Section 1850.315 - Provider Appeal ProcessThe 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.(c) If an MHP does not respond within 60 calendar days to the appeal, the appeal shall be considered denied in full by the MHP.Cal. Code Regs. Tit. 9, § 1850.315
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.
1. New section filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).