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

Universal Citation: 9 CA Code of Regs 1850.210

Current through Register 2024 Notice Reg. No. 38, September 20, 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.

(b) A Notice of Action is required when the MHP denies or modifies an MHP payment authorization request from a provider for a specialty mental health service that has already been provided to the beneficiary when the denial or modification is a result of post-service, prepayment determination by the MHP that the service was not medically necessary or otherwise was not a service covered by the MHP.

(c) The MHP shall deny the MHP payment authorization request and provide the beneficiary of the MHP with a Notice of Action when the MHP does not have sufficient information to approve or modify, or deny on the merits, an MHP payment authorization request from a provider within the timeframes required by Sections 1820.220 or 1830.215.

(d) The MHP shall provide the beneficiary of the MHP with a Notice of Action if the MHP fails to notify the affected parties of a grievance decision within 60 calendar days, an appeal decision within 45 days, or an expedited appeal decision within three working days. If the timeframe for a grievance, appeal or expedited appeal decision is extended pursuant to Sections 1850.206, 1850.207 or 1850.208 respectively, the MHP shall provide a beneficiary of the MHP with a Notice of Action if the MHP fails to notify the affected parties of the grievance, appeal or expedited appeal decision within the extension period.

(e) The MHP shall provide a beneficiary of the MHP with a Notice of Action if the MHP fails to provide a specialty mental health service covered by the MHP within the timeframe for delivery of the service established by the MHP.

(f) The MHP shall comply with the requirements of Section 1850.212 regarding the content of Notices of Action and with the following timeframes for mailing of Notices of Action:

(1) The written Notice of Action issued pursuant to Subsections (a) or (b) shall be deposited with the United States postal service in time for pick-up no later than the third working day after the action, except that a Notice of Action issued pursuant to Subsection (a)(1) shall be provided in accordance with the applicable timelines of Title 22, Section 51014.1.

(2) The written Notice of Action issued pursuant to Subsections (c) or (d) shall be deposited with the United States Postal Service in time for pick-up on the date that the applicable timeframe expires.

(3) The written Notice of Action issued pursuant to Subsection (e) shall be deposited with the United States Postal Service in time for pick up on the date that the timeframe for delivery of the service established by the MHP expires.

(g) When a Notice of Action would not be required under Subsections (a), (b), or (c), the MHP shall provide a beneficiary of the MHP with Notice of Action under this Subsection when the MHP or its providers determine that the medical necessity criteria in Section 1830.205(b)(1), (b)(2), (b)(3)(C) or 1830.210(a) have not been met and that the beneficiary is, therefore, not entitled to any specialty mental health services from the MHP. A Notice of Action pursuant to this Subsection is not required when a provider, including the MHP acting as a provider, determines that a beneficiary does not qualify for a specific service covered by the MHP, including but not limited to crisis intervention, crisis stabilization, crisis residential treatment services, psychiatric inpatient hospital services, or any specialty mental health service to treat a beneficiary's urgent condition, provided that the determination does not apply to any other specialty mental health service covered by the MHP. The Notice of Action under this Subsection, shall, at the election of the MHP, be hand delivered to the beneficiary on the date of the action or mailed to the beneficiary in accordance with Subsection (f)(1) and shall specify the information contained in Section 1850.212(b).

(h) For the purpose of this Section, each reference to a Medi-Cal managed care plan in Title 22, Section 51014.1, shall mean the MHP.

(i) For the purposes of this Section, "medical service" as cited in Title 22, Section 51014.1, shall mean specialty mental health services that are subject to prior authorization by an MHP pursuant to Subchapters 2 and 3, beginning with Sections 1820.100 and 1830.100, respectively.

(j) The MHP shall retain copies of all Notices of Action issued to beneficiaries under this Section in a centralized file accessible to the Departmen and other appropriate oversight entities as specified in the contract between the Department and the MHP.

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 2 heading and repealer and new section filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).
8. Change without regulatory effect amending subsection (j) 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: Section 14684, Welfare and Institutions Code; and 42 CFR Part 438, Sections 438.210 and 438.404.

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