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ERISA defines a denial as an adverse determination related to the following:

  • Failure to provide or make payment (in whole or part) for benefits including any denial, reduction, termination.
  • Failure to provide or make payment that is based on a determination of a member’s eligibility to participate in a plan.
  • Includes a denial, reduction, termination of, or failure to provide or make payment (in whole or part) for a benefit resulting from application of any utilization review.
  • Failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or Investigational, or not necessary or appropriate.
  1. Decision Making Process

No individual, other than a licensed physician or a licensed healthcare professional who is competent to evaluate the specific clinical issues involved in the healthcare services requested by the provider, may deny or modify requests for authorization of healthcare services for an enrollee for reasons of medical necessity. The decision of the physician or other healthcare professional shall be communicated to the provider and the enrollee. If the healthcare service plan requests medical information from providers in order to determine whether to approve, modify, or deny requests for authorization, the plan shall request only the information reasonably necessary to make the determination.

  • Only California licensed physicians are to evaluate specific clinical issues may deny or modify requests for service based on medical necessity.
  • Behavioral Health care practitioners are available to review cases pertaining to their specialty.
  • Only a psychiatrist, doctoral-level clinical psychologist or certified addiction medicine specialist may deny or modify request for behavioral health care services based on medical necessity.
  • Consultation will be with an appropriate behavioral health practitioner or use of behavioral health UR criteria prior to denial.
  • SCMC to assure that only the Medical Director and/or physician member of the UM Committee may make a medical necessity denial determination.
  • SCMC is responsible classifying and documenting denials appropriately for medical and non-medical necessity denials.


  • A licensed physician will do a review of any denial for medical necessity.
  • A physician, dentist, vision, or pharmacist, as appropriate, reviews any non-behavioral health denial of care based on medical necessity.
  • A physician or a chiropractor may review denial files for chiropractic services.
  • A physician or a physical therapist reviews physical therapy denials.
  • A physician or a dentist may review denial for dental procedures.
  • A physician or a pharmacist may review denial files for pharmaceutical services.
  • Appropriate behavioral health practitioner or pharmacist, as appropriate, reviews any behavioral health denial of care based on medical necessity.
  • A doctoral level clinical psychologist or certified addiction-medicine specialists may review behavioral health denials.
  1. Initial Practitioner Notification of Denials
  • Physician reviewer will be available by phone to physicians to discuss determinations.
  • Written communication to the referring physician or other healthcare provider must include the name and phone number of the health care professional responsible for the denial, delay, or modification.
  • For delay notifications, the notification will contain a description of the criteria or guideline used including a citation of the specific regulations or plan authorization procedures supporting the action and the clinical reason for the decisions regarding medical necessity and when the enrollee can expect a decision.
  • Practitioners shall be notified by telephone of all denials that pertain to the members they are treating (e.g., a Surgeon must be notified that his/her member had a surgical procedure denied, even if the service had to be requested by the primary care Physician). Notification will be documented in PCM (Patient Chart Manager (HMO authorization Log) with date and time that the practitioner was notified that a physician or other reviewer is available to discuss the denial.
  • The treating providers can readily access SCMC’s Medical Director by phone at 818-504-4750, Monday through Friday 8:30am to 5:00 pm and afterhours for peer to peer reviews regarding adverse decisions. Turnaround time for Medical Director to contact treating provider is 48 hours. Each request for a peer to peer is documented and monitored for completion.

Denials, Deferrals, Modifications, and Termination Letters

  1. Will be issued appropriately and include instructions on how to file an appeal that is in compliance with all regulatory requirements.
    1. SCMC shall provide required notification to beneficiaries and representatives in accordance with the timeframes set forth in Title 22, CCR, Sections 51014.1 and 53894. Such notice shall be deposited with the United States Postal Service in time for pick-up no later than the third working day after the decision is made, not to exceed 14 calendar days from receipt of the original request for Medi-Cal and 30 days for Healthy Families/Healthy Kids

Per Title 22, notice of denial is not required if the denial is a denial of a request for prior authorization for coverage for treatment that has already been provided to the patient

  1. SCMC will follow CMS regulations for timeliness of notifications for Medicare members.
  2. SCMC prohibits the use of verbal denials and other intangible methods of documenting physician reviews of authorization request.
  3. SCMC will ensure that the member and provider notifications of prior authorizations decisions are in adherence with written notification standards.
  4. Deferrals: Medi-Cal requests maybe deferred for up to – 14 days (from SCMCs receipt of the request for prior authorization) to allow the provider time to submit additional information requested by SCMC and to allow time for SCMC to decide. If, after 28 days from SCMC receipt of the request for prior authorization, the provider has not complied with SCMC’s request for additional information, SCMC shall provide the patient notice of denial. If within – 14-day period, the provider does comply, SCMC shall take appropriate action on the request for prior authorization as supplemented by the additional information, including providing any notice to the patient. (Health Net).
    1. It is up to the health plan to notify SCMC. if they are adopting the 14/14-day rule for deferrals.
  5. Pended: If SCMC cannot make a determination for non-urgent prospective or continued stay reviews within the required time frames due to not receiving all of the requested necessary information, then SCMC will immediately notify the health care provider and the covered person in writing. Notification will be sent upon the expiration of the required five (5) business days’ time frame or as soon as SCMC becomes aware that they will not be able to meet the required five (5) business days’ time frame, whichever occurs first. The notification must specify the information requested, but not received, and the anticipated date on which a prospective or continued stay review determination may be rendered. Upon receipt of all necessary information, SCMC will render a prospective or continued stay review determination within the required five (5) business days’ time frames.
    1. Notifications sent to members and Practitioners include:
  1. Information was requested but not received
  2. Consultation by an expert reviewer is required
  3. Additional examinations or test are required
  4. Time Frame for submitting the information
  5. Expected date of decisions
  6. Type of expert reviewer required, if applicable
  7. Modification: Services requested may be modified without sending a modification notice only in the following situations:
  • Modification of request for durable medical equipment if the substituted equipment can perform all medically significant functions that would have been performed by the requested equipment.
  • Modification of the duration of any approved therapy or length of stay in an acute facility if SCMC provides an opportunity for the provider to request additional therapy or inpatient days before the end of the approved duration of therapy or length of stay.
  1. Terminations: Action to terminate or reduce the level of treatment or service currently being received. SCMC shall notify members’ notice of action taken to terminate a treatment regimen already in place. In the case of concurrent review, care shall not be discontinued until the enrollee’s treating provider had been notified of the plan’s decision, and a care plan has been agreed upon by the treating provider that is appropriate for the medical needs of that patient.

Serra will verify the member’s preferred language prior to issuing the NOA’s in the appropriate preferred language. Serra will verify if the member has requested an alternative format prior to issuing the NOA’s in the appropriate format.

Translation of Written Materials and Alternative Format– SCMC has a process to translate member materials into county specific threshold languages or alternative format. Translation assistance and alternative format is available for all denials, deferrals, modification and termination letters. Enrollees preferred language/requested alternative format will be verified prior to issuing an NOA in the appropriate preferred language/requested alternative format.

The threshold languages for LA County are:

  • Arabic
  • Armenian
  • Cambodian
  • Cantonese
  • Chinese
  • Farsi
  • Korean
  • Mandarin
  • Russian
  • Spanish
  • Tagalog
  • Vietnamese
  1. Health Plan address & telephone number for obtaining information on legal service organizations for representation.
  2. Non-Discrimination Notice

Member notification is required within 2 working days of making the decision. If there is a request for additional information, then the decision must be made within 5 days not to exceed 14th calendar days. If the requested information is not received by the 14th calendar day, an NOA denial letter is issued, and the member is to be notified on that day.

  • Urgent Denials: Member and provider are notified within 24 hours by phone and a denial letter is mailed out within 24 hours.

SCMC will specify utilization review criteria (a description/explanation of the criteria or guidelines used).

Alternative treatment plan (requires only for modification of request that were not approved as initially requested. (Industry Collaborative Effort (ICE) recommends that ER denial letters should indicate that care could have been provided at an urgent care setting or during office hours.

  • Appeal rights and Independent Medical Review (IMR) information (An explanation of appeal process including the opportunity to request IMR in cases where member believes that health care services have been improperly denied or modified. Urgent and concurrent denial notification shall include additional information regarding expedited appeal rights.
  • For urgent care situations, expedited external review may occur at the same time as the internal appeal process. SCMC may discontinue the internal appeal for all member request that were addressed by the external review if it is not required to continue the internal appeal process under state law. (SCMC continues the internal appeal process for the components of the request that are not addressed in the external review).
  • Member may request an independent, external review for any referral that is denied, modified or delayed because of lack of medical necessity.
  • SCMC will provide any relevant medical information such as the member’s medical condition, health care service being provided. The confidentiality of all medical records information shall be maintained pursuant to applicable state and federal laws.

Additional Notification Requirements

  • Member’s right to call the State Medi-Cal Managed Care Ombudsman Office for answering questions or help in appealing the decision.
  • Member’s right to, and method of obtaining, a fair hearing to contest the denial, deferral, or modification action and the decision SCMC has made.
  • Member’s right to represent himself/herself at the fair hearing or to be represented by legal counsel, friend, or another spokesperson.
  • Name and address of SCMC and State toll-free telephone number for obtaining information on legal service organization for representation.
  • Member’s right to appeal within at least 90 days to appeal the decision through the health plan’s grievance/appeal process.
  • Member’s right to appeal to the Department of Managed Health Care (DMHC) if not satisfied with the appeal decision at the Plan Level.

Rescinding or Modifying an Authorization– AB 1455 requirement – Prohibit the UM organization from rescinding or modifying an authorization once services have been rendered by the provider.

AB 1324 Serra Community Clinic will identify and manage open authorizations and ensure that the provider’s claims are paid appropriately for services provided in good faith when an authorization has been given, but the member is later determined to have been ineligible at the time of service.

Terminal Illness

Denial of coverage to an enrollee with a terminal illness for treatment, services or supplies deemed experimental, as recommended by a participating plan provider. (Terminal illness refers to an incurable or irreversible condition that has a high probability of causing death within one year or less). The following information shall be provided to the enrollee within five business days.

  • A statement with the specific medical and scientific reasons for denying coverage
  • A description of alternative treatment, services, or supplies covered by the plan, if any.
  • Copies of the plan’s grievance procedures or complaint form, or both. The complaint for should provide an opportunity for the enrollee to request a conference as a part of the plan’s grievance procedures. Upon receiving a complaint form requesting a conference, the plan shall provide the enrollee,
  • Conference within 30 days, an opportunity to attend a conference, to review the information provided to the enrollee. The conference shall be conducted by a plan representative having authority to determine the disposition of the complaint. The plan shall allow attendance, in person, at the conference, by an enrollee, a designee of the enrollee, or both, or, if the enrollee is a minor or incompetent, the patent, guardian, or conservator of the enrollee, as appropriate.
  • Conference within 5 days-If the treating participating physician determines, after consultation with the health plan medical Director or his or her designee, based on standard medical practice, that the effectiveness of either the proposed treatment, services, or supplies or any alternative treatment, services, or supplies covered by the plan, would be materially reduced if not provided at the earliest possible date.
  • Nothing in this section shall limit the responsibilities, rights, or authority.

Department of Managed Care (DMHC) information

Contact numbers shall be in a 12-font bold face type and include:

Toll-free telephone number: 1-888-HMO-2219

Hearing and speech impaired telephone number: 1-877-688-9891

California Relay Service telephone numbers: 1-800-735-2929 \(TTY) or 1-888-877-5378 (TTY)

Internet website:

  • Non-Discrimination Notice-Notice informing individuals and nondiscrimination and accessibility requirements.
  • Multi Language letter (LAP Notice of Translation)- ICE DMHC Notice of translation

Translation of Written Materials and Alternative Format– SCMC has a process to translate member materials into county specific threshold languages or alternative format. Translation assistance and alternative format is available for all denials, deferrals, modification and termination letters. Enrollees preferred language/requested alternative format will be verified prior to issuing an NOA in the appropriate preferred language/requested alternative format.

Instructions for filing grievance against health plan

ERISA Rights Statement – “If your group health plan is subject to the Employee Retirement Income Security Act (ERISA), you may be entitled to additional rights. Please consult with your plan administrator to determine if your plan is governed by ERISA

  • Statement of right to bring civil action when all required reviews of the request including the appeal process, has been completed and there is still disagreement with the outcome of the resolution.
  • Statement of right to request, free of charge, copies of all documents, records and other information relevant to the request for benefits.
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