The URL can be used to link to this page

Home My WebLink Aboutappendix-a-healthpac-dofr-v1.8.26 HealthPAC DOFR Page 1 Division of Financial Responsibility – DOFR Effective January 1, 2026 HEALTH CARE SERVICE CBO + AHS PCP Clinics AHS Hospitals/ Specialty County Referral to AHS Authorization Required COMMENTS ABORTION / REGNANCY SERVICES / FAMILY PLANNING NA NA N N Limited to Family PACT (California Family Planning, Access, Care, and Treatment). ALLERGY IMMUNOTHERAPY x Y N ALLERGY TESTING, TREATMENT AND SERUM x Y N AMBULANCE - EMERGENCY ● In Area ● Out of Area x NA N N Key: CBO = Community Based Organization AHS = Alameda Health System PCP = Primary Care Provider County = ACH and/or one of its departments “x” = indicates this group is financially responsible for the provision of the designated service NA = Non-Covered Service N = No Y = Yes Appendix A HealthPAC DOFR Page 2 HEALTH CARE SERVICE CBO + AHS PCP Clinics AHS Hospitals/ Specialty County Referral to AHS Authorization Required COMMENTS ANESTHESIOLOGY (related to surgery) x N N BLOOD/BLOOD PRODUCTS ● Blood Bank ● Autologous/Homologous Storage and Collection of Blood x x x Y N CARDIAC REHABILITATION - When associated with Inpatient ● Technical Component ● Professional Component x x Y N CARDIAC REHABILITATION – If in MD office or referred by MD office, except when associated with IP stay ● Technical Component ● Professional Component x x Y N CCS N/A N/A Carve out to CCS CHEMICAL DEPENDENCY / SUBSTANCE ABUSE x x N Y Limited to authorized services for individuals with co- occurring mental health conditions. BHCS needs to authorize that client meets specialty mental health eligibility criteria. CHEMOTHERAPY ● Drugs, including Epogen, Neupogen and adjunctive therapies x N N HealthPAC DOFR Page 3 HEALTH CARE SERVICE CBO + AHS PCP Clinics AHS Hospitals/ Specialty County Referral to AHS Authorization Required COMMENTS ● Facility Component ● Professional Component x x COSMETIC SURGERY (Medically Necessary) ● Facility Component ● Professional Component x x Y N CRITICAL CARE VISITS ● Facility ● Professional x x N/A N/A DENTAL SERVICES ● Facility Component ● Professional Component x x x x N N DIAGNOSTIC TESTING IN OFFICE (EKG, X-RAY) x N N DIAGNOSTIC TESTING (Including but not limited to sleep studies, CT scans, PET Scans, MRIs, hearing tests, diagnostic colonoscopies, EEG etc.) ● Facility Component ● Professional Component x x Y N When associated with IP stay, Ambulatory or OP Surgery and ER; includes outside facility during an IP stay. DURABLE MEDICAL EQUIPMENT ● Outpatient ● Surgically Implanted x x Y Y • Authorized by AHS, PCP clinic provides MD contact, documentation of medical necessity HealthPAC DOFR Page 4 HEALTH CARE SERVICE CBO + AHS PCP Clinics AHS Hospitals/ Specialty County Referral to AHS Authorization Required COMMENTS ● Process does not require that members register or visit AHS site EMERGENCY ADMISSIONS ● Facility Component ● Professional Component x x N N HealthPAC patients should not be billed beyond the co-pay schedule for facility and professional services. EMERGENCY ROOM VISITS ● Facility Component ● Professional Component x x N N HealthPAC patients should not be billed beyond the co-pay schedule for facility and professional services. EXTENDED CARE/SKILLED NURSING FACILITY ● Facility Component ● Professional Component x x Y Y AHS authorization HEMODIALYSIS ● Facility Component ● Dialysis Drugs ● Professional Component x x x Y N IMMUNIZATIONS – Standard Adult and Pediatric—NOT TRAVEL related and NOT work related. x N N INJECTIBLES x Y N LABORATORY SERVICES Office Reference lab (per defined CPT code) x x Y Y Authorization for reference lab done by AHS LITHOTRIPSY Y N HealthPAC DOFR Page 5 HEALTH CARE SERVICE CBO + AHS PCP Clinics AHS Hospitals/ Specialty County Referral to AHS Authorization Required COMMENTS ● Facility Component ● Professional Component x x MEDICAL SUPPLIES x x Y N BEHAVIORAL HEALTH – John George/Inpatient and ER ● Facility Component ● Professional Component x x Y No authorization required for ER. Services covered under separate contract b/w BHCS and AHS. BEHAVIORAL HEALTH – Specialty Outpatient ● Facility Component ● Professional Component x x x x N Y ● Auth Completed by BHCS (for specialty behavioral health only) ● Specialty mental health services for HealthPAC patients that meet diagnostic criteria. OFFICE VISITS ● Primary Care ● Mental Health x x N N PATHOLOGY- When associated with IP, Ambulatory Surgery or Emergency Room ● Professional Component ● Technical Component x x N N Except PAP smears PATHOLOGY – In MD office or when referred by MD office, except when associated with, IP stay, OP/Ambulatory Surgery or ER, as noted above ● Technical Component x N N HealthPAC DOFR Page 6 HEALTH CARE SERVICE CBO + AHS PCP Clinics AHS Hospitals/ Specialty County Referral to AHS Authorization Required COMMENTS ● Professional Component x PHARMACY SERVICES x x N/A N HealthPAC has an approved formulary available at https://health.alamedacountyc a.gov/healthpac/ Clinics are responsible for filling prescriptions for patients assigned to medical home after being released from an inpatient stay. Hospitals generally provide a 3-day fill. PODIATRY x x Y N Referral required for hospital- based service only. PROSTHETIC/ORTHOTIC DEVICES ● Outpatient ● Surgically Implanted x x Y N PSYCHOLOGY SERVICES x x x Y (for County provided services) Medi-Cal exclusion allows services at FQHC. County provides services for SMI population. RADIATION THERAPY x Y N Specialty Care Office Procedures x Y N Specialty Care Office Visits x Y N Specialty Procedures ● Diagnostic ● Therapeutic x x Y N HealthPAC DOFR Page 7 HEALTH CARE SERVICE CBO + AHS PCP Clinics AHS Hospitals/ Specialty County Referral to AHS Authorization Required COMMENTS SURGERY - Inpatient ● Facility Component ● Professional Component x x Y N SURGERY – Outpatient ● Facility Component ● Professional Component x x Y N THERAPY: Physical ● Inpatient ● Outpatient/Office x x Y N TRANSPLANTS ● Facility Component ● Organ Procurement ● Covered Immunosuppressive ● Professional Component NA NA N/A N Not a covered benefit TRANSPORTATION, NON- EMERGENCY MEDICAL x x Y Authorization done by CBO and AHS. HealthPAC NON-COVERED SERVICES COMMENTS ● Acupuncture ● Adult Day Health Care ● Alopecia treatment ● Artificial Insemination, Infertility Services and Conception by artificial means ● Audiology ● Bariatric Surgery ● Biofeedback ● Chemical dependency services (without co-occurring mental health condition) NON- COVERED MEDICAL SERVICES HealthPAC DOFR Page 8 HealthPAC NON-COVERED SERVICES COMMENTS ● Chiropractic ● Custodial Care ● Cosmetic Services - to change the way you look, not medically necessary ● Exercise and hygiene equipment ● Home health ● Hospice Care ● Incontinence Supplies ● Infertility Testing and Treatment... Refer to Family PACT ● Inpatient Convenience items ● Maternity - deliveries ● Organ Transplants and Post-Transplant Services ● Private Rooms ● Reversal of Sterilization ● Services provided as a requirement of employment, licensing or court order ● Speech and hearing exams ● Travel & lodging expenses ● Therapy- occupational, respiratory and speech ● Vision care - services only include procedures for evaluation of visual system. Does NOT include eyeglasses or other eye appliances. ● Services provided outside of the HealthPAC provider network