Cal. Code Regs. Tit. 22, § 51159 - Utilization Controls

Utilization controls that may be applied to services set forth in this chapter include:

(a) Prior authorization, which is approval in advance of the rendering of service of the medical necessity and program coverage of the requested services, by a Department of Health consultant or PCCM plan.

In determining what services shall be subject to prior authorization, the Director shall consider factors which include, but are not limited to:

(1) Whether the services to be controlled are generally considered to be elective procedures.

(2) Whether other physician procedures not subject to prior authorization are sufficient in scope and number to afford beneficiaries reasonable access to necessary health care services.

(3) The level of program payment for procedures.

(4) The cost effectiveness of applying prior authorization as a utilization control.

(b) Postservice prepayment audit, which is review for medical necessity and program coverage after service was rendered but before payment is made. Payment may be withheld or reduced if the service rendered was inappropriate.

(c) Postservice postpayment audit, which is review for medical necessity and program coverage after service was rendered and the claim paid. The department may take appropriate steps to recover payments made if subsequent investigation uncovers evidence that the claim should not have been paid.

(d) Limitation on number of services, which means certain services may be restricted as to number within a specified time frame.

Notes

Cal. Code Regs. Tit. 22, § 51159

1. New section filed 7-1-75 as an emergency; designated effective 7-1-75 (Register 75, No. 27).
2. Certificate of Compliance filed 10-24-75 (Register 75, No. 43).
3. Amendment filed 9-1-82 as an emergency; effective upon filing (Register 82, No. 37). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 12-30-82.
4. Certificate of Compliance transmitted to OAL 12-30-82 and filed 2-3-83 (Register 83, No. 6).
5. Amendment of subsection (a) filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 7-9-90.
6. Amendment refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed by operation of law on 11-6-90.
7. Request to readopt amendment on an emergency basis pursuant to Government Code section 11346.1 granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No. 6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or emergency language will be repealed by operation of law on the following day.
8. Certificate of Compliance as to 11-6-90 order transmitted to OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).
9. Amendment of subsection (a) filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No. 18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or emergency language will be repealed by operation of law on the following day.
10. Certificate of Compliance as to 3-25-91 order including amendment of NOTE transmitted to OAL 7-19-91 and filed 8-19-91 (Register 92, No. 1).
11. Change without regulatory effect amending NOTE filed 12-16-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 51).

Note: Authority cited: Section 20, Health and Safety Code; and Sections 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14021, 14053, 14088.16, 14105, 14106, 14124.24, 14131, 14132, 14133 and 14133.25, Welfare and Institutions Code.

1. New section filed 7-1-75 as an emergency; designated effective 7-1-75 (Register 75, No. 27).
2. Certificate of Compliance filed 10-24-75 (Register 75, No. 43).
3. Amendment filed 9-1-82 as an emergency; effective upon filing (Register 82, No. 37). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 12-30-82.
4. Certificate of Compliance transmitted to OAL 12-30-82 and filed 2-3-83 (Register 83, No. 6).
5. Amendment of subsection (a) filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 7-9-90.
6. Amendment refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed by operation of law on 11-6-90.
7. Request to readopt amendment on an emergency basis pursuant to Government Code section 11346.1 granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No. 6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or emergency language will be repealed by operation of law on the following day.
8. Certificate of Compliance as to 11-6-90 order transmitted to OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).
9. Amendment of subsection (a) filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No. 18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or emergency language will be repealed by operation of law on the following day.
10. Certificate of Compliance as to 3-25-91 order including amendment of Note transmitted to OAL 7-19-91 and filed 8-19-91 (Register 92, No. 1).
11. Change without regulatory effect amending Note filed 12-16-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 51).