A referral is a request for review. Authorization is the health plan’s decision that a defined service is appropriate for a particular member, under a particular scope and period. Keeping those two moments separate prevents a painful mistake: arranging a move around a benefit that has not been approved.
Authorization is specific
Ask what service was approved, who will provide it, the effective dates and what happens if the member’s needs or setting changes.
What the plan is reviewing
The plan reviews whether the member meets the applicable service criteria, needs a nursing-facility level of care, can live safely in an assisted living setting and has chosen to receive the service. It also considers the proposed provider and individualized service needs.
The exact workflow differs among plans. Some use internal care managers; others work through contracted organizations. County and network availability can affect which provider options are practical, but the plan should still explain how a member can request review.
Clinical eligibility is only one part
A diagnosis alone does not establish that an RCFE is the right level of care. Reviewers need to understand daily-function support, supervision, medication needs, cognitive and behavioral considerations, recent utilization and foreseeable risks.
The receiving setting matters too. A residence may be licensed but unable to support a particular transfer need, restricted health condition, behavior pattern or staffing demand. Admission acceptance and health-plan authorization should inform each other, but they are not the same decision.
What a clear authorization should answer
Families should receive enough information to act safely. If the notice is hard to interpret, call the plan and ask for a plain-language explanation. Keep the written notice with the admission agreement and transition plan.
Do not accept an informal “looks good” as the final answer when deposits, discharge dates or transportation are involved.
- The name of the authorized Community Support
- The provider or process for selecting a provider
- The scope, frequency or level of service
- The authorization start and end dates
- Member responsibilities and excluded costs
- How to request review if the decision is adverse
When the decision is partial or conditional
A plan may authorize less than requested, require additional information or approve a service only after a condition is met. Ask which condition remains open, who can satisfy it and whether the current request stays active while that work occurs.
If the family disagrees with an adverse service determination, the member retains grievance and appeal rights. Deadlines and steps matter, so use the notice from the plan rather than a generic online description.
Keep one source of truth
Maintain a small authorization log with the request date, reference number, documents sent, calls, decision and effective dates. Share updates only with authorized participants and avoid sending protected information through ordinary email.
For common process delays, continue with Why CalAIM referrals stall.
Sources & important note
Zeal reviewed the primary sources below while preparing this article. Policies, benefits and individual circumstances can change; confirm current requirements with the responsible agency, health plan and licensed provider.
- DHCS: Community Supports Policy Guide, Volume 1
- DHCS: Medi-Cal Managed Care Health Plan Directory
- DHCS: Community Supports Policy Guide appeal and grievance requirements
Editorially reviewed September 2026.