1. (a) Hospitals and the individual, group or organizational providers who have provided specialty mental health services under Sections 1820.225, 1830.230, and 1830.245 to a beneficiary during the psychiatric inpatient hospital stay that is the subject of the appeal may appeal separately to the Department unless they have agreed to another arrangement as a term of their contract with the MHP.

2. (b) If a provider chooses to appeal an MHP's denial or modification of MHP payment authorization, the provider shall submit an appeal to the Department in writing, along with supporting documentation, within 30 calendar days from the date the MHP's written decision of denial or modification is submitted to the provider. The provider may appeal to the Department within 30 calendar days after 60 calendar days from submission of the appeal under Section 1850.315(a) to the MHP, if the MHP fails to respond. Supporting documentation shall include, but not be limited to:

   1. (1) Any documentation supporting allegations of timeliness, if at issue, including fax records, phone records or memos.
   2. (2) Clinical records supporting the existence of medical necessity if at issue.
   3. (3) A summary of reasons why the MHP should have approved the MHP payment authorization.
   4. (4) A contact person(s) name, address and phone number.
3. (c) The Department shall notify the MHP and the provider of its receipt of a request for appeal pursuant to this Section within seven calendar days from the date of receipt of the request. The notice to the MHP shall include a request to the MHP for specific documentation supporting denial of the MHP payment authorization and a request for documentation establishing any agreements with the appealing provider or other providers who may be affected by the appeal pursuant to Subsection (a).
4. (d) The MHP shall submit the requested documentation within 21 calendar days of the date the notice to the MHP from the Department pursuant to Subsection (c) was received by the MHP or the Department shall decide the appeal based solely on the documentation filed by the provider.

5. (e) The Department shall have 60 calendar days from the receipt of the MHP's documentation or from the 21st calendar day after the request for documentation was received by the MHP, whichever is earlier, to notify the provider and the MHP, in writing, of its decision, including a statement of the reasons for the decision that addresses each issue raised by the provider and the MHP, and any actions required by the MHP or the provider to implement the decision. At the election of the provider, if the Department fails to act within the 60 calendar days, the appeal may be considered to have been denied by the Department.

   1. (1) The Department may allow both a provider representative(s) and the MHP representative(s) an opportunity to present oral argument to the Department.
   2. (2) If applicable, the provider shall submit a revised request for MHP payment authorization within 30 calendar days from receipt of the Department's decision to uphold the appeal.
   3. (3) If applicable, the MHP shall have 14 calendar days from the receipt of the provider's revised MHP payment authorization request to approve the MHP payment authorization or submit documentation to the Medi-Cal fiscal intermediary required to process the MHP payment authorization.

When an appeal concerning the denial or modification of an MHP payment authorization request for the specialty mental health services provided in an emergency as described in Sections 1820.225, 1830.230, and 1830.245 is denied in full or in part by the MHP's Provider Appeal Process on the basis that the provider did not comply with the required timelines for notification or submission of the MHP payment request, that the medical necessity criteria were not met, or that the requirements of Section 1820.220(j)(5) for approval of administrative days were not met, the provider may appeal the denial or modification to the Department. A hospital may not appeal the denial or modification of MHP payment authorization to the Department when the denial or modification is based on the MHP's determination that a hospital has failed to comply with mandatory provisions of the contract between the provider and the MHP as allowed by Sections 1820.220(g), (j) and 1820.225(d)(5).

Note: Authority cited: Section 14680, Welfare and Institutions Code. Reference: Section 14684, Welfare and Institutions Code.

History

1. New section filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).