Cal. Code Regs. tit. 9, § 1830.215 – MHP Payment Authorization.

(a) The MHP may require that providers obtain MHP payment authorization of any or all specialty mental health services covered by this Subchapter as a condition of reimbursement for the service in accordance with the provisions of this Section. MHP payment authorization under this Section shall be provided in compliance with timelines and other provisions in title 42, Code of Federal Regulations, Section 438.210.
(b) The MHP's authorization function may be assigned to a person, an identified staffing unit, a committee, or an organizational executive who may delegate the authorization function; including any such persons or entities affiliated with a contracting provider to which the MHP has delegated the authorization function.
(c) The individuals who review and approve or deny requests from providers for MHP payment authorization shall be licensed mental health professionals or waivered/registered professionals of the MHP of the beneficiary. Licensed psychiatric technicians and licensed vocational nurses may approve or deny such requests only when the provider indicates that the beneficiary to whom the specialty mental health services will be delivered has an urgent condition as defined in Section 1810.253.
(d) The MHP may require that providers obtain MHP payment authorization prior to rendering any specialty mental health service covered by this Subchapter as a condition of reimbursement for the service, except for those services provided to beneficiaries with emergency psychiatric conditions as provided in Sections 1830.230 and 1830.245.
(e) Notwithstanding the provisions of Subsections (a) and (d), the MHP shall require that providers obtain MHP payment authorization for day rehabilitation, day treatment intensive and EPSDT supplemental specialty mental health services as required in the MHP contract with the Department.
(f) Notwithstanding the discretion given to MHPs in Subsections (a) and the requirements of Subsection (c), the MHP shall comply with the specific MHP payment authorization requirements of Sections 1830.230, 1830.245, and 1830.250.
(g) Whether or not the MHP payment authorization of a specialty mental health service is required pursuant to this Section, the MHP may require that providers notify the MHP of their intent to provide the service prior to the delivery of the service.
1. (1) If the MHP does not require notice or has not informed providers of the notice requirement, MHP payment authorization requests presented for authorization beyond the timelines established by the MHP shall be accepted for consideration by the MHP when the MHP determines that the provider was prevented from submitting a timely request because of a reason that meets one of the criteria specified in Subsections (g)(1)(A)-(B). The MHP may accept MHP payment authorizations requests presented beyond the timelines specified in the Subchapter for other acceptable reasons as determined by the MHP. The provider shall submit factual documentation deemed necessary by the MHP with the MHP payment authorization request. Any additional documentation requested by the MHP shall be submitted within 60 calendar days of the MHP's request. The documentation shall verify that the late submission was due to:
  1. (A) A natural disaster that has:
    1. 1. Destroyed or damaged the provider's business office or records, or
    2. 2. Substantially interfered with the provider's agent's processing of requests for MHP payment authorization; or
  2. (B) Delays caused by other circumstances beyond the provider's control. Documentation shall include evidence that the circumstance causing the delay was reported to a law enforcement or fire agency, if the circumstance is required to be reported. Circumstances that shall not be considered beyond the control of the provider include but are not limited to:
    1. 1. Negligence by employees.
    2. 2. Misunderstanding of program requirements.
    3. 3. Illness or absence of any employee trained to prepare MHP payment authorizations.
    4. 4. Delays caused by the United States Postal Service or any private delivery service.
2. (2) If the MHP does require such notice, the MHP shall inform providers of this requirement by including the MHP requirement in a publication commonly available to all providers serving beneficiaries. If notice is required and given by the provider, the MHP shall consider requests for MHP payment authorization submitted beyond the timelines for submission established by the MHP in accordance with the provisions of Subsection (g)(1). If notice is required and not given by the provider, the MHP may deny requests for MHP payment authorization submitted beyond the timelines for submission established by the MHP, regardless of the reason for the late submission.
(h) In accordance with title 42 CFR section 438.210(b)(2)(ii), the MHP shall consult with a provider requesting authorization when appropriate.

Note: Authority cited: Section 14680, Welfare and Institutions Code. Reference: Sections 5777, 5778 and 14684, Welfare and Institutions Code; and 42 Code of Federal Regulations, Section 438.210.

History

1. New section filed 10-31-97 as an emergency; operative 11-1-97 (Register 97, No. 44). A Certificate of Compliance must be transmitted to OAL by 3-2-98 or emergency language will be repealed by operation of law on the following day.

2. New section refiled 3-2-98 as an emergency; operative 3-2-98 (Register 98, No. 10). A Certificate of Compliance must be transmitted to OAL by 6-30-98 or emergency language will be repealed by operation of law on the following day.

3. New section refiled 6-17-98 as an emergency; operative 6-30-98 (Register 98, No. 25). Pursuant to Chapter 324 (Statutes of 1998) Item 4440-103-0001(4), a Certificate of Compliance must be transmitted to OAL by 7-1-99 or emergency language will be repealed by operation of law on the following day.

4. Editorial correction of History 3 (Register 98, No. 39).

5. Editorial correction extending Certificate of Compliance date to 7-1-2001 pursuant to Chapter 50 (Statutes of 1999) Item 4440-103-0001(4) (Register 99, No. 33). Notwithstanding any other provision of law, emergency regulations adopted pursuant to Welfare and Institutions Code section 14680 to implement the second phase of mental health managed care as provided in this part shall remain in effect until permanent regulations are adopted, or June 30, 2006, whichever occurs first.

6. Editorial correction of History 5 (Register 2000, No. 42).

7. New subsection (c), subsection relettering and amendment of Note filed 6-19-2003 as an emergency; operative 7-1-2003 (Register 2003, No. 25). A Certificate of Compliance must be transmitted to OAL by 10-29-2003 or emergency language will be repealed by operation of law on the following day.

8. Certificate of Compliance as to 7-1-2003 order transmitted to OAL 10-6-2003 and filed 11-18-2003 (Register 2003, No. 47).

9. Editorial correction of History 5 and repealer and new section filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).

10. Amendment of subsection (a) and new subsection (h) filed 10-18-2010; operative 11-17-2010 (Register 2010, No. 43).