(a) Continued medical assistance as set forth
in (b), (c), and (d) below, pending a hearing decision shall be provided only
if the beneficiary appeals in writing to the Department for a hearing within 10
days of the mailing or personal delivery of the notice of action pursuant to
section
51014.1(c), (e) or
(f), or before the effective date of
action.
(b) In the case of a
termination or reduction pursuant to section
51014.1(c),
authorization shall be maintained until the period covered by the existing
authorization expires, the date a hearing decision is rendered, or the date on
which the hearing is otherwise withdrawn or closed, whichever is
earliest.
(c) In the case of a
termination of acute care services pursuant to section
51014.1(f), acute
care authorization pending a hearing shall begin:
(1) The first day after the previously
approved length of stay for continuing acute care if the request for extension
by a provider was submitted to the on-site Medi-Cal reviewer during the first
on-site visit after the previously approved length of stay expired.
(2) The sixth day of hospitalization if a
request for extension pursuant to section
51003(c)(2)(B)5.
was submitted to the on-site Medi-Cal reviewer during the first on-site visit
after the first five days of hospitalization.
(3) The day the request for extension was
submitted to the Department or to the Medi-Cal managed care plan if neither (1)
nor (2) apply.
(4) The date of the
termination decision if a decision on the request for extension was initially
deferred pending the receipt of additional information.
Authorization pending a hearing pursuant to this
subdivision shall end on the date a hearing decision is rendered, the date on
which the hearing appeal is withdrawn or closed, the date the treating
physician documents that the beneficiary is ready for lower level of care, or
the date of discharge, whichever is earliest.
(d) In the case of a termination or reduction
of non-acute care services pursuant to section
51014.1(e),
authorization shall begin:
(1) Upon
expiration of the previous authorization if the request by a provider for
reauthorization is submitted prior to such expiration, or
(2) The day of receipt of a completed request
for reauthorization not requiring additional information from the provider,
or
(3) The date of deferral of a
decision on a request for reauthorization, when such deferral was necessary
because of an incomplete request or because additional medical information is
needed.
Authorization pending a hearing pursuant to this
subdivision ends on the date through which services were requested by the
treating physician, the date a hearing decision is rendered, or the date on
which the hearing appeal is withdrawn or closed, whichever is
earliest.
(e)
Notwithstanding (a), (c), and (d), continued medical assistance pursuant to (c)
or (d):
(1) is not required at a greater
amount or frequency of services than approved for the immediately preceding
period of authorization,
(2) is not
required in the case of acute care services if the beneficiary has been
discharged from the hospital at the time that continued authorization would
otherwise be put into effect,
(3)
is not required in the case of non-acute care services requested for a limited
time period, if they have been provided in full at the time that continued
authorization would otherwise be put into effect.
(f) 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.
(g) 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.
Notes
Cal. Code Regs. Tit. 22, §
51014.2
1.
Amendment refiled by the Department of Health Services with the Secretary of
State on 5-30-89 as an emergency pursuant to Health and Safety Code section
1275.3;
operative 5-30-89. Submitted to OAL for printing only pursuant to Government
Code section
11343.8
(Register 89, No. 23). For prior history, see Register 89, No. 1.
2.
Certificate of Compliance as to 5-30-89 order transmitted to OAL 9-27-89 and
filed 10-26-89 (Register 89, No. 44).
3. Amendment 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
and
14124.5,
Welfare and Institutions Code; and Sections
1250,
1267.7
and
1275.3,
Health and Safety Code. Reference: Sections
10950,
14088,
14088.4,
14124.5
and
14311,
Welfare and Institutions Code; and Sections
1250
and
1275.3,
Health and Safety Code.
1. Amendment
refiled by the Department of Health Services with the Secretary of State on
5-30-89 as an emergency pursuant to Health and Safety Code section
1275.3;
operative 5-30-89. Submitted to OAL for printing only pursuant to Government
Code section
11343.8
(Register 89, No. 23). For prior history, see Register 89, No. 1.
2. Certificate of Compliance as to 5-30-89 order transmitted to OAL 9-27-89 and
filed 10-26-89 (Register 89, No. 44).
3. Amendment 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).
