Cal. Code Regs. Tit. 22, § 53261 - Notice to Members of Plan Action to Deny, Defer or Modify a Request for Medical Services
(a) The
plan shall provide members with a notice of an action taken by the plan to deny
a request by a provider for any medical service. Notice in response to an
initial request from a provider shall be provided in accordance with this
section. Notice in response to a request for continuation of a medical service
shall be provided in accordance with section
51014.1. Notice of denial shall
not be required in the following situations:
(1) The denial is a denial of a request for
prior authorization for coverage for treatment that has already been provided
to the member.
(2) The denial is a
non-binding verbal description to a provider of the services which may be
approved by the plan.
(3) The
denial is a denial of a request for drugs, and a drug identical in chemical
composition, dosage, and bioequivalence may be obtained through prior
authorization from the plan or from the list, established by the plan, of drugs
available without prior authorization from the plan.
(b) The plan shall provide members with a
notice of deferral of a request by a provider for a medical service. Notice of
the deferral shall be delayed for 30 days to allow the provider of the medical
services time to submit the additional information requested by the plan and to
allow time for the plan to make a decision. If, after 30 days from the plan's
receipt of the request for prior authorization, the provider has not complied
with the plan's request for additional information, the plan shall provide the
member notice of denial pursuant to subdivision (a). If, within that 30 day
period, the provider does comply, the plan shall take appropriate action on the
request for prior authorization as supplemented by the additional information,
including providing any notice to the member.
(c) The plan shall provide members notice of
modification of a request by a provider for prior authorization. Notice in
response to an initial request from a provider shall be provided in accordance
with this subdivision. Notice in response to a request for continuation of a
medical service shall be provided in accordance with section
51014.1. Notice of modification
pursuant to this subdivision shall not be required in the following situations:
(1) The plan may modify a request for durable
equipment without notice, as long as the substituted equipment is capable of
performing all medically significant functions that would have been performed
by the requested equipment.
(2) The
plan may modify the duration of any approved therapy or the length of stay in
an acute hospital inpatient facility without notice as long as the plan
provides an opportunity for the provider to request additional therapy or
inpatient days before the end of the approved duration of the therapy or length
of stay.
(d) The written
notice of action issued pursuant to subdivision (a), (b), or (c) shall be
deposited with the United States postal service in time for pick-up no later
than the third working day after the action and shall specify:
(1) The action taken by the plan.
(2) The reason for the action
taken.
(3) A citation of the
specific regulations or plan authorization procedures supporting the
action.
(4) The member's right to a
fair hearing, including:
(A) The method by
which a hearing may be obtained.
(B) That the member may be either:
1. Self represented.
2. Represented by an authorized third party
such as legal counsel, relative, friend or any other
person.
(C) The time
limit for requesting fair hearing.
(e) For the purposes of this section, medical
services means those services that are subject to prior authorization under the
plan's authorization procedures.
(f) The provisions of this section apply only
for medical services that are covered in the contract between the Department
and the plan.
(g) The provisions of
this section do not apply to the decisions of providers serving plan members
when prior authorization of the service by the plan's authorization procedures
is not a condition of payment to the provider for the medical
service.
Notes
Note: Authority cited: Section 14312, Welfare and Institutions Code. Reference: Section 14450, Welfare and Institutions Code.
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