(a) Nursing facility services necessary for the treatment of illness or injury are covered subject to the provisions of this section: (b) Nursing facility services are covered only after prior authorization has been obtained from the designated Medi-Cal consultant for the field office area in which the nursing facility is located. The authorization request shall be initiated by the facility and shall be signed by the attending physician. Nursing facility services may be authorized either for a distinct-part nursing facility (a facility that is a distinct part of an acute care hospital), or for a freestanding nursing facility (a facility that is not part of an acute care hospital). (1) Distinct-part nursing facility care at the distinct-part nursing facility reimbursement rate for any Medi-Cal patient determined to need long-term nursing care shall be authorized when any one of the following conditions is met: (A) There is no freestanding nursing facility within 15 miles, which shall be defined as 30 minutes at 30 miles per hour, from the established residential address of that patient prior to admission to nursing care and the distinct-part nursing facility is within a shorter actual travel time than the closest freestanding nursing facility able and willing to admit the patient. (B) There is a freestanding nursing facility within 15 miles, as defined in subparagraph (A) from the established residential address of the patient before admission to nursing care, but after reasonable placement efforts, no such facility is able and willing to accept the patient, and the distinct-part nursing facility is within a shorter travel time than the closest freestanding nursing facility able and willing to admit the patient, within the 25-day placement period. (C) There is no freestanding nursing facility within 30 minutes actual travel time from the established residential address of the immediate family member, such as the spouse, parent, child, or sibling of the patient, who certifies that he or she is the family member who will be most frequently visiting and helping with the personal needs of the patient, or if there is such a freestanding nursing facility, there is none able and willing, after reasonable placement efforts, to accept the patient, and the distinct-part nursing facility is within a shorter travel time than the closest freestanding nursing facility. In this case, the distinct-part nursing facility shall submit with the treatment authorization request a signed statement from the immediate family member certifying that he or she is the person who will be most frequently visiting and seeing to the personal needs of the patient. The signed statement of the family member shall contain an explanation of the relationship to the patient, the residential address used in calculating the distance to the distinct-part nursing facility, and the mode of transportation to be used. A copy of this certification shall be kept in the patientâs file at the distinct-part nursing facility. (D) The immediate family member who will be most frequently visiting and seeing to the personal needs of the patient cannot, because of established health reasons, travel to a freestanding nursing facility that is able and willing to admit the patient and that is within 30 minutes actual travel time, but he or she is able to travel to the distinct-part nursing facility. The certification so stating, and signed by that family member, shall be submitted with the treatment authorization request. A copy of this certification shall be kept in the patientâs file at the distinct-part nursing facility. (E) The patient has a spouse residing in the same distinct-part nursing facility. (F) The patient is currently, as of the time approval is sought, residing in the distinct-part nursing facility and has been continuously residing in that facility for at least 120 consecutive days, and payment has been made or approved during the 120 consecutive days by Medicare, ot
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