California PHC

PHC California will pay SNF WQIP to contracted facilities with qualifying bed days.

SNF WQIP qualifying bed days are:

• Calendar days during which a Member receives SNF Level-B services inclusive of the first day of a Member’s stay and excluding the day of discharge unless it is also the first day of stay

• Rendered during the Program Year (PY)

• Billed under a Network Provider Agreement with PHC California

• Days for which Medi-Cal is the primary payer and where Medicare is no longer covering any portion of the bed day

Below is the current list of SNFs with whom PHC California is contracted (updated 3.1.2025):

If you are a SNF and are interested in contracting with PHC California please contact Provider Relations  by email [email protected] or by phone (888) 726-5411.

SNF WQIP payments will be made by PHC California to SNF WQIP-eligible Network Providers based on an interim and final per diem amount calculated by the Department of Health Care Services (DHCS) in accordance with the preprint approved by the Centers for Medicare & Medicaid Services (CMS) and DHCS’ SNF WQIP Technical Program Guide. For each Program Year (PY), DHCS will aim to calculate quality scores and provide payment exhibits directing Medi-Cal Managed Care Plans to pay the interim per diem amount during the first part of the calendar year following the Rating Period, and the final per diem amount during the second part of the calendar year following the Rating Period.

PHC California is responsible for calculating the number of SNF WQIP qualifying bed days and paying the directed per diem amount for all clean and complete SNF WQIP qualifying bed days without regard to when these bed days are reported to DHCS consistent with any reporting requirements applicable to the SNF.

PHC California is responsible for netting out any previously directed interim payment amounts from the final payment. PHC California is responsible for recouping or withholding any amounts related to Class AA or A citations from interim and final payments as described below.

PHC California must make payments to SNF WQIP-eligible Network Providers for qualifying bed days within 45 calendar days of receiving payment exhibits from DHCS or within 30 calendar days of receiving a Clean Claim from the Provider, whichever is later.

Class AA and A Citations
In accordance with the SNF WQIP program’s requirements, PHC California must withhold SNF WQIP payments for facilities with one or more Class AA or A citations issued by the California Department of Public Health (CDPH) for violations that occur wholly or in part during the PY.

• Class AA citations are issued to facilities for actions that are the proximate cause of resident death. Facilities with one or more class AA citations partly or wholly in the PY are disqualified from payments for that PY.

• Class A citations are issued to facilities for actions where there is imminent danger of death or serious harm to a resident or a substantial probability of death or serious physical harm. Facilities with one or more class A citations partly or wholly in the PY receive a 40 percent penalty to the per diem payment amount for that PY.

CDPH publishes state enforcement action data, including Class AA and A citations, on the CDPH State Enforcement Actions Dashboard.  If PHC California becomes aware of an applicable citation for a PY after the time of an interim or final payment, PHC California must recoup and withhold the applicable payments retroactively for the respective PY.

To submit a grievance, providers should complete a Provider Grievance Form and submit it to the plan. We accept grievances over the telephone, by fax and mail.

Call:
(888) 726-5411, Monday through Friday, 8:30 a.m. – 5:30 p.m. Closed weekends and holidays.

Fax:
(888) 235-7695

Write:
Contracting and Provider Relations
PHC California
1710 N. La Brea Ave.
Los Angeles, CA 90046

For more information on the grievance and appeals process.

PHC California’s Long Term Services and Supports (LTSS) Liaison is available to help long term care facilities address claims and payment issues and assist with care transitions to best support Members’ needs.

Contact the LTSS Liaison at:

Tiffany Jarrett
[email protected]
(800) 474-1434

Webinar dates and information are TBD.