10208 — Medical Services

Link to TCADD Policy 10201

SCOPE:

This procedure applies to all employees of Tri-Counties Regional Center (TCRC).  The purpose is to provide guidelines to Service Coordinators and Services and Supports Managers in handling requests for services that fall into the area of medical services.

This procedure applies to speech therapy, occupational therapy, physical therapy and any other medical services that potentially could be covered under health insurance. 

TCRC may consider funding medical services under extreme circumstances when a family/person served does not have access to any other funding stream, including private insurance, or generic sources for purchasing the needed service and the need is directly related to the developmental disability. 

Procedure:

Per Welfare and Institutions Code section 4659(d), regional centers are prohibited from purchasing medical or dental services for a person served three years of age or older, unless the regional center is provided with documentation of a Medi-Cal, private insurance, or health care service plan’s denial and the regional center determines that an appeal by the person served or family of the denial does not have merit. In addition, section 4648(a) (8) states that regional center funds shall not be used to supplant the services of other publicly funded agencies. 

1. The first step will be to identify and clarify the service need.  The need may be identified through gathering existing information, asking for additional assessment or other means. Examples: IEP/School assessments, medical assessments, etc.  In most circumstances a prescription or doctor’s order will be required.  Present all gathered information to the Clinical Team for their assessment of the need and the clinical appropriateness of the service.
2. If the need is for speech, occupational, or physical therapy services, all funding through the educational system must be pursued prior to TCRC’s consideration of funding. 
3. The service coordinator will verify if the family/person served has Medi-Cal, and/or private insurance, and if so, shall work with them to utilize those resources.
4. If denied by private insurance or Medi-Cal, denial letters must be obtained by the person served, or the family, and submitted to the service coordinator. 
5. In most circumstances, an appeal of the denial will be required.  Service coordinators shall work with their manager to determine if an appeal is appropriate. 
6. For persons served, who due to their immigration status lack necessary documentation, the service coordinator shall advise the family/person served to utilize Emergency Medi-Cal and contact other available generic resources. If none of the generic resources available provide funding for the service needed, the service coordinator shall then consult with the TCRC Physician and appropriate Manager of Services and Supports. 
7. If it is agreed that TCRC will fund the service, the service coordinator will prepare an addendum/amendment to the Individual Program Plan (IPP).  Funding for the service is on a time-limited basis (usually up to one (1) year).  All speech and language services to children over the age of 12 are an exception to TCRC policy and therefore, the exception process will need to be followed. 
8. Exceptions to TCRC policy for funding medical services may be approved by the Director of Services and Supports or designee on a time-limited basis and until another reliable funding stream is identified.

Authorizing funding for medical services:

Prior to requesting funding, the service coordinator shall ensure that all the available generic resources have been accessed.  Included in the request must be written documentation of the denial.  If an appeal is warranted, then a copy of that appeal must also be included. 

TCRC may fund the service while the family/person served is pursuing coverage but before the denial is made, or pending a final decision on an administrative appeal, when provision of the service is essential to the individual’s well-being and delaying the service would significantly adversely affect their developmental progress.     

The planning team may determine that a medical service identified in the IPP or IFSP is not available within 60 calendar days through private health insurance policy or health care service plan or under the Medi-Cal program and therefore, in compliance with paragraph (1) of subdivision (d) of Section 4659, will be authorized for purchase-of-service funding by the regional center.

Funding timeline:

1. Written documentation must be received from the family/person served confirming pursuit of coverage. 
2. After the documentation is received, the service coordinator may request funding for the service for up to three months.
3. Documentation in writing, regarding the progress of the insurance carrier’s determination (acceptance or denial of the service) must be provided prior to the authorization end-date for the funding of the service to continue.
4. The service can then be funded for an additional three months pending the final decision on an administrative appeal.
5. Once the service coordinator receives notification that funding of the service has been approved by Medi-Cal/private insurance, the service coordinator shall cancel the authorization.
6. If the administrative appeal is denied, then the service coordinator can request that the service continue for up to one year as approved by the Services and Supports Manager.  Every six months the planning team must review the progress and the need for continuation of the services.
7. Service providers must submit progress reports at least every six months, as agreed by the IPP team.  All reports must include sufficient data to reflect progress on outlined goals, including baseline, current progress, and expected timelines for goals to be met. Reports must be received by TCRC at least 30 days prior to the end of the authorization in order for the team to be able to assess the need to continue. 

Authorizing funding for dental anesthesia services:

1. The Patient’s dentist has recommended anesthesia for dental work. The Planning team agrees that dental anesthesia should be explored. Documentation should be provided that explains what has been tried and failed, showing that anesthesia is in the patient’s best interest to receive dental treatment and will provide the greatest safety to the patient and the provider. Individuals and families need to be made aware of TCRC’s process for anesthesia funding prior to making an appointment.
2. Insurance: Generic resources must be utilized first. Families and individuals with private dental insurance may be considered for dental anesthesia funding in all or part.  A denial from the insurance or a pre-authorization showing the percentage of coverage for anesthesia is required for consideration.  The service coordinator will forward denials and pre-authorizations to the TCRC Dental Coordinator for review. Families or individuals with only Medi-Cal Dental coverage do not require a denial for anesthesia funding.
3. Funding for anesthesia will be provided only when a vendored anesthesiologist is used. A list of qualified providers is available on TCRC’s Intranet under Dental Resources.  Link to vendored sedation dentists:  https://tcrc.box.com/s/x2a5amsnqkmcjh6i197l40f1ceusllba
4. Reimbursements after the appointment and use of non-vendored providers will be exceptions and may be considered for extenuating circumstances per planning team agreements.  
5. Anesthesia guidelines are funding for up to 2 hours every 6 months.  Occasionally a provider will need to have more time for treatment and exceptions can be made. 
   1. A provider may go over the approved 2 hours during the appointment to finish work started; they may request an exception after the appointment for the additional time. Medical clearance is not necessary for this type of exception.
   1. When a provider diagnoses treatment that will need pre-approval by insurance, they will need to have the patient return in less than 6 months.  This is also an exception and will require medical clearance from the patient’s primary care physician.
   1. Prior to an appointment a provider may determine that a particular procedure, or group of procedures will exceed the 2-hour limit, additional time can be requested.  This is also an exception that requires medical clearance by the primary care physician.
   1. Medical clearances are typically the vendor’s responsibility to obtain from the primary care physician; however, the service coordinator may be needed to provide additional information, such as names and contact information.
6. Medical clearances need to be included with the vendor’s request and provided to TCRC management for exception approval. Occasionally emergencies occur and providers do their best to get someone in pain to be seen as quickly as possible.  They may still need medical clearance if it has been less than 6 months. These requests should be given priority.

Once the request for anesthesia is submitted by provider an IPP amendment or exception and authorization will be created for the service. Service coordinators should ensure that the provider receives a signed copy of the IPP amendment or exception.

Revision Date: 5.13.2025