reglab/statecodes huggingface dataset:
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 4 - Federal Financial Participation › Article 3 - Specialty Mental Health Services Other than Psychiatric Inpatient Hospital Services › Section 1840.370 - Lockouts for Psychiatric Health Facility Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Psychiatric Health Facility Services are not reimbursable on
						days when the following services are reimbursed, except for day of admission to
						Psychiatric Health Facility Services:
(a)
					 Adult Residential Treatment Services
(b)
					 Crisis Residential Treatment Services
(c) Crisis Intervention
(d) Day Treatment Intensive
(e) Day Rehabilitation
(f) Psychiatric Inpatient Hospital
					 Services
(g) Medication Support
					 Services
(h) Mental Health
					 Services
(i) Crisis
					 Stabilization
(j) Psychiatric Nursing
					 Facility Services.
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						will be repealed by operation of law on the following day.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						language will be repealed by operation of law on the following day.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						repealed by operation of law on the following day.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 and repealer and new
						section filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).
Note: Authority cited: Section
						  14680,
						  Welfare and Institutions Code. Reference: Section
						  5778,
						  Welfare and Institutions Code.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 4 - Federal Financial Participation › Article 3 - Specialty Mental Health Services Other than Psychiatric Inpatient Hospital Services › Section 1840.372 - Lockouts for Medication Support Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The maximum amount claimable for Medication Support Services
						in a 24-hour period is 4 hours.
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 and repealer and new
						section filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).
Note: Authority cited: Section
						  14680,
						  Welfare and Institutions Code. Reference: Section
						  5778,
						  Welfare and Institutions Code.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 4 - Federal Financial Participation › Article 3 - Specialty Mental Health Services Other than Psychiatric Inpatient Hospital Services › Section 1840.374 - Lockouts for Targeted Case Management Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Targeted
					 Case Management Services are not reimbursable on days when the following services
					 are reimbursed, except for day of admission or for placement services as provided in
					 Subsection (b):
(1) Psychiatric Inpatient Hospital
					 Services
(2) Psychiatric Health Facility
					 Services
(3) Psychiatric Nursing
					 Facility Services
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 1 - Beneficiary Problem Resolution Processes › Section 1850.205 - General Provisions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An MHP
					 shall develop problem resolution processes that enable a beneficiary to resolve a
					 problem or concern about any issue related to the MHP's performance of its duties
					 under this Chapter, including the delivery of specialty mental health
					 services.
(b) The MHP's beneficiary
					 problem resolution processes shall include:
(1) A
					 grievance process;
(2) An appeal
					 process; and
(3) An expedited appeal
					 process.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 1 - Beneficiary Problem Resolution Processes › Section 1850.206 - The Grievance Process

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
In addition to meeting the requirements of Section
						1850.205, the grievance process shall,
						at a minimum:
(a) Allow beneficiaries to
					 present their grievance orally or in writing.
(b) Provide for a decision on the grievance and
					 notify the affected parties within 60 calendar days of receipt of the grievance.
					 This timeframe may be extended by up to 14 calendar days if the beneficiary requests
					 an extension or if the MHP determines that there is a need for additional
					 information and that the delay is in the beneficiary's interest. If the MHP extends
					 the timeframes, the MHP shall, for any extension not requested by the beneficiary,
					 notify the beneficiary of the extension and the reasons for the extension in
					 writing. The written notice of the extension is not a Notice of Action as defined in
					 Section 1810.230.5.
(c) Provide for notification of the beneficiary or
					 the appropriate representative in writing of the grievance decision and
					 documentation of the notification or efforts to notify the beneficiary, if he or she
					 could not be contacted.
1. New section
						filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).
Note: Authority cited: Section
						  14680,
						  Welfare and Institutions Code. Reference: Section
						  14684,
						  Welfare and Institutions Code; and Title 42, Code of Federal Regulations, Part 438,
						  Subpart F.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 1 - Beneficiary Problem Resolution Processes › Section 1850.207 - The Appeal Process

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
In addition to meeting the requirements of Section
						1850.205, the appeal process shall, at a
						minimum:
(a) Allow a beneficiary to file an
					 appeal orally or in writing.
(b) Require
					 a beneficiary to follow an oral appeal with a written appeal. The date the MHP
					 receives the oral appeal shall be considered the filing date for the purpose of
					 applying the appeal timeframes in Subsection (c).
(c) Provide for a decision on the appeal and
					 notify the affected parties within 45 calendar days of receipt of the appeal. This
					 timeframe may be extended by up to 14 calendar days, if the beneficiary requests an
					 extension or the MHP determines that there is a need for additional information and
					 that the delay is in the beneficiary's interest. If the MHP extends the timeframes,
					 the MHP shall, for any extension not requested by the beneficiary, notify the
					 beneficiary of the extension and the reasons for the extension in writing. The
					 written notice of the extension is not a Notice of Action as defined in Section
					 1810.230.5.
(d) Inform the beneficiary of his or her right to
					 request a fair hearing after the appeal process of the MHP has been
					 exhausted.
(e) Allow the beneficiary to
					 have a reasonable opportunity to present evidence and allegations of fact or law, in
					 person or in writing.
(f) Allow the
					 beneficiary and/or his or her representative to examine the beneficiary's case file,
					 including medical records, and any other documents or records considered before and
					 during the appeal process.
(g) Allow the
					 beneficiary and/or his or her representative, or the legal representative of a
					 deceased beneficiary's estate to be included as parties to the appeal.
(h) Notify the beneficiary and/or his or her
					 representative of the resolution of the appeal in writing. The notice shall contain:
(1) The results of the appeal resolution
					 process.
(2) The date that the appeal
					 decision was made.
(3) If the appeal is
					 not resolved wholly in favor of the beneficiary, the notice shall also contain
					 information regarding the beneficiary's right to a fair hearing and the procedure
					 for filing for a fair hearing, if the beneficiary has not already requested a fair
					 hearing on the issue involved in the appeal.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 1 - Beneficiary Problem Resolution Processes › Section 1850.208 - The Expedited Appeal Process

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
In addition to meeting the requirements of Section
						1850.205 and
						1850.207(a), (d), (e), (f), (g), and
						(i), the expedited appeal process shall, at a
						minimum:
(a) Be used when the MHP
					 determines or the beneficiary and/or the beneficiary's provider certifies that
					 taking the time for a standard appeal resolution could seriously jeopardize the
					 beneficiary's life, health or ability to attain, maintain, or regain maximum
					 function.
(b) Allow the beneficiary to
					 file the request for an expedited appeal orally without requiring that the request
					 be followed by a written appeal.
(c)
					 Ensure that punitive action is not taken against a beneficiary or a provider because
					 they request an expedited appeal or support a beneficiary's request for an expedited
					 appeal.
(d) Resolve an expedited appeal
					 and notify the affected parties in writing, no later than three working days after
					 the MHP receives the appeal. This timeframe may be extended by up to 14 calendar
					 days if the beneficiary requests an extension, or the MHP determines that there is
					 need for additional information and that the delay is in the beneficiary's interest.
					 If the MHP extends the timeframes, the MHP shall, for any extension not requested by
					 the beneficiary, notify the beneficiary of the extension and the reasons for the
					 extension in writing. The written notice of the extension is not a Notice of Action
					 as defined in Section
					 1810.230.5.
(e) Provide a beneficiary with a written notice of
					 the expedited appeal disposition and make reasonable efforts to provide oral notice
					 to the beneficiary and/or his or her representative. The written notice shall meet
					 the requirements of Section
					 1850.207(h).
(f) If the MHP denies a request for expedited
					 appeal resolution, the MHP shall:
(1) Transfer the
					 expedited appeal request to the timeframe for appeal resolution as required by
					 Section 1850.207(c).
(2) Make reasonable efforts to give the
					 beneficiary and his or her representative prompt oral notice of the denial of the
					 request for an expedited appeal and provide written notice within two calendar days
					 of the date of the denial. The written notice of the denial of the request for an
					 expedited appeal is not a Notice of Action as defined in Section
					 1810.230.5.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 1 - Beneficiary Problem Resolution Processes › Section 1850.209 - Beneficiary Problem Resolution Processes Established by Providers

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Nothing in
					 this Section and Sections
					 1850.205,
					 1850.206,
					 1850.207, and
					 1850.208 precludes a provider other than
					 the MHP from establishing beneficiary problem resolution processes for beneficiaries
					 receiving services from that provider. When such processes exist, beneficiaries
					 shall not be required by the MHP to use or exhaust the provider's processes prior to
					 using the MHP's beneficiary problem resolution process, unless the following
					 conditions have been met:
(1) The MHP delegates
					 the responsibility for the beneficiary problem resolution process to the provider in
					 writing, specifically outlining the provider's responsibility under the
					 delegation.
(2) The provider's
					 beneficiary problem resolution process fully complies with this Section, Section
					 1850.205, and, depending on processes
					 delegated, Sections
					 1850.206,
					 1850.207, and/or 1850.208.
(3) No beneficiary is prevented from accessing the
					 grievance, appeal or expedited appeal processes solely on the grounds that the
					 grievance, appeal or expedited appeal was incorrectly filed with either the MHP or
					 the provider.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 2 - Fair Hearing and Notice of Action › Section 1850.210 - Provision of Notice of Action

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The MHP
					 shall provide a beneficiary of the MHP with a Notice of Action when the MHP denies
					 or modifies an MHP payment authorization request from a provider for a specialty
					 mental health service to the beneficiary.
(1)
					 Except as provided in Subsection (c), when the denial or modification involves a
					 request from a provider for continued MHP payment authorization of a specialty
					 mental health service or when the MHP reduces or terminates a previously approved
					 MHP payment authorization, notice shall be provided in accordance with Title 22,
					 Section 51014.1.
(2) Notice is not required when a denial is a
					 non-binding verbal description to a provider of the specialty mental health services
					 that may be approved by the MHP.
(3)
					 Notice is not required when the MHP modifies the duration of any approved specialty
					 mental health services as long as the MHP provides an opportunity for the provider
					 to request MHP payment authorization of additional specialty mental health services
					 before the end of the approved duration of services.
(4) Except as provided in Subsection (b), notice
					 is not required when the denial or modification is a denial or modification of a
					 request for MHP payment authorization for a specialty mental health service that has
					 already been provided to the beneficiary.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 2 - Fair Hearing and Notice of Action › Section 1850.212 - Contents of a Notice of Action

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Notice
					 of Action, issued pursuant to Section
					 1850.210(a)-(e) shall
					 contain the following information:
(1) The action
					 taken by the MHP.
(2) The reason for the
					 action taken.
(3) A citation of the
					 specific regulations or MHP payment authorization procedures supporting the
					 action.
(4) The beneficiary's right to
					 file an appeal or expedited appeal with the MHP.
(5) The beneficiary's right to a fair hearing or
					 to request an expedited fair hearing, including:
(A) The method by which a hearing may be
					 obtained.
(B) That the beneficiary may
					 be either:
1. Self-represented.
2. Represented by an authorized third party such
					 as legal counsel, relative, friend or any other person.
(C) An explanation of the circumstances under
					 which a specialty mental health service will be continued if a fair hearing is
					 requested.
(D) The time limits for
					 requesting a fair hearing or an expedited fair
					 hearing.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 2 - Fair Hearing and Notice of Action › Section 1850.213 - Fair Hearings

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The fair
					 hearings under this Article shall be administered by the Department, in accordance
					 with Title 22, Sections
					 50951 and
					 50953.
(b) The MHP shall carry out the final decisions of
					 the fair hearing process with respect to issues within the scope of the MHP's
					 responsibilities under the contract between the MHP and the Department.
(c) Nothing in this section is intended to prevent
					 the MHP from pursuing any options available for appealing a fair hearing
					 decision.
1. New section
						filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).
2.
						Designation of existing section as subsection (a) and new subsections (b)-(c) filed
						10-18-2010; operative 11-17-2010 (Register 2010, No. 43).
3. Change
						without regulatory effect amending subsection (a) and NOTE filed 8-24-2015 pursuant
						to section 100, title 1, California Code of
						Regulations (Register 2015, No. 35).
Note: Authority cited: Sections
						  10725,
						  14684
						  and
						  14700,
						  Welfare and Institutions Code. Reference: Section
						  14684,
						  Welfare and Institutions Code.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 3 - Provider Problem Resolution and Appeal Processes › Section 1850.305 - General Provisions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An MHP
					 shall develop provider problem resolution and appeal processes that enable providers
					 to resolve MHP payment authorization issues or other complaints and concerns. The
					 MHP shall not subject a provider to discrimination or any other penalty for using
					 the provider problem resolution and appeal processes.
(b) The MHP shall ensure that participating
					 providers are provided written information regarding the provider problem resolution
					 and appeal processes.
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 3
						heading and repealer and new section filed 5-19-2006; operative 6-18-2006 (Register
						2006, No. 20).
Note: Authority cited: Section
						  14680,
						  Welfare and Institutions Code. Reference: Section
						  14684,
						  Welfare and Institutions Code.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 3 - Provider Problem Resolution and Appeal Processes › Section 1850.310 - Provider Problem Resolution Process

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The Provider Problem Resolution Process shall, at a
						minimum:
(a) Include a means to accept
					 written or verbal concerns or complaints from providers and address these concerns
					 or complaints quickly and easily.
(b)
					 Utilize simple, informal, and easily understood procedures.
(c) Inform providers of their right to access the
					 Provider Appeal Process at any time before, during, or after the Provider Problem
					 Resolution Process has begun when the complaint concerns a denied or modified
					 request for MHP payment authorization or the processing or payment of a provider's
					 claim to the MHP and whether accessing the Provider Problem Resolution Process will
					 affect the provider's timelines for accessing the Provider Appeal Process.
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 and repealer and new
						section filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).
Note: Authority cited: Section
						  14680,
						  Welfare and Institutions Code. Reference: Section
						  14684,
						  Welfare and Institutions Code.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 3 - Provider Problem Resolution and Appeal Processes › Section 1850.315 - Provider Appeal Process

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The Provider Appeal Process shall include the
						following:
(a) A provider may appeal a
					 denied or modified request for MHP payment authorization or a dispute with the MHP
					 concerning the processing or payment of a provider's claim to the MHP. The written
					 appeal shall be submitted to the MHP within 90 calendar days of the date of receipt
					 of the non-approval of payment or within 90 calendar days of the MHP's failure to
					 act on the request in accordance with the time frames required by Sections
					 1820.220 or
					 1830.250, or established by the MHP
					 pursuant to Section
					 1830.215.
(b) The MHP shall have 60 calendar days from its
					 receipt of the appeal to inform the provider in writing of the decision, including a
					 statement of the reasons for the decision that addresses each issue raised by the
					 provider, and any action required by the provider to implement the decision.
(1) If the appeal concerns the denial or
					 modification of an MHP payment authorization request, the MHP shall utilize
					 personnel not involved in the initial denial or modification decision to determine
					 the appeal decision.
(2) If the appeal
					 is not granted in full, the provider shall be notified of any right to submit an
					 appeal to the Department pursuant to Section
					 1850.320.
(3) If applicable, the provider shall submit a
					 revised request for MHP payment authorization within 30 calendar days from receipt
					 of the MHP's decision to approve the MHP payment authorization request.
(4) If applicable, the MHP shall have 14 calendar
					 days from the date of receipt of the provider's revised request for MHP payment
					 authorization to submit the documentation to the Medi-Cal fiscal intermediary that
					 is required to process the MHP payment authorization.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 3 - Provider Problem Resolution and Appeal Processes › Section 1850.320 - Provider Appeals to the Department

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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).
(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.
(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) Any documentation supporting
					 allegations of timeliness, if at issue, including fax records, phone records or
					 memos.
(2) Clinical records supporting
					 the existence of medical necessity if at issue.
(3) A summary of reasons why the MHP should have
					 approved the MHP payment authorization.
(4) A contact person(s) name, address and phone
					 number.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 3 - Provider Problem Resolution and Appeal Processes › Section 1850.325 - Provider Appeal Process - Claims Processing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Notwithstanding Sections
						1850.305-1850.320:
(a) A Fee-for-Service/Medi-Cal hospital or a
					 psychiatric nursing facility may file an appeal concerning the processing or payment
					 of its claims for payment for services directly to the fiscal intermediary
					 postmarked or FAXED within 90 calendar days of the date the payment was due. The
					 fiscal intermediary shall have 60 calendar days from the receipt of the appeal to
					 make a determination in writing to the provider.
(b) An MHP may file an appeal concerning the
					 processing or payment of its claim for services paid through the
					 Short-Doyle/Medi-Cal system to the Department postmarked or FAXED within 90 calendar
					 days of the date the payment was due. The Department shall have 60 calendar days
					 from the receipt of the appeal to make a determination in writing to the
					 MHP.
1. New section
						filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).
2. Change
						without regulatory effect amending NOTE filed 7-29-2014 pursuant to section
						100, title 1, California Code of
						Regulations (Register 2014, No. 31).
Note: Authority cited: Sections
						  14680,
						  14700
						  and
						  14718,
						  Welfare and Institutions Code. Reference: Sections
						  14684
						  and
						  14718,
						  Welfare and Institutions Code.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 3 - Provider Problem Resolution and Appeal Processes › Section 1850.350 - MHP/MHP Subcontractor Client Record Review Findings Appeal Process

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) MHP and MHP
					 subcontractor appeals process
(1) The appeal
					 process consists of:
(A) An informal appeal
					 process as specified in section
					 1850.350 (b).
(B) A formal appeal process.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 4 - Resolution of Disputes Between MHPs Regarding MHP of Beneficiary › Section 1850.405 - Arbitration Between MHPs

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Under the
					 following arbitration processes the MHP of the beneficiary may be determined to be
					 different than that specified in the MEDS file.
(b) Any two or more MHPs may develop an
					 arbitration agreement to provide for determining final responsibility for MHP
					 payment authorization as described in Subchapters 2 and 3, beginning with Sections
					 1820.100 and
					 1830.100, respectively, when there is a
					 dispute between the participating MHPs. Each arbitration agreement must:
(1) Provide for the selection of an
					 arbitrator.
(2) Include timelines for
					 filing and resolution.
(3) Include
					 criteria that will serve as a basis for a decision.
(4) Specify that decisions reached under the
					 arbitration process will be final.
(5)
					 Be signed by all participating MHPs or their designees.
(6) Require that all decisions of the arbitrator
					 shall be in writing.
(7) Provide that a
					 copy of each decision shall be forwarded to the affected MHPs within 14 calendar
					 days of the decision.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 4 - Resolution of Disputes Between MHPs Regarding MHP of Beneficiary › Section 1850.415 - Implementation of the Arbitrators' Decision

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
When the arbitrators acting under Section
						1850.405 determine that an MHP is
						responsible for payment for specialty mental health services previously authorized
						by another MHP, the MHP found responsible for payment of services shall perform,
						within 14 calendar days from the date of the arbitrator's decision, any action
						required of the MHP to implement the decision of the arbitration process. The
						Department reserves the right to take action necessary to implement the decision of
						the arbitration process if the MHP found to be responsible fails to comply with the
						decision.
1. New section
						filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).
Note: Authority cited: Section
						  14680,
						  Welfare and Institutions Code. Reference: Sections
						  5777,
						  5778
						  and
						  14684,
						  Welfare and Institutions Code
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 4 - Resolution of Disputes Between MHPs Regarding MHP of Beneficiary › Section 1850.420 - Provision of Medically Necessary Services Pending Resolution of Dispute

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A dispute regarding the MHP of the beneficiary shall not delay
						medically necessary services to beneficiaries. The MHP of the beneficiary as
						identified on the MEDS file shall be responsible for providing or authorizing and
						paying for the service until the dispute is resolved.
1. New section
						filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).
Note: Authority cited: Section
						  14680,
						  Welfare and Institutions Code. Reference: Sections
						  5777,
						  5778
						  and
						  14684,
						  Welfare and Institutions Code.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 5 - Resolution of Disputes Between MHPs and Medi-Cal Managed Care Plans › Section 1850.505 - Requests for Resolution

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(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.
(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.
(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.
(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) 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) History of attempts to resolve the
					 issue.
(3) Justification for the desired
					 remedy.
(4) Documentation regarding the
					 issue.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 5 - Resolution of Disputes Between MHPs and Medi-Cal Managed Care Plans › Section 1850.515 - Department's Responsibility for Review of Disputes

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 Department shall designate at least one and no more than two individuals to review
					 the dispute and make a joint recommendation to the Director of the Department or
					 his/her designee(s).
(b) The
					 recommendation shall be based on a review of the submitted documentation in relation
					 to the statutory, regulatory and contractual obligations of the MHP and the Medi-Cal
					 Managed Care Plan.
(c) The individuals
					 reviewing the dispute may, at their discretion, allow representatives of both the
					 MHP and the Medi-Cal Managed Care Plan an opportunity to present oral
					 argument.
1. New section
						filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).
2. Change
						without regulatory effect amending section heading, subsection (a) and NOTE filed
						8-24-2015 pursuant to section
						100, title 1, California Code of
						Regulations (Register 2015, No. 35).
Note: Authority cited: Sections
						  10725,
						  14680
						  and
						  14700,
						  Welfare and Institutions Code. Reference: Sections
						  14681,
						  14683,
						  14684,
						  14718
						  and
						  14721,
						  Welfare and Institutions Code.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 5 - Resolution of Disputes Between MHPs and Medi-Cal Managed Care Plans › Section 1850.520 - Department's Decision

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 Director of the Department or his/her designee(s) shall issue a written decision to
					 the MHP and the Medi-Cal Managed Care Plan within 30 calendar days:
(1) From the receipt of the documentation
					 requested from the other party, or
(2)
					 From the twenty-first calendar day after the request for documentation, whichever is
					 earlier.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 5 - Resolution of Disputes Between MHPs and Medi-Cal Managed Care Plans › Section 1850.525 - Provision of Medically Necessary Services Pending Resolution of Dispute

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A dispute between an MHP and a Medi-Cal Managed Care Plan
						shall not delay medically necessary specialty mental health services, physical
						health care services, or related prescription drugs and laboratory, radiological, or
						radioisotope services to beneficiaries. Until the dispute is resolved, the following
						shall apply:
(a) The parties may agree to
					 an arrangement satisfactory to both parties regarding how the services under dispute
					 will be provided; or
(b) When the
					 dispute concerns the Medi-Cal Managed Care Plan's contention that the MHP is
					 required to deliver specialty mental health services to a beneficiary either because
					 the beneficiary's condition would not be responsive to physical health care based
					 treatment or because the MHP has incorrectly determined the beneficiary's diagnosis
					 to be a diagnosis not covered by the MHP, the Medi-Cal Managed Care Plan shall
					 manage the care of the beneficiary under the terms of its contract with the State
					 until the dispute is resolved. The MHP shall identify and provide the Medi-Cal
					 managed care plan with the name and telephone number of a psychiatrist or other
					 qualified licensed mental health professional available to provide clinical
					 consultation, including consultation on medications to the Medi-Cal managed care
					 plan provider responsible for the beneficiary's care.
(c) When the dispute concerns the MHP's contention
					 that the Medi-Cal Managed Care Plan is required to deliver physical health care
					 based treatment of a mental illness, or to deliver prescription drugs or laboratory,
					 radiological, or radioisotope services required to diagnose or treat the mental
					 illness, the MHP shall be responsible for providing or arranging and paying for
					 those services to the beneficiary until the dispute is resolved.
1. New section
						filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).
Note: Authority cited: Section
						  14680,
						  Welfare and Institutions Code. Reference: Sections
						  5778,
						  5780,
						  14681,
						  14683
						  and
						  14684,
						  Welfare and Institutions Code.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 5 - Resolution of Disputes Between MHPs and Medi-Cal Managed Care Plans › Section 1850.530 - Financial Liability

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) When the
					 resolution of a dispute under this Article includes a determination that the
					 unsuccessful party in the dispute has a financial liability to the other party for
					 services rendered by the successful party, financial liability and the liquidation
					 of that liability shall follow the criteria of Subsections (b)-(d).
(b) Unless determined otherwise as provided in
					 Subsection (c), financial liability shall not exceed the lower of the following
					 rates, in effect at the time the services were rendered:
(1) The usual and customary charges made to the
					 general public by the provider who rendered the service.
(2) The fee-for-service rates for similar services
					 under the Medi-Cal program. Upon determination of the financial liability, if no
					 final rate has been established for the providers who rendered the services for the
					 period and type of services in question, then the applicable interim rate shall be
					 used for the final determination of financial liability.
California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 5 - Problem Resolution Processes › Article 5 - Resolution of Disputes Between MHPs and Medi-Cal Managed Care Plans › Section 1850.535 - Additional Conditions of the Dispute Resolution Process

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Nothing in
					 this Article shall preclude the Department from taking oversight/corrective actions
					 against its plans.
(b) Nothing in this
					 Article shall preclude a beneficiary from utilizing the MHP's beneficiary problem
					 resolution process or any similar process offered by the Medi-Cal managed care plan
					 or to request a fair hearing. When there is a conflict between a fair hearing
					 decision and a decision by the Department under this Article, the fair hearing
					 decision shall take precedence.
1. New section
						filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).
2. Change
						without regulatory effect amending section and NOTE filed 8-24-2015 pursuant to
						section 100, title 1, California Code of
						Regulations (Register 2015, No. 35).
Note: Authority cited: Sections
						  10725,
						  14680
						  and
						  14700,
						  Welfare and Institutions Code. Reference: Sections
						  14681,
						  14683,
						  14684,
						  14718
						  and
						  14721,
						  Welfare and Institutions Code.