by Audits and Investigations (A&I) of the hospitals' cost report; and the all-inclusive rate per discharge (ARPD) is calculated by the Department of Health Services, Hospital Reimbursement Section (HRS), Rate Development Branch (RDB), based on data submitted by the hospital. The ARPD is the key element in computing the Maximum Inpatient Reimbursement Limitation (MIRL), e.g., final settlement. The calculation of the ARPD/MIRL is the best mechanism the state has in quantifying the cost behaviors of inpatient hospitals and achieving the goal of containing the escalating cost of health care.


Rural Health Clinics - "Rural health clinic" means an organized outpatient clinic or hospital outpatient department, located in a rural shortage area, which has been certified by the Secretary, United States Department of Health and Human Services.

An RHC must be located in an area not delineated as an urbanized area by the Census Bureau. In addition, the clinic must be located in a medically underserved area and/or a health professional shortage area. In addition to a medical director, all RHCs must have a physician assistant or nurse practitioner at least 60% of the time the clinic is in operation.


State Hospital - COMING SOON


Subacute Freestanding - Subacute level of care means a level of care needed by a patient who does not require hospital acute care but who requires more intensive licensed skilled nursing care than is provided to the majority of patients in a skilled nursing facility. Subacutes exist as part of a freestanding nursing facility or a distinct part of a hospital. Refer to the DP-NF / Subacute audit manual

Targeted Case Management -COMING SOON

Audits & Investigations

Contact: 916-440-7550

Mailing Address:

P.O. Box 997413, MS 2000

Sacramento, CA 95899-7413