Physicians · Hospitals · SNFs · Case managers
Refer a patient
One fax or one call. We confirm receipt, verify eligibility, complete the start-of-care assessment, and return the plan of care to you for signature.
Send a referral
- Fax
- Tap to copy · 24 hours
- Phone
- 747-262-1676Intake line · verbal orders accepted
Please do not email protected health information. Fax and phone only.
Talk to intake directly
Call with a verbal order, a question about eligibility, or a discharge that needs to happen today. We tell you on the call what, if anything, is still needed, and confirm receipt of every referral back to your office.
- Verbal orders accepted; written order returned for signature
- Eligibility and homebound status checked before the first visit
- Five counties, including hard-to-reach areas other agencies decline: Antelope Valley, high desert, mountain communities
- Plan of care, condition changes and discharge summary come to you
From referral to start of care
- STEP 1
You send the referral
Fax orders and clinical notes, or call intake. A verbal order is fine to start; we'll send it back for signature.
- STEP 2
We verify and schedule
Insurance, homebound status and service area are confirmed. We call the patient or family to schedule the first visit.
- STEP 3
Start-of-care assessment
An RN or therapist completes the comprehensive assessment (OASIS) in the home and builds the plan of care with the patient.
- STEP 4
Plan of care to you
You receive the plan of care for review and signature, with visit frequencies and goals by discipline.
- STEP 5
Ongoing communication
Order clarifications, condition changes and recertification summaries come to your office. Call the case manager any time.
- STEP 6
Discharge
Goals met, or care transitioned. You receive a discharge summary.
What your office can expect
- Referral acknowledgedWe confirm receipt of every referral back to your office and tell you what, if anything, is still needed.
- Eligibility verified before start of careCoverage and homebound status are checked up front, so care isn't interrupted later by a benefits problem.
- Plan of care sent for your signatureFollowing the start-of-care assessment, the plan of care (CMS-485) comes to you for review and signature.
- Change-in-condition notificationYou hear from the case manager when your patient's status changes or orders need adjusting — not at recertification.
- Discharge summaryA summary of care and status at discharge is sent to the referring and primary physicians.
What to include
Complete referrals start faster.
- Signed order or verbal order (we'll send the written order back for signature)
- Face-to-face encounter documentation
- Patient demographics, insurance and best contact for patient/family
- Recent H&P, discharge summary or progress notes
- Current medication list
- Any wound, DME or therapy specifics you want on the plan of care
Quick reference
Medicare home health eligibility
The three things we check on every referral. Source: Medicare Benefit Policy Manual, Chapter 7; 42 CFR 424.22.
Homebound status
- Criterion 1: needs the aid of supportive devices, special transportation or another person to leave home, OR leaving home is medically contraindicated.
- Criterion 2: a normal inability to leave home AND leaving requires a considerable and taxing effort.
- Absences for medical care, adult day care, religious services and infrequent short non-medical trips do not disqualify.
Face-to-face encounter
- An in-person or telehealth encounter related to the primary reason for home care.
- Within 90 days before or 30 days after the start of care.
- Performed by the certifying physician/allowed practitioner, or by the hospitalist/attending during an acute or post-acute stay.
- The certifying practitioner documents the encounter date in the certification.
Skilled need
- Intermittent skilled nursing, physical therapy, speech-language pathology, or a continuing need for occupational therapy.
- Services must be reasonable and necessary for the diagnosis or treatment of the illness or injury.
Services & coverage
Disciplines
RN · LVN · PT / PTA · OT / COTA · SLP · MSW · Home health aide
Services
- Skilled Nursing
- Physical Therapy
- Occupational Therapy
- Speech Therapy
- Medical Social Services
- Medical Supply
- Assisted Living Facility Support
- Adult Respite
- Geriatric Care Management
- Post-Hospitalization Support
- Post-Surgery Support
- Personal Care and Management
Payers
Traditional Medicare · Aetna · Anthem · Blue Shield · Cigna · UnitedHealthcare · Carelon · Choice Physicians Network / Choice Medical Group
Coverage area
Los Angeles County, Orange County, Ventura County, San Bernardino County, Riverside County.
Questions from referring offices
Yes. We cover hard-to-reach areas inside our five counties that other agencies routinely decline because of drive time: the Antelope Valley, the high desert, mountain towns and outlying communities. Call intake with the address and we will confirm on the phone.
Yes. Call intake, and we will take the verbal order and send the written order and plan of care for your signature.
Yes — see our Insurance page for the current list. We verify authorization requirements with the plan before the start of care.
The certifying practitioner, or a hospitalist/attending if the encounter happened during an inpatient or post-acute stay. We will tell you if the documentation we receive won't meet the requirement, so it can be fixed before it becomes a billing problem for anyone.
The plan of care comes to you for signature after the start-of-care visit. You will hear from the case manager about condition changes and order clarifications, and you receive summaries at recertification and discharge.
We see patients in assisted living and board-and-care settings, and coordinate with the community's staff.
Please don't. Use fax or phone. We do not accept referral documentation by unsecured email or through this website.
Ready to refer?
Fax the packet or call intake. You will hear back from us on receipt and on start of care.
Physicians & discharge planners: fax referrals to