CurrentCenCal HealthPolicy MS-23

Member Appeals

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Governs CenCal Health’s receipt, documentation, review, resolution, and notification processes for Member Appeals involving benefit decisions, including applicable rights to continuation of benefits and State Hearings.

Policy Summary

PayerCenCal Health

PolicyMember Appeals

Policy CodePolicy MS-23

Change TypeAdministrative reorganizationno material clinical or coverage changes

Effective DateJuly 1, 2023

Next Review DateNot specified

Key ActionProviders filing an Appeal on behalf of a Member must obtain and submit the Member’s written consent.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daysAppeal filing period

30 daysStandard Appeal resolution

72 hoursExpedited Appeal resolution

2 business daysInitial clinical routing

120 daysState Hearing request period

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CurrentCenCal HealthPolicy MS-23

Member Appeals

Customize your policy alerts

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Get alerted when Policy MS-23 changes without checking for updates manually.

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Policy Summary

PayerCenCal Health

PolicyMember Appeals

Policy CodePolicy MS-23

Change TypeAdministrative reorganizationno material clinical or coverage changes

Effective DateJuly 1, 2023

Next Review DateNot specified

Key ActionProviders filing an Appeal on behalf of a Member must obtain and submit the Member’s written consent.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daysAppeal filing period

30 daysStandard Appeal resolution

72 hoursExpedited Appeal resolution

2 business daysInitial clinical routing

120 daysState Hearing request period

Appeal Eligibility and Review Pathways

Appeal initiation and eligibility

A Member Appeal may be initiated when a Member or authorized representative disagrees with a benefit-related decision, coverage dispute, or medical-necessity prior authorization determination associated with an NOA or NABD.

Eligible filer

ONE of
- The Member files the Appeal.
- An appointed representative files the Appeal, with at least verbal authorization or an Appointment of Representative Form documented.
- A provider files on behalf of the Member with the Member's participation and written consent.

The Appeal is submitted by telephone, Appeal form, in person, or other correspondence; a verbal Appeal is processed from the date the oral request is received.

The Appeal is generally filed within 60 calendar days from the date on the Notice of Action or Notice of Adverse Benefit Determination.within 60 calendar days

Review pathway criteria

Appeals are routed according to whether they are clinical, non-clinical, expedited, or otherwise subject to a specialized process.

A clinical Appeal is reviewed by a Health Services Nurse and, when applicable, an independent physician reviewer.

A non-clinical or administrative Appeal, including a billing dispute, is confirmed by a Health Services Nurse to have no clinical component; any clinical concern requires recoding and clinical review.

A qualifying Expedited Appeal is evaluated immediately under DHCS criteria and routed for expedited clinical review and resolution within 72 hours; a request that does not meet expedited criteria follows the standard 30-day Appeal process.within 72 hours; otherwise within 30 calendar days

A prior authorization adverse determination, including a TAR or RAF, is automatically treated as requiring clinical necessity review by a physician reviewer who was not involved in the original decision.

Continuation and external review rights

Members retain continuation-of-benefits and State Hearing rights when applicable.

Benefits continue, when applicable, for a timely Appeal involving discontinuation, suspension, reduction, or termination of services, pending resolution of the Appeal.

The Member may request a State Hearing within 120 calendar days of the Plan's Notice of Appeal Resolution or the applicable deemed-exhaustion date.within 120 calendar days

If CenCal Health fails to meet required Appeal timeframes, the Member is deemed to have exhausted the Plan's Appeal process and may initiate a State Hearing.

Appeal and Hearing Timeframes

Standard Appeal filing period

Filing deadlineWithin 60 calendar days from the date on the NOA or NABD

Eligible filerThe Member or an appointed representative may file an Appeal

Applicable decisionsBenefit-related decisions and Adverse Benefit Determinations may be appealed

Initial documentation clinical routing

Standard routing deadlineForward initial Appeal documentation within 2 business days of receipt

Expedited requestsForward documentation immediately when the Appeal is expedited

Routing destination

Appeal Administration and Required Actions

Documentation Required

Provider-Filed Appeal Consent

When a provider files an Appeal on a Member’s behalf, the submission must include the Member’s written consent. Requests from providers for Expedited Appeals must also include the Member’s written consent.

Provider-filed Appeals without the Member’s written consent cannot be processed as filed on the Member’s behalf.

Documentation Required

Appeal Intake and Tracking

Document every identified Appeal in CenCal Health’s online tracking system as soon as it is received or identified, using the system’s eligibility and demographic data for reporting and regulatory compliance. Immediately alert the appropriate Grievance and Appeals staff about any Expedited Appeal request.

Provide Members assistance completing Appeal forms and coordinate delivery of documents used by CenCal Health reviewers when requested by the Member or representative.
Record Member issues, supporting documentation, and applicable coding in the tracking system.

Unsupported block type: info

Appeal Administration Terms

Appointed representative

DefinitionA person authorized to act for a Member in an Appeal

Authorization optionsThe Member must provide at least verbal authorization or complete and submit an Appointment of Representative Form

Filing authorityThe representative may initiate an Appeal on the Member's behalf

Adverse Benefit Determination

DefinitionA Plan decision regarding authorization or benefits that the Member may challenge through the Appeals system

ExamplesA denial or other decision involving benefit-related services or medical-necessity prior authorization

Policy Summary

PayerCenCal Health

PolicyMember Appeals

Policy CodePolicy MS-23

Change TypeAdministrative reorganizationno material clinical or coverage changes

Effective DateJuly 1, 2023

Next Review DateNot specified

Key ActionProviders filing an Appeal on behalf of a Member must obtain and submit the Member’s written consent.

SourceLink

On This Page

Plan Medical Management Team or a licensed clinical professional reviewer

Written Appeal follow-up call

Follow-up deadlineCall the Member or appointed representative within 1 business day of receiving a written Appeal

Responsible staffGrievance & Appeals Coordinator

Additional intake actionMail requested Appeal forms no later than the next business day

Coding and documentation verification

Verification deadlineRefer each Appeal to a Health Services Nurse within 2 calendar days

Verification purposeVerify the accuracy of the Appeal coding and confirm the appropriate records and documentation for physician review

Reviewer qualificationThe Health Services Nurse is a California-licensed Registered Nurse

Expedited Appeal resolution

Resolution deadlineResolve a qualifying Expedited Appeal within 72 hours or 3 calendar days

Initial handlingEvaluate and forward the request immediately upon receipt

Nonqualifying requestsMove to the standard 30-day Appeal process when DHCS expedited criteria are not met

Standard Appeal resolution

Resolution deadlineResolve and notify the Member within 30 calendar days of receipt

Written decisionProvide a clear and concise explanation of the Plan's decision

Oral AppealsThe 30-calendar-day period applies whether or not an oral Appeal is followed by a written Appeal

Written Appeal acknowledgement

Acknowledgement deadlineAcknowledge receipt in writing within 5 calendar days

Required acknowledgement detailsInclude the receipt date, issue summary, resolution timeframe, Coordinator name and telephone number, and Plan address

Member participationMembers may submit additional comments, documents, and other information related to the Appeal

Experimental or investigational face-to-face meeting

Meeting deadlineHold the face-to-face meeting or hearing within 5 calendar days of the request

Applicable denialExperimental or investigational treatment procedure or service denial

Meeting participantsCenCal Health's Medical Director and/or physician designee

State Hearing request

Request deadlineRequest a State Hearing within 120 calendar days of the NAR or applicable deemed-exhaustion date

Deemed exhaustionA Member may request a State Hearing when CenCal Health fails to meet required Appeal timeframes

Continuation of benefitsBenefits continue pending State Hearing resolution when a timely Appeal concerns discontinuation of benefits

Standard State Hearing request timeframe

Standard request period120 calendar days from the date of the Plan's Notice of Appeal Resolution Letter

Covered decisionsDenial, termination, or modification of a service or prior authorization decision

Member noticeState Hearing filing information is provided in DHCS-approved Evidence of Coverage or Member Handbook language

State Hearing final decision timeframe

Final decision deadlineThe state must issue a final decision within 90 calendar days from the State Hearing request date

Member notificationCenCal Health notifies Members of the applicable State Hearing decision timeframe

Responsible agencyThe Department of Social Services conducts the State Hearing process

Expedited State Hearing final decision timeframe

Expedited decision deadlineThe state must issue a final decision within 3 working days from the request date

Applicable processExpedited State Hearing

Member notificationThe timeframe is explained in the Member's Evidence of Coverage or Member Handbook

Unsupported block type: prior_auth

Unsupported block type: documentation

Unsupported block type: info

Unsupported block type: billing_rule

Denial Risk

Expedited Appeal Handling

Evaluate every request for Expedited Appeal handling immediately against DHCS criteria and route it to the Medical Management Team or licensed clinical professional nurse and the Chief Medical Officer or Medical Director. Qualifying requests must be resolved and communicated within 72 hours (three calendar days).

If the request does not meet DHCS criteria, proceed under the standard 30-calendar-day process and notify the requestor verbally and in writing of the downgrade.
The downgrade notice must advise the Member of the right to file a Grievance against the downgrade.
For an expedited case, notify the Member or appointed representative by telephone and in writing of the outcome within the 72-hour timeframe; written notice is sent by certified U.S. mail.

Unsupported block type: info

Unsupported block type: prior_auth

Unsupported block type: documentation

Unsupported block type: denial_risk

Unsupported block type: documentation

Unsupported block type: info

An Adverse Benefit Determination is communicated through an NABD and may be appealed within the applicable filing period

Aid Paid Pending

DefinitionContinuation of benefits during an applicable Appeal

Applicable service changesA timely Appeal of a decision to terminate, suspend, or reduce services may qualify

Plan actionCenCal Health advises Members about Aid Paid Pending and forwards requests to the Legal Department for approval

Expedited Appeal

DefinitionAn Appeal that meets DHCS criteria for accelerated handling

Qualifying riskDelay could seriously jeopardize the Member's life, health, or ability to attain, maintain, or regain maximum function

Resolution standardA qualifying Expedited Appeal is resolved within 72 hours or 3 calendar days

Notice of Appeal Resolution

DefinitionThe written notice communicating CenCal Health's final Appeal decision

Required contentThe notice includes the decision explanation, applicable criteria, and reviewer information when required

Member rightsThe notice includes the Member's right to request a State Hearing

Notice of Action

DefinitionA notice associated with a benefit-related decision or authorization determination that may be appealed

Appealable mattersCoverage disputes and disagreements with medical-necessity prior authorization decisions may be associated with an NOA

Filing periodA Member may appeal an NOA within 60 calendar days from its date

Medi-Cal Rx

DefinitionThe DHCS pharmacy benefit program that assumed Medi-Cal pharmacy grievance and Appeal responsibilities

Appeal pathwayPharmacy-related Appeals are directed through the Medi-Cal Rx Customer Service Center and applicable State Fair Hearing process

CenCal Health roleCenCal Health transfers pharmacy Appeal callers to the Medi-Cal Rx Customer Service Center through Magellan Rx

Specialty mental health services

DefinitionSpecialty mental health services administered through Santa Barbara County Behavioral Wellness Department or Mental Health Services of San Luis Obispo County

Appeal routingSpecialty mental health Appeals are forwarded to the applicable county behavioral health entity

CenCal Health responsibilityCenCal Health initiates and investigates mild-to-moderate behavioral health Appeals