Cal. Code Regs. Tit. 22, § 51014.1 - Fair Hearing Related to Denial, Termination or Reduction in Medical Services
(a) In addition to
any notice mailed pursuant to section
50179,
53261,
53452,
56261, or
56452, each beneficiary shall be
informed in writing, at the time of application to the program and by the
Department on a quarterly basis thereafter, of the right to a fair hearing upon
receipt of notice of:
(1) Any action, other
than approval, including but not limited to deferral or denial, taken by the
Department or a Medi-Cal managed care plan on a request by a provider for any
medical service.
(2) Any intended
action by the Department or a Medi-Cal managed care plan to terminate or reduce
any medical service.
(b)
The written notice of the right to a fair hearing shall specify:
(1) The method by which a hearing may be
obtained.
(2) That the beneficiary
may be either:
(A) Self represented.
(B) Represented by an authorized third party
such as legal counsel, relative, friend or any other
person.
(3) The
circumstances under which the medical service shall be continued pending
decision on the fair hearing.
(4)
The time limit for requesting fair hearing.
(c) Except as provided in (d), notice of
intended action to reduce or terminate authorization for a medical service
prior to expiration of the period covered by the authorization shall be mailed
by the Department or by the Medi-Cal managed care plan to the beneficiary at
least 10 days before the effective date of action. The notice shall include:
(1) A statement of the action the Department
or Medi-Cal managed care plan intends to take.
(2) The reason for the intended
action.
(3) A citation of the
specific regulations or Medi-Cal managed care plan authorization procedures
supporting the intended action.
(4)
An explanation of the beneficiary's right to request a fair hearing for the
purpose of appealing the Department's or Medi-Cal managed care plan's
decision.
(5) An explanation of the
procedure to request a hearing.
(6)
An explanation of the circumstances under which a medical service shall be
continued if a hearing is requested.
(d) The Department or Medi-Cal managed care
plan may dispense with the 10 day mailing requirement in (c), but shall mail
the notice of action before the date of action and shall meet all other
requirements, when any of the following circumstances occur:
(1) The Department or Medi-Cal managed care
plan receives a clear written statement signed by the beneficiary stating that
the beneficiary no longer wishes to receive continuous medical
service.
(2) The beneficiary has
been admitted or committed to an institution and is no longer eligible for
Medi-Cal benefits or, for a Medi-Cal managed care plan member, is no longer
enrolled in the Medi-Cal managed care plan.
(3) The beneficiary has been accepted for
medical assistance in another state or a new jurisdiction and that fact has
been established by the jurisdiction presently providing assistance.
(4) A change in level of medical care is
prescribed by the beneficiary's physician.
(5) The Department, or Medi-Cal managed care
plan with the concurrence of the Department, obtains facts indicating the
medical service should be terminated because of the probable fraud of the
beneficiary. In this case notice shall be mailed at least 5 days before the
action becomes effective.
(e) Except as provided in (g), notice of a
reduction or termination as defined in (e)(1) and (2) shall be mailed by the
Department or Medi-Cal managed care plan to the beneficiary or to the person
identified as the beneficiary's authorized representative in records submitted
by the health care provider requesting the services. The notice shall contain
the information required by (c), except that it shall describe the action the
Department or Medi-Cal managed care plan has taken rather than an action it
intends to take. It shall be deposited with the United States postal service in
time for pick-up no later than the third working day after the reduction or
termination.
(1) "Termination" as used in this
subdivision means denial by the Department or Medi-Cal managed care plan of a
request for non-acute continuing services, as defined in section
51003(c)(1).
(2) "Reduction" as used in this subdivision
means approval by the Department or Medi-Cal managed care plan of a request for
non-acute continuing services as defined in section
51003(c)(1), at
less than the amount or frequency requested and less than the amount or
frequency approved on the immediately preceding authorization. There is no
reduction if a shorter time period of services than requested is approved, as
long as the amount or frequency of services during that period has not been
reduced from the previously approved level.
(f) Except as provided in (g), notice of a
termination as defined in (f)(1), shall be personally delivered or mailed as
provided below. Notice shall be personally delivered to the beneficiary in his
or her hospital room unless the beneficiary's treating physician has certified
in writing that such personal delivery may result in serious harm to the
beneficiary. If the treating physician has so certified, notice shall be mailed
to the mailing address of the beneficiary or the person, if any, identified as
the beneficiary's authorized representative in hospital medical records or
documents submitted by the hospital to the Department or Medi-Cal managed care
plan. Notice required by this subdivision shall contain the information
required by (c) except that it shall describe the action the Department or
Medi-Cal managed care plan has taken rather than an action it intends to take.
It shall be personally delivered or be mailed no later than the first working
day after termination.
(1) "Termination" as
used in this subdivision means denial by the Department or Medi-Cal managed
care plan of a request by a provider for acute continuing services, as defined
in section
51003(c)(2).
There is no termination when the field office consultant or Medi-Cal managed
care plan approves less than the full number of acute care days
requested.
(g) Notice of
termination or reduction as provided for in (e) and (f) is not required in any
of the following circumstances:
(1) By the
date that notice would otherwise be personally delivered or mailed;
(A) Non-acute services requested for a
limited time period are provided in full or,
(B) In the case of acute care services, the
beneficiary is discharged from the hospital.
(2) The only days of acute care denied have
already been provided to the beneficiary.
(3) The Department or Medi-Cal managed care
plan authorized acute care days subject to specific services being performed
during a specified time, and the Department or Medi-Cal managed care plan
retroactively denies these previously authorized days because such services
were delayed or not performed.
(h) Notice of action taken, or intended
action other than approval for either a written or verbal request by a provider
for medical service, other than those specified under subdivisions (c), (e) and
(f) or sections
53261 or
56261, shall be transmitted by the
Department or Medi-Cal managed care plan to the provider of service. The method
of transmittal of the notice of action taken or intended action may be either
written or verbal. Should the beneficiary not receive notification from the
provider of the Department's or Medi-Cal managed care plan's decision, the
beneficiary may contact the provider to obtain such notification.
(i) For the purposes of this section,
"medical service" means those services that are subject to prior authorization
pursuant to section
51003 or the Medi-Cal managed care
plan's authorization procedures.
(j) For the purposes of this section,
"Medi-Cal managed care plan" means a prepaid health plan as defined in section
50071.5 or a primary care case
management plan as defined in section
50071.8.
(k) The provisions of this section apply to
Medi-Cal managed care plans only for beneficiaries who are enrolled in the
Medi-Cal managed care plan and for medical services that are covered in the
contract between the Department and the Medi-Cal managed care plan. The
provisions of this section do not apply to the decisions of providers serving
beneficiaries enrolled in Medi-Cal managed care plans when prior authorization
of the service by the Medi-Cal managed care plan's authorization procedures is
not a condition of payment for the medical service.
Notes
2. Certificate of Compliance filed 6-28-79 (Register 79, No. 26).
3. Amendment of subsection (c) and new subsections (e)-(g) filed 10-26-90 as an emergency; operative 10-26-90 (Register 90, No. 50). A Certificate of Compliance must be transmitted to OAL by 2-25-91 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 10-26-90 order transmitted to OAL 2-22-91 and filed 3-25-91 (Register 91, No. 15).
5. Amendment of section and NOTE filed 10-17-95; operative 11-16-95 (Register 95, No. 42).
Note: Authority cited: Sections 10725, 14105, 14124.5 and 14312, Welfare and Institutions Code. Reference: Sections 10950, 14088, 14088.4, 14124.5 and 14311, Welfare and Institutions Code.
2. Certificate of Compliance filed 6-28-79 (Register 79, No. 26).
3. Amendment of subsection (c) and new subsections (e)-(g) filed 10-26-90 as an emergency; operative 10-26-90 (Register 90, No. 50). A Certificate of Compliance must be transmitted to OAL by 2-25-91 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 10-26-90 order transmitted to OAL 2-22-91 and filed 3-25-91 (Register 91, No. 15).
5. Amendment of section and Note filed 10-17-95; operative 11-16-95 (Register 95, No. 42).
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