(a) A provider of services may appeal the decision of a Medi-Cal consultant regarding a Treatment Authorization Request (TAR), as follows:(1) The provider shall submit a TAR appeal within 180 calendar days from the date of the decision on the original TAR.(2) When the last day of the 180 calendar day appeal period falls on a Saturday, Sunday or Holiday, the final date to submit the TAR appeal will be the next business day.(b) The TAR appeal, regardless of submission method, shall include: (1) The original TAR number and service type requested,(2) The date(s) or service(s) in dispute,(3) The reason the appeal should be granted, and(4) Any additional documentation that a provider chooses to submit that supports the basis for the conclusion that the services are medically necessary.(c) An eTAR appeal shall: (1) Be submitted through the Medi-Cal eTAR web portal system.(2) Include the special handling indicator found in the Medi-Cal eTAR web portal system that indicates that the submission is an electronic appeal.(d) A provider may submit a paper TAR appeal when there is a disruption in the Medi-Cal eTAR web portal system that delays the provider from submitting the TAR appeal for more than 72 consecutive hours; and the Department has directed the provider to submit a paper TAR appeal.(e) A provider who submitted a paper TAR based on the Department's consideration of the provider's capacity to submit an eTAR, as described in Section 51002.5(a), may submit a paper TAR appeal.(f) A paper TAR appeal shall:(1) Include a new, completed TAR for the services appealed; and(2) Be submitted to the Department; and either(3) Be post marked by the United States Postal Service; or(4) Be personally delivered to the Department and date stamped upon receipt; or(5) Be labeled with the date deposited with a common carrier for delivery to the Department.(g)(1) The Department shall review an eTAR appeal and enter the appeal decision and the basis for that decision into the Medi-Cal eTAR web portal system.(2) The Department shall review a paper TAR appeal and:(A) Enter the appeal decision and the basis for that decision into the Medi-Cal eTAR web portal system; and(B) Send the appeal decision and the basis for that decision to the provider.(h) When the appeal decision is based on a review of documented medical necessity: (1) For an eTAR appeal, the decision shall be entered into the Medi-Cal eTAR web portal system within 180 calendar days from the date that the eTAR appeal was submitted through the Medi-Cal eTAR web portal system.(2) For a paper TAR appeal, the decision shall be entered into the Medi-Cal eTAR web portal system and sent to the provider within 180 calendar days from the date that the paper TAR appeal was received by the Department.(i) When the appeal decision is a denial based on failure to submit the appeal within 180 calendar days from the date of the decision on the original TAR:(1) For an eTAR appeal, the decision shall be entered into the Medi-Cal eTAR web portal system within 60 calendar days from the date that the eTAR appeal was submitted through the Medi-Cal eTAR web portal system.(2) For a paper TAR appeal, the decision shall be entered into the Medi-Cal eTAR web portal system and sent to the provider within 60 calendar days from the date that the paper TAR appeal was received by the Department.(j) If a provider is not satisfied with the appeal decision, the provider may seek a judicial remedy pursuant to Section 1085 of the Code of Civil Procedure.Cal. Code Regs. Tit. 22, § 51003.1
1. New section filed 4-14-93 as an emergency; operative 4-14-93. Submitted to OAL for printing only pursuant to section 8, AB 1773 (Chapter 939, Statutes of 1992) (Register 93, No. 16).
2. Renumbering of former section 51003.1 to section 51003.3 and new section 51003.1 filed 2-22-2007; operative 3-24-2007 (Register 2007, No. 8).
3. Repealer and new section and amendment of NOTE filed 12-13-2018; operative 4-1-2019 (Register 2018, No. 50). Note: Authority cited: Sections 10725, 14105, 14124.5, 14132.22, 14132.5, 14133, 14133.01 and 14133.05, Welfare and Institutions Code; and Sections 20 and 1267.7, Health and Safety Code. Reference: Sections 14053, 14064, 14081, 14087, 14088, 14088.16, 14088.2, 14103.6, 14105.12, 14132, 14132.22, 14132.25, 14132.5, 14132.42, 14132.8, 14133, 14133.01, 14133.05, 14133.1, 14133.25 and 14133.3, Welfare and Institutions Code; Jeneski v. Meyers (1984) 163 Cal. App. 3d 18, 209 Cal. Rptr. 178; Duran v. Belshe, San Diego County Superior Court Case No. 674204, (1995); and Fresno Community Hospital and Medical Center v. State of California, et al., Fresno County, Superior Court Case No. 555694-9, (1996).
1. New section filed 4-14-93 as an emergency; operative 4-14-93. Submitted to OAL for printing only pursuant to section 8, AB 1773 (Chapter 939, Statutes of 1992) (Register 93, No. 16).
2. Renumbering of former section 51003.1 to section 51003.3 and new section 51003.1 filed 2-22-2007; operative 3-24-2007 (Register 2007, No. 8).
3. Repealer and new section and amendment of Note filed 12-13-2018; operative 4/1/2019 (Register 2018, No. 50).