SECTION 3


                                            HOSPITAL REFERRAL SYSTEM


1.        GENERAL


Acute care hospitals identify and refer individuals to the Depart­ment of Social Services (DSS) to apply for Medi-Cal and/or County Medical Services (CMS) benefits.  Referrals are made for current inpatients who have little or no insurance to pay for hospi­talization expenses. This section describes the hospital referral process including the time frames and forms involved.  This section also describes the procedure for decentralizing a Medi-Cal referral from a Hospital Outstation Service (HOS) worker to a district worker, and a CMS referral from a HOS worker to the CMS Eligibility Unit.





Procedures for releasing information concerning applicants or beneficiaries eligibility are located in MPG Article 2, Section 1.  Form 14-10 DSS, Transmittal of CMS/Medi-Cal Information, can be completed and sent to the hospital without a signed written authorization by the beneficiary to release information.





Hospital referrals are processed by DSS eligibility staff through one of two systems.


A.       Hospital Outstation Service (HOS)


Hospitals contracting with the Hospital Council to have Eligi­bility Technicians (workers) stationed in their facility will refer potential Medi-Cal and CMS patients to the HOS worker located in the hospital.



B.       Centralized Referral Procedures


1)      Medi-Cal


Hospitals which do not contract for a HOS worker will refer patients by calling a centralized referral number 694-2341. 


This number is answered by a duty worker (worker) in the Special Medical Unit (SMU) located in the Kearny Mesa District Office.



a)        Key Person


When the patient has a key person to act on his or her behalf the duty worker will tell the caller to have the patient or key person apply either at the district office responsible for the area in which the patient lives or the district where the key person resides.  No further action is required.  When the patient is unable to apply, and has no key person, the worker will complete a screening over the phone.



b)        Screening Procedure


The duty worker will open a pending case.  The case folder will be sent to the responsible district super­visor appointed as HOS Liaison (See Appendix 4-3-A).  Cases for patients who live within the zip codes assigned to the Kearny Mesa District Office (KMDO) will be sent to the KMDO Generic Intake Supervisor.  The case folder will contain:


                                (1)    A Preliminary Information Sheet (07-108)


                                (2)    An Application form (CA-1)


                                (3)    A Medi-Cal/CMS Transmittal form (14-10).  This form notifies the hospital that the referral has been forwarded to the responsible district office.


(4)     An Applicant Notice (14-08).  This form tells the patient who will be contacting him or her to complete the application.



2)      CMS


Hospitals which do not contract for a HOS worker will call the CMS Eligibility Unit number 565-3138.  A Patient Services Specialist (PSS) will complete a CMS Application form CMS-1, and obtain the patient's phone number, date of admission, date of birth, and Social Security Number.  The PSS will arrange an intake interview with the patient or key person.




A.       Hospitals


The workers stationed at the following facilities process Medi-Cal and CMS applications for inpatients and patients scheduled for admittance.  They are supervised by a Kearny Mesa District supervisor.


Alvarado Hospital

Children's Hospital

Chula Vista Community Hospital

Grossmont District Hospital

Hillside Hospital

Mercy Hospital Medical Center

Mission Bay Hospital

Palomar Medical Center

Paradise Valley Hospital

Physicians and Surgeons Hospital

Pomerado Hospital

Scripps Memorial - Chula Vista

Scripps Memorial - Encinitas

Scripps Memorial - La Jolla

Sharp Cabrillo Hospital

Sharp Memorial Hospital

Tri-City Medical Center

UCSD Medical Center

Valley Medical Center

Villa View Community Hospital



B.       Referral Process


Hospital staff review all admissions for potential Medi-Cal and/or CMS eligibility.  Persons potentially eligible are referred in writing to the HOS worker.  The referral "packet" usually includes a CA-1, a copy of the hospital admission face sheet and, in some cases, additional information on other family members.  However, if no CA-1 is provided, the worker com­pletes a CA-1 and enters the date of the referral as the appli­cation date.



C.       Application Process


Upon receipt of the referral the HOS worker contacts the patient in the hospital.  If the patient is unable to complete the application, an attempt is made to contact an appropriate family member or key person.


If a referral does not reach the HOS worker prior to the patient's discharge, the HOS worker may choose to process the application or decentralize it, depending on the patient's ability to return to the hospital to complete the application and depending upon the workload of the HOS worker.  Refer to section F below for decentralization procedures.


When the application is granted or denied, the HOS worker notifies the hospital by sending form 14-10 DSS, indicating the action taken. On CMS referrals, the CMS Eligibility Unit is also notified via the 14-10 DSS.


If a referral is received on a person who has an active Medi-Cal case, the HOS worker completes a 14-10 DSS to advise the hospital of the current status, and sends a copy to the worker who has the active case.  Any further communication should be between the hospital and the worker assigned to the active case.



D.       Active Cases


After a Medi-Cal case is granted and the hospital is notified of the status, the case is routed through an HOS supervisor for assignment to the district in which the patient lives.


E.       Closed Cases


After a CMS case is certified, and closed, and the hospital is notified of the status, the closed CMS case is routed through an HOS supervisor to Records Library.  Closed Medi-Cal cases will also be sent to Records Library via the HOS Supervisor.



F.       Decentralization


Decentralization is the process of sending Medi-Cal referrals to the responsible district office serving the area in which the patient lives, and CMS referrals to the CMS Eligibility Unit.  Hospital referrals are decentralized primarily because patients are discharged prior to the HOS worker receiving the referral.  Referrals may also be decentralized because of a shortage in HOS staff or a lack of a Spanish-speaking HOS worker.


The following procedures were developed to ensure that re­ferrals are processed in a timely manner.


1)      HOS Supervisor


The HOS Supervisors assigned to the Kearny Mesa District Office maintain a list of all Medi-Cal and CMS referrals which are decentralized from HOS hospitals.



2)      HOS Worker


a)        HOS workers mail or give form 14-08 DSS to each applicant whose referral is decentralized.  The form advises the individual to contact the appropriate HOS liaison (Appendix A) if he or she has not been contacted within five working days from the date the referral packet was sent to the HOS ES.


b)        The HOS worker completes form 14-10 DSS to advise the hospital and the CMS Eligibility Unit, if necessary, that the application is being decentralized, and pro­vide the name and phone number of the district HOS liaison.


c)        To decentralize a Medi-Cal application, the HOS worker sends a referral packet to the district HOS liaison.  The referral packet is sent via the HOS ES and includes the 14-08 DSS, CA-1, and 14-10 DSS.  Operations Hand­book Chapter V, Appendix F outlines district boundaries by zip codes to ensure that they are decentralizing to the correct district office.


d)        To decentralize a CMS application, the HOS worker sends the referral packet to the CMS Eligibility Unit at 0557 County CMS.



3)      District Medi-Cal Liaison


One Eligibility Supervisor from each district office will serve as the district's HOS Liaison.  That ES is respon­sible for receiving Medi-Cal referrals decentralized from HOS.  The HOS Liaison:                                                                       


a)        Maintains a log of decentralized referrals, including date received and the worker to whom the case is assigned;


b)        Returns the tear-off portion of the transmittal Form 14‑12 DSS (Appendix D) to the Kearny Mesa District HOS worker at W92, to advise HOS of the assigned worker;


c)        Receives phone inquiries from hospital staff and HOS supervisors regarding the status of a referral;


d)        Responds to applicant inquiries regarding the status of the application and worker assignment;


e)        Assures prompt processing of decentralized applications; and


f)         Assures that the hospital is notified via Form 14-10 DSS by the assigned worker of the disposition of the appli­cation (granted/denied) upon completion of the Intake process.



4)      District Assigned Worker


a)        Within three (3) days of receipt of an HOS decentral­ized referral in district, the district assigned worker initiates contact with the applicant in order to obtain a Statement of Facts, and to schedule an Intake inter­view.


Many applicants, for whom decentralization is neces­sary, do not recognize the need to pursue a Medi-Cal application once they have been discharged from the hospital and have already received medical services.  To assist hospital providers to obtain Medi-Cal and to reduce the use of County-only funds, workers will initiate contact with the applicant to schedule an intake interview.


                                The worker will mail a Statement of Facts (MC 210) and an appointment letter to the applicant which either schedules an intake appointment or asks the applicant to call for an appointment within 10 days of the date of the letter.


                                If the applicant does not respond to the appointment letter, and the applicant has a telephone, the worker will call the applicant to discuss the importance of com­pleting the application for Medi-Cal and schedule an intake appointment.  The telephone contact must be documented in the case narrative.


                                If the applicant cannot be reached by phone the worker will mail a second appointment letter and gives the appli­cant at least 10 days to respond.


Applications are not to be denied because the applicant does not initiate contact with the assigned district worker.  However, if the applicant does not respond to the worker's attempts to obtain a Statement of Facts and/or schedule an intake interview, then the application is denied for failure to provide a Statement of Facts and/or attend the intake interview, and the appropriate NOA is sent.



b)        Immediately upon determination of eligibility, the worker will complete and forward form 14-10 DSS to the appro­priate hospital (see disposition/routing instructions at the bottom of the 14-10 DSS).  This ensures that the hospital receives prompt notice of the disposition of the application, and reduces the number of telephone contacts and written inquiries to DSS for disposition/status information.



5)      CMS Liaison


                        A Patient Services Specialist (PSS) located in the CMS Eligibility Unit has been designated as the HOS Liaison.  The PSS receives CMS referrals decentralized from HOS and:


a)        Maintains a log of the referrals including receipt date, and name of the CMS Representative to whom the case is assigned.


b)        Reviews the referral to see if the patient meets CMS age and residency requirements.  If these two criteria are met, the PSS arranges an intake interview appoint­ment for the patient with a CMS Representative.  If these criteria are not met, the PSS sends the patient a notice of action denying CMS.


c)        Returns the tear-off portion of form 14-12 DSS to the HOS worker to advise HOS of the assigned CMS Representative.





1.     MEDI-CAL



        District                            M.S.        Supervisor                                      Phone Number


        El Cajon                          W99                                          LK00              (720) 441-4133


        Escondido                      N85         Jeanie O'Brien            EK30             (753) 740-8840


        Kearny Mesa                   W92         Carol Hempstead       HR75             (750) 694-2691


        Lemon Grove                   W260       Chris Garcia               GKl0              (723) 668-3961


        Logan Heights                 W248       Ken Shortall               CA20             (743) 531-4599


        Mission Valley                 W431       Jill Aurand                  MP20/MP60   (730) 557-4102


        Northeast                        W89         Laura Hattaway           NA90             (721) 589-4598


        Oceanside                       Nl06         Kim Forrester             KC36             (752) 967-4535


        South Bay                       W97         Frank Over                 VNAC            (744) 585-5133


        Southeast                        W69         Enid Lane                  SA50             (741) 266-3707



2.     CMS



        CMS Eligibility Unit    0557A               Lucy Mocete               565-3138