Medi-Cal Program Amends Regulations Regarding Treatment Authorization Requests and Appeals

17 April 2007 Publication
Authors: Judith A. Waltz

Legal News Alert: Health Care

Effective April 1, 2007, the California Department of Health Services (“DHS”) made two significant amendments to the regulations governing Treatment Authorization Requests (“TARs”) and appeals from denied TARs. First, the amendments provide clarification that TARS are to be reviewed only for medical necessity (not, e.g., for timeliness). Second, the amendments replace the current two-level appeal process with a single level of appeal.

Under the Medi-Cal program, providers are required to obtain approval from DHS for many services in order to obtain payment from Medi-Cal. Among the services which require TARs, subject to limited exceptions, are inpatient hospital services, skilled nursing facility and subacute services, adult day healthcare services, and home health services. In order to obtain approval of the service, the provider must submit a TAR and certain supporting documentation to DHS, which reviews the TAR and determines whether the services are medically necessary and should be approved.

Clarification That TARs Are To Be Reviewed For Medical Necessity Only
The first significant change made by DHS in the revised regulations is to clarify that TARs are reviewed for medical necessity only. Prior to 2000, TARs generally had to be submitted in advance of the service or within a limited number of days following provision of the service. In 2000, the California Legislature amended the Welfare and Institutions Code to remove these timeliness requirements for the submission of TARs, and provided that DHS may only review TARs for medical necessity. 

DHS has now amended the regulations to conform to the legislative change made in 2000. Thus, TARs do not need to be submitted in advance of the service. DHS will not deny TARs on the basis of timeliness, but will review them for medical necessity only.

Implementation Of A Single-Level Administrative Appeal Process
The second significant change made by DHS was to revise the appeal process that providers may utilize to contest the denial of a TAR. The regulations previously provided for a two-step administrative appeal process, with the first level of appeal to the appropriate Medi-Cal Field Office and the second level of appeal to the Medi-Cal Field Services Headquarters in Sacramento. DHS has amended the regulations to provide a single level of appeal, which is to the Medi-Cal Operations Division Headquarters in Sacramento. This appeal must be filed within 180 calendar days from the date a decision on the TAR is made by DHS.

DHS has clarified that any appeals that were adjudicated prior to April 1, 2007 will continue to be processed according to the previous two-level administrative appeal process. For TARs that were originally adjudicated on or after April 1, 2007, there will be a single level of appeal to the Medi-Cal Operations Division Headquarters in Sacramento.

If the provider is not satisfied with DHS’ final decision in the TAR appeal, it may seek judicial review through a petition for writ of mandate.

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