Member Appeals of Adverse Benefit Determinations

Provider-Filed Appeal Consent

A provider may file an Appeal on a Member’s behalf only with the Member’s participation and written consent authorizing the provider to act. The Appeal will not be initiated until the signed consent is received.

• Obtain written Member consent before initiating a provider-filed Appeal.
• A Member may also appoint a representative with verbal authorization or an Appointment of Representative Form.

Provider Documentation for Appeal Review

For clinical Appeal review, provide complete and pertinent documentation so the physician reviewer can evaluate the request, including the original denial and Appeal history, current medical records, provider responses, and prior actions related to the denial.

• Medical records, chart notes, and associated clinical documentation.
• Dates of service and other information requested to validate the Appeal.
• Previous denial and Appeal history, current provider responses, and any prior actions taken.

Prior Authorization Adverse Determination Review

CenCal Health initiates Appeals involving coverage disputes or requests to reverse a prior authorization decision for medical necessity when the matter is associated with a Notice of Action (NOA) or Notice of Adverse Benefit Determination (NABD). Prior authorizations resulting in an adverse determination, including TARs and RAFs, are automatically treated as requiring clinical review and are referred to a physician reviewer who was not involved in the original decision.

• Submit the clinical records and supporting information needed to review the prior authorization dispute.
• The initial review follows the applicable pre-service review and timeliness requirements.

Independent Physician Reviewer Required

The physician reviewer must be independent of the initial review and any prior decision. The reviewer may not be the original reviewing physician and may not be subordinate to a physician who participated in the initial review or decision.

• Use a different physician for the Appeal review.
• The reviewer may consult a practitioner in the same or a similar specialty who typically treats the condition.

Implement a Favorable Appeal Decision

When an Appeal decision is favorable, Medical Management UM, CM, or the clinical designee must approve the service authorization in the Health Information System on the same business day and coordinate implementation with the G&A Coordinator.

• Ensure services are scheduled as promptly as the Member’s condition requires and no later than 72 hours from the overturned decision.
• Coordinate with the appropriate physician, facility, or pharmacy when services are needed within 72 hours.

Route Medi-Cal Rx Pharmacy Appeals

CenCal Health does not process pharmacy-benefit Appeals except for Physician Administered Drugs (PADs). Route other Medi-Cal Rx pharmacy Appeals to the Medi-Cal Rx Customer Service Center through Magellan Rx.

• Transfer the Member or appointed representative to 1-800-541-5555; TTY 1-800-430-7077.
• Medi-Cal Rx pharmacy Appeals use the DHCS State Fair Hearing process; contact with the Customer Service Center does not affect the right to request a State Hearing.
• CenCal Health may provide Magellan Rx with requested assistance but does not resolve these Appeals.

Route Mental and Behavioral Health Appeals

Immediately forward specialty mental health Appeals to the applicable county mental health entity and advise the Member. CenCal Health staff initiate and investigate mild-to-moderate behavioral health Appeals and enter them in the online tracking system.

• Forward specialty mental health Appeals to Santa Barbara County Behavioral Wellness Department or MHS-SLO, as applicable.
• Offer a warm transfer and explain that the Appeal is being forwarded for resolution.
• Forward documentation and summaries to the appropriate entity; the county QA Manager acknowledges receipt within one business day.

Process Expedited Appeals

Expedited Appeal requests must be reviewed immediately and resolved within 72 hours (three calendar days) when DHCS expedited criteria are met. The G&A Coordinator immediately forwards the request to the Clinical Quality Nurse and Chief Medical Officer or Medical Director for criteria review.

• Prepare the clinical review packet and physician review summary without delay.
• Provide the outcome to the requestor within the 72-hour allowable review period.
• The physician reviewer must be independent of the initial reviewer and any prior decision-maker.

Process Favorable Appeal Decisions

For a favorable Appeal decision, ensure the authorization is entered in the Health Information System the same business day and coordinate prompt implementation of the approved service.

• Coordinate scheduling with the G&A Coordinator and the appropriate physician, facility, or pharmacy.
• Services must be scheduled as promptly as the Member’s condition requires and, after an overturned decision, within 72 hours.

Notify the Member of Appeal Disposition

Notify the Member or appointed representative of the Appeal disposition by telephone when required and in writing using the required Notice of Appeal Resolution (NAR) or other mandated language. Written decisions must be mailed within the applicable timeframe, and expedited outcomes must be communicated within 72 hours.

• Explain the decision and the criteria used to make it clearly and concisely.
• Provide oral and written notification for expedited outcomes; send the written notification by certified U.S. mail.
• Provide required language, accessibility, nondiscrimination, translation, and language-assistance information.

Process Expedited Appeal Determinations

Within 72 hours of receiving an Expedited Appeal, the Clinical Quality Nurse notifies the G&A Coordinator of the physician reviewer’s or designee’s determination. The G&A Coordinator then notifies the Member by telephone and in writing in a clear and concise manner.

• Communicate whether the request met expedited criteria and the outcome of expedited review.
• Send the written notice by certified U.S. mail.
• If the request does not meet expedited criteria, initiate standard 30-day Appeal review.

Convert Nonqualifying Expedited Requests to Standard Review

If an Expedited Appeal request does not meet DHCS criteria, convert it to the standard 30-day Appeal process. Notify the requestor verbally, followed by written notice that the request was downgraded, and advise the Member of the right to file a Grievance regarding the downgrade.

• Initiate standard review without delay.
• Include the downgrade explanation in the acknowledgment or written notice.

Provide Further Appeal Rights

Notify the Member in the NAR that they may request a Department of Social Services State Hearing if they disagree with a denial, termination, or modification of a prior authorization service request.

• The Member may request a State Hearing within 120 calendar days from the date of the NAR letter.
• Include the DSS “Your Rights” enclosure and DHCS-approved instructions for requesting a State Hearing.
• In deemed-exhaustion cases, provide the applicable 120-day period measured from the missed or deficient notice timeframe.

Quality Review Final Appeal Notices

The G&A QI Manager reviews every final Appeal letter before issuance to confirm that it clearly explains the decision and identifies the criteria used to make the determination.

• Complete QI Manager review and approval for all final Appeal correspondence.
• Ensure required mandated language and culturally and linguistically appropriate notice requirements are included.