1. (a) Except as provided in Subsection (c), when an MHP has a dispute with a Medi-Cal Managed Care Plan that cannot be resolved to the satisfaction of the MHP concerning the obligations of the MHP or the Medi-Cal Managed Care Plan under their respective contracts with the State, State Medi-Cal laws and regulations, or an MOU as described in Section 1810.370, the MHP may submit a request for resolution to the Department.
2. (b) Except as provided in Subsection (c), when a Medi-Cal Managed Care plan has a dispute with an MHP that cannot be resolved to the satisfaction of the Medi-Cal Managed Care Plan concerning the obligations of the MHP or the Medi-Cal Managed Care Plan under their respective contracts with the State, State Medi-Cal laws and regulations, or an MOU as described in Section 1810.370, the Medi-Cal Managed Care Plan may submit a request for resolution to the Department.
3. (c) If the MHP and the Medi-Cal managed care plan have agreed in the MOU entered into pursuant to Section 1810.370 to binding arbitration as the means for resolving disputes, the MHP and the Medi-Cal managed care plan may not request resolution of the dispute under this Section.

4. (d) If the MHP and the Medi-Cal Managed Care Plan have an MOU pursuant to Section 1810.370, a request for resolution shall be submitted to the Department within 15 calendar days of the completion of the dispute resolution process between the parties as provided in the MOU. If there is no MOU, a request for resolution shall be submitted to the Department within 30 calendar days after the event giving rise to the dispute. The request for resolution shall contain the following information:

   1. (1) A summary of the issue and a statement of the desired remedy, including any disputed services that have been or are expected to be delivered to the beneficiary and the expected rate of payment for each type of service.
   2. (2) History of attempts to resolve the issue.
   3. (3) Justification for the desired remedy.
   4. (4) Documentation regarding the issue.
5. (e) Upon receipt of a request for resolution, the Department shall notify the other party within seven calendar days. The notice to the other party shall include a copy of the request and will ask for a statement of the party's position on the dispute, any relevant documentation supporting its position, and any dispute of the rate of payment for services included by the other party in its request.
6. (f) The other party shall submit the requested documentation within 21 calendar days from notification of the party from whom documentation is being requested by the party that received the initial request for resolution or the Department shall decide the dispute based solely on the documentation filed by the initiating party.

Note: Authority cited: Sections 10725, 14680 and 14700, Welfare and Institutions Code. Reference: Sections 14681, 14683, 14684, 14718 and 14721, Welfare and Institutions Code.

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

8. Change without regulatory effect amending subsections (b), (d) and (e)-(f) and amending Note filed 8-24-2015 pursuant to section 100, title 1, California Code of Regulations (Register 2015, No. 35).