Cal. Code Regs. Tit. 22, § 56261 - Notice to Members of PCCM Plan Action to Deny, Defer or Modify a Request for Medical Services

(a) The PCCM plan shall provide members with a notice of an action taken by the PCCM 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 PCCM 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 PCCM plan or from the list, established by the PCCM plan, of drugs available without prior authorization from the plan.

(b) The PCCM 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 PCCM plan to make a decision. If, after 30 days from the PCCM plan's receipt of the request for prior authorization, the provider has not complied with the PCCM plan's request for additional information, the PCCM plan shall provide the member notice of denial pursuant to subdivision (a). If, within that 30 day period, the provider does comply, the PCCM 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 PCCM 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 PCCM 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 PCCM 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 PCCM 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 PCCM plan.

(2) The reason for the action taken.

(3) A citation of the specific regulations or PCCM 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 PCCM 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 PCCM 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 PCCM plan's authorization procedures is not a condition of payment to the provider for the medical service.

Notes

Cal. Code Regs. Tit. 22, § 56261

1. New section filed 10-17-95; operative 11-16-95 (Register 95, No. 42).

Note: Authority cited: Sections 14105 and 14124.5, Welfare and Institutions Code. Reference: Section 14450, Welfare and Institutions Code.

1. New section filed 10-17-95; operative 11-16-95 (Register 95, No. 42).