(a) A provider of
services may appeal the decision of a Medi-Cal consultant regarding a Treatment
Authorization Request (TAR), as follows:
(1)
The provider shall submit a TAR appeal within 180 calendar days from the date
of the decision on the original TAR.
(2) When the last day of the 180 calendar day
appeal period falls on a Saturday, Sunday or Holiday, the final date to submit
the TAR appeal will be the next business day.
(b) The TAR appeal, regardless of submission
method, shall include:
(1) The original TAR
number and service type requested,
(2) The date(s) or service(s) in
dispute,
(3) The reason the appeal
should be granted, and
(4) Any
additional documentation that a provider chooses to submit that supports the
basis for the conclusion that the services are medically
necessary.
(c) An eTAR
appeal shall:
(1) Be submitted through the
Medi-Cal eTAR web portal system.
(2) Include the special handling indicator
found in the Medi-Cal eTAR web portal system that indicates that the submission
is an electronic appeal.
(d) A provider may submit a paper TAR appeal
when there is a disruption in the Medi-Cal eTAR web portal system that delays
the provider from submitting the TAR appeal for more than 72 consecutive hours;
and the Department has directed the provider to submit a paper TAR
appeal.
(e) A provider who
submitted a paper TAR based on the Department's consideration of the provider's
capacity to submit an eTAR, as described in Section
51002.5(a), may
submit a paper TAR appeal.
(f) A
paper TAR appeal shall:
(1) Include a new,
completed TAR for the services appealed; and
(2) Be submitted to the Department; and
either
(3) Be post marked by the
United States Postal Service; or
(4) Be personally delivered to the Department
and date stamped upon receipt; or
(5) Be labeled with the date deposited with a
common carrier for delivery to the Department.
(g)
(1) The
Department shall review an eTAR appeal and enter the appeal decision and the
basis for that decision into the Medi-Cal eTAR web portal system.
(2) The Department shall review a paper TAR
appeal and:
(A) Enter the appeal decision and
the basis for that decision into the Medi-Cal eTAR web portal system;
and
(B) Send the appeal decision
and the basis for that decision to the provider.
(h) When the appeal decision is based on a
review of documented medical necessity:
(1)
For an eTAR appeal, the decision shall be entered into the Medi-Cal eTAR web
portal system within 180 calendar days from the date that the eTAR appeal was
submitted through the Medi-Cal eTAR web portal system.
(2) For a paper TAR appeal, the decision
shall be entered into the Medi-Cal eTAR web portal system and sent to the
provider within 180 calendar days from the date that the paper TAR appeal was
received by the Department.
(i) When the appeal decision is a denial
based on failure to submit the appeal within 180 calendar days from the date of
the decision on the original TAR:
(1) For an
eTAR appeal, the decision shall be entered into the Medi-Cal eTAR web portal
system within 60 calendar days from the date that the eTAR appeal was submitted
through the Medi-Cal eTAR web portal system.
(2) For a paper TAR appeal, the decision
shall be entered into the Medi-Cal eTAR web portal system and sent to the
provider within 60 calendar days from the date that the paper TAR appeal was
received by the Department.
(j) If a provider is not satisfied with the
appeal decision, the provider may seek a judicial remedy pursuant to Section
1085
of the Code of Civil Procedure.