Mga FAQ ng Tagapagbigay ng Programa sa Skilled Nursing Facility at Quality Incentive Program Provider

The SNF WQIP directed payment provides supplemental reimbursement to participating network Skilled Nursing Facilities (SNF) through performance based directed payment to incentivize workforce and quality for Medi-Cal certified SNFs.

Managed Care Plans (MCPs) make directed payments to eligible SNFs based on utilization during the calendar year (CY) of the program.

Directed passthrough payments will be determined based on how SNFs perform on DHCS’s selected WQIP metrics. WQIP payment will also be reduced for facilities with Class A or AA citations from California Department of Public Health (CDPH) for violations that occurred.

Freestanding skilled nursing facility contracted with the Alliance for the current working CY.

SNF WQIP payments are not applicable to the following:

• Hospice days
• Services where Medi-Cal was not the primary payer (Part A and or Part B, OHC)
• Freestanding pediatric subacute care facilities, distinct part facilities and SNFs with 100 percent designated special treatment program (STP) beds

• Services rendered for CY2023 PY 1
• Services rendered for CY2024 PY 2
• Services rendered for CY2025 PY 3
• Services rendered for CY2025 PY 4

A per-diem rate will be calculated by DHCS for each facility based on the facility’s performance on metrics, which are described in the SNF WQIP Technical Program Guide.

The guide can be found on the DHCS SNF WQIP website.

The Alliance will issue payments on a per diem basis based on eligible/accepted bed days for the specific CY.

DHCS will provide the Alliance with specific per diem exhibits, and the Alliance has 45 calendar days from the date of receiving the exhibits to issue payments to all eligible SNFs. Delay in receiving funds may delay payment timing.

Yes, the Alliance will share reconciliation reports quarterly for all contracted SNFs for the current working CY. Because the reports contain protected health information (PHI), the Alliance prefers to share the reports via secure email or Secure File Transfer Protocol (SFTP) to authorized user(s).

To request your reconciliation report, email the LTSS Liaison Team at [email protected]. Include the following in your request:

• Your name and title
• SNF Name, NPI and TIN/EIN
• Statement indicating you are an authorized representative to receive PHI

Should you need assistance with setup for SFTP access, please reach out to [email protected].

SNFs should report SNF WQIP days discrepancies to the Alliance as soon as possible. To expedite the investigation of your discrepancy report, please provide detailed information about the claim(s) in question, such as:

• SNF Name
• Claim Type (Institutional or Professional)
• SNF Claim Number/ Patient Control Number
• Alliance Claim Number (from the 835 file)
• Bill Type (Institutional) or Place of Service (Professional)
• Category of Service
• Member Last Name
• Member First Name
• Admission Date (for Institutional)
• Discharged Date (for Institutional)
• Petsa ng Kapanganakan
• Alliance Member ID
• DHCS CIN Number for the Patient
• Paid Amount
• Billing Provider NPI

Send the detailed information along with your questions to the LTSS Liaison Team at [email protected].

SNFs can submit provider inquiries/disputes related to the processing or non-payment of SNF WQIP directed payments, including the calculation of SNF WQIP qualifying bed days.

SNFs can use the Form ng Pagtatanong ng Provider to submit inquiries/disputes via these methods:

Email: [email protected]

Fax: 831-430-5569

Regular mail:
Alyansa para sa Kalusugan ng Central California
ATTN: Mga Pagtatanong at Pagtatalo ng Provider
1600 Green Hills Rd., Ste. 101 Scotts Valley, CA 95066

For more details on our Provider Dispute Resolution Process, please refer to our Provider Manual (Section 17).

The Alliance will provide written notification of the SNF dispute results within 30 working days from the date of receipt for contracted providers and within 45 working days for non-contracted providers.

A SNF has 12 months from the Alliance’s payment check date to dispute the payment.