Notification of Utilization Review Determinations

Issue Notices for All Authorization Decisions

Conduct prospective, concurrent, and retrospective utilization review or utilization management when reviewing requests for medical necessity, including decisions to approve, modify, defer, delay, or deny services. Send a written Notice of Action (NOA) to the Member and requesting Provider for every authorization decision, including applicable Community Supports determinations.

• Apply authorization and review requirements consistently with Cal. H&S Code §1367.01 and applicable parity requirements for mental health and substance use disorder benefits.
• Ensure decisions and Appeals are timely and are not unduly delayed when the Member's condition requires time-sensitive services.

Notify Provider and Member of Determinations

Communicate each approval, modification, delay, deferral, or denial to both the requesting Provider and the affected Member or authorized representative within the applicable timeframe. Identify the specific health care services approved and provide written notices as required.

• Notify the requesting Provider of the authorization decision within 24 hours of determination and send the Provider written communication within two working days when required.
• Send the Member the written NOA within two working days for applicable determinations, subject to the shorter or otherwise controlling timeframes for standard, expedited, concurrent, and retrospective reviews.
• For retrospective reviews, communicate the decision to the requesting Provider and the Member who received the services, or the Member's designee, within 30 calendar days after receiving reasonably necessary information.

Provide Clinical Contact Information for Adverse Decisions

For any Provider communication regarding a modification, delay, or denial, identify the health care professional responsible for the decision and provide a direct telephone number or extension that allows the Provider to contact that professional easily.

• Include the responsible professional's name and direct contact information in the written communication to the requesting Provider.

Include Required NOA Content

Issue every NOA for an adverse benefit determination resulting from prospective, concurrent, or retrospective review in writing and in the required format and language. The notice must clearly explain the action, include the fully translated written clinical rationale at the point of determination, and explain the reason for the action.

• Provide reasonable, free access upon request to documents, records, and other information relied on for the decision, including clinical criteria, medical-necessity criteria, processes, strategies, and evidentiary standards.
• Explain how to file a grievance, request an administrative hearing, and obtain aid paid pending when applicable.
• Explain the right to request an Appeal within 60 calendar days, the one-level Appeal process, and how to request an expedited Appeal when resolution is needed in less than 72 hours because of an imminent and serious threat to health, severe pain, or potential loss of life, limb, or major bodily function.
• Explain State Fair Hearing rights after exhaustion or deemed exhaustion of the internal Appeal process, including when CenCal Health fails to issue a Notice of Appeal Resolution or extension notice within 30 calendar days.
• Explain the right to continue receiving Covered Services pending Appeal resolution and CenCal Health's obligation to continue benefits when required.
• Use DHCS NOA templates and the NOA Your Rights Attachment without modification unless DHCS has reviewed and approved the change; only the specific reasons for CenCal Health's action may be inserted as permitted.

Process Standard Prior Authorization Requests

For standard prior authorization requests, respond as expeditiously as the Member's condition requires, no later than five working days after receiving information reasonably necessary and requested to make the decision, and no later than 14 calendar days after receipt of the request.

• Apply the standard authorization timeframe to routine requests and issue the determination and required NOA within the applicable notification timeframe.
• If a request is delayed beyond five working days, notify the Provider and Member in writing, state the anticipated decision date, and provide the information required for the applicable authorization timeframe.

Manage Standard Authorization Extensions

A standard authorization timeframe may be extended by up to 14 additional calendar days only when the Member or Provider requests the extension, or when CenCal Health documents to DHCS the need for additional information and explains how the extension is in the Member's interest.

• Document at least one attempt to obtain the necessary information.
• Send the Member and requesting Provider a written notice identifying the specific information needed, the anticipated determination date, and the Member's right to file a grievance regarding the extension.
• After receiving the information, issue the decision within the shortest applicable timeframe, no later than seven calendar days and no later than the permitted additional 14-calendar-day period; allow sufficient time for continuation of benefits.

Process Concurrent Reviews Without Interrupting Care

Process concurrent authorization requests within five working days or less, consistent with the urgency of the Member's medical condition. Do not discontinue care during concurrent review until the treating Provider has been notified of the decision and an appropriate care plan has been agreed upon.

• Coordinate the decision and care plan with the treating Provider to avoid interruption of medically necessary care.

Process Expedited and Urgent Requests

Use expedited processing when a Provider indicates, or CenCal Health or its applicable contractor or Network Provider determines, that applying the standard timeframe could seriously jeopardize the Member's life, health, or ability to attain, maintain, or regain maximum function. Decide and issue the written NOA to the requesting Provider and Member as expeditiously as the condition requires, but no later than 72 hours after receipt of the request.

• Apply expedited processing to urgent concurrent requests, including ongoing inpatient care, when the standard timeframe presents the stated risk.
• If the request is delayed beyond 72 hours, notify the Provider and Member in writing of the anticipated decision date and request the specific information needed to determine medical necessity.
• After receiving requested information, decide within the shortest applicable timeframe and no later than 72 hours, unless a permitted extension applies.

Manage Expedited Authorization Extensions

An expedited authorization deadline may be extended by up to 14 additional calendar days only when the Member or Provider requests the extension, or when CenCal Health documents to DHCS the need for additional information and how the extension serves the Member's interest.

• Document at least one attempt to obtain the necessary information and, when applicable, the justification in the Member's record.
• Send the Member and requesting Provider a written NOA identifying the information needed, the anticipated decision date, and the Member's right to file a grievance regarding the extension.
• Do not exceed the permitted 14-calendar-day extension and issue the decision within the shortest timeframe appropriate to the Member's condition.

Handle Incomplete Retrospective Review Information

When information reasonably necessary for a retrospective determination is missing, notify the Provider and Member within the required timeframe of the specific information needed and the anticipated determination date. Allow 30 calendar days to submit the requested information, then decide using the information available at the end of that period if the information remains incomplete or is not received.

• Apply the incomplete-information rule at the end of the 30th calendar day; do not defer the decision indefinitely.
• Communicate the resulting decision within the applicable 30-calendar-day retrospective review timeframe.