​​​AUDITS & INVESTIGATIONS - Provider Descriptions

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Provider Descriptions

Health care providers subject to audit include acute care inpatient hospitals and long-term care facilities (such as skilled nursing and intermediate care).

1. Acute Hospital
2. Home Office Acute Hospital
3. Home Office - All Long Term Care Provider Types
4. Intermediate Care Developmentally Disabled
5. Intermediate Care Developmentally Disabled Habilitative
6. Intermediate Care Developmentally Disabled Nursing
7. Intermediate Care Facility
8. Local Educational Agency Medi-Cal Billing Option Program
9. Nursing Facility
10. Targeted Case Management 

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.

Home Office - Acute Hospital and 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 generally incurs costs and provides services to or on behalf of the individual health facility.

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.

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.           

Local Educational Agency Medi-Cal Billing Option Program - Provides the federal share of reimbursement for health assessment and treatment for Medi-Cal eligible children receiving special education services and family members within the school environment.  The provider (generally a school district or county office of education) employs or contracts with qualified medical practitioners to render certain health services. 

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.​ 

Targeted Case Management - The Targeted Case Management Program (TCM) provides specialized case management services to Medi-Cal eligible individuals in a defined target population to gain access to needed medical, social, educational, and other services. TCM Services are provided by Local Governmental Agencies (LGAs). An LGA is defined by law as a county or chartered city. The LGA must have a signed Medi-Cal Provider Agreement with the Department in order to provide the TCM services to needed populations.