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“HOW TO CHALLENGE MEDI-CAL MANAGED CARE AND
CCS NON-PANELED ER DENIALS”
DISCLAIMER: The intent of this program is to present accurate and authoritative information in regard to the subject matter covered. It is presented with the understanding that ERN/NCRA is not engaged in the rendition of legal advice. If legal advice or other expert assistance is required, you should seek the counsel of an attorney with the expertise in the area of inquiry.
“The significant problems we face today
cannot be solved at the same level of thinking
we were at when we created them.”
- Albert Einstein.”
Under existing California law, (b) it is the public policy of the State of California that a health care practitioner be encouraged to advocate for appropriate health care for his or her patients. For purposes of this section, "to advocate for appropriate health care" means to appeal a payer's decision to deny payment for a service pursuant to the reasonable grievance or appeal procedure established by a medical group, independent practice association, preferred provider organization, foundation, hospital medical staff and governing body, or payer…
…or to protest a decision, policy, or practice that the health care practitioner, consistent with that degree of learning and skill ordinarily possessed by reputable health care practitioners with the same license or certification and practicing according to the applicable legal standard of care, reasonably believes impairs the health care practitioner's ability to provide appropriate health care to his or her patients (Business and Professions Code § 510.)
California Children’s Services (“CCS”) is a statewide program that treats children with certain physical limitations and chronic health conditions or diseases.
CCS provides diagnostic and treatment services, medical case management, and physical and occupational therapy services to children under the age of 21 with CCS eligible conditions.
Per Insurance Code Sections 12693.62, 12693.64 and 12693.66: Services authorized by the CCS program are excluded from the plan’s responsibilities. These services are carved out of Medi-Cal Managed Care. The CCS program is under the jurisdiction of the California Department of Health Services.
HOW DO YOU DETERMINE IF A MEDI-CAL BENEFICIARY IS A CCS PATIENT WITH A CCS ELIGIBLE CONDITION?
In order to qualify families MUST:
Complete an application form and return it to their county CCS office
Give CCS all of information requested so CCS can determine if the family qualifies
Apply to Medi-Cal if CCS believes the family’s income qualifies them for the Medi-Cal program.
Per 22 CCR §41515.1:
Medical eligibility for the CCS program, as specified in Sections 41515.2 through 41518.9 shall be determined BY THE CCS PROGRAM MEDICAL CONSULTANT OR DESIGNEE through the review of medical records that document the applicant’s medical history, results of a physical examination by a physician, laboratory test results, radiologic findings, or other tests or examinations that support the diagnosis of the eligible condition (Emphasis added.)
Welfare and Institutions Code § 14103.6:
The consultants shall render decisions on prior authorization requests in a timely manner. A timely manner shall be deemed to be an average of five working days after the prior authorization request is received by the department. A decision shall be an approval, denial, modification, or request for additional information. A supplemental authorization request submitted with additional information requested by a consultant shall be processed in a timely manner as if it were an original authorization request. If no decision on a prior authorization request is rendered by the consultant within 30 days of receipt by the department, the request shall be deemed to be approved (Emphasis added.)
Patient comes into ER.
Patient is stabilized, but cannot be safely discharged and needs to be admitted for post-stabilization services.
*YOUR RESPONSIBILITIES:
1) Seek to obtain the name and contact information of the patient’s health care service plan and document your attempts to ascertain this information pursuant to Health and Safety Code § 1262.8 (b)(1-2) OR 1371.4 (j.)
2) If the patient has Medi-Cal Managed Care Plan (MCP) coverage, contact the MCP for authorization if identification was made as required above.
3) Contact is made by either following the instructions on the patient’s health care service plan member card or using the contact information provided by the plan to the DMHC or hospital (See Health and Safety Code § 1262.8 (j)(k.)
4) A representative of the hospital is only required to make more than one telephone call to health care service plan, or its contracting medical provider (Health and Safety Code § 1262.8 (j)(k.)
At which time, the MCP either:
Gives you authorization
Denies authorization, but fails to transfer the patient (if so, post-stabilization is statutorily deemed authorized – See Health and Safety Code § 1262.8 (d) and 1371.4 (j).)
Fails to either authorize or arrange for the prompt transfer of the patient within 30 minutes of being contacted (also deeming the service statutorily authorized as set forth above.)
Patient is discharged without any disapproval from the MCP
You submit your claim to the MCP
The MCP denies the claim because: “Services are CCS eligible” OR
“CCS eligible condition/ hospital is non-paneled”
We are looking for CCS emergency and poststabilization denials because the provider is not paneled; specifically when the plan waited until patient discharge to request a CCS review.
1. Did the patient’s eligibility show they are a CCS patient with a “CCS eligible condition”?
If no
Go to Question 2
If yes Hospitals should refer patients under the age of 21 that may have a CCS-eligible condition (listed
in Sections 41515.2 through 41518.9 of Title 22 of the California Code of Regulations) to the county CCS office so that CCS can make the determination as to whether or not the patient’s condition is CCS-eligible.
Just because the patient has a condition that is included on the list of CCS-eligible conditions does not mean that it is in fact a CCS-eligible condition. CCS is the only one that can make this determination.
2. Did the MCP refer their member to CCS prior to discharge?
If no MCP remains responsible for providing services and case management for the patient. The MCP’s
responsibility for providing all covered medically necessary health care and case management changes at the time that CCS eligibility is determined by the CCS program. (See DHCS’s website and MMCD Policy Letter No 96-10)
MCPs must comply with Health and Safety Codes
If services were authorized/statutorily authorized, and case management did not change while the patient was in-house, the MCP must pay the claim.
Plans have the responsibility to develop and implement procedures to ensure the timely referral of children with CCS eligible conditions to the county CCS program (MMCD Policy Letter No 96-10.)
PAYORS CANNOT DENY PAYMENT FOR POST-STABILIZATION SERVICES THAT WERE STATUTORILY AUTHORIZED WHEN:
THEY WERE NOTIFIED THAT THE PATIENT REQUIRED POST-STABILIZATION TREATMENT
THEY ISSUED A REFERENCE NUMBER AND
THEY FAILED TO NOTIFY THE PROVIDER OF CCS ELIGIBILITY OR ANY DISAPPROVAL PRIOR TO THE COMMENCEMENT OF THE DELIVERY OF POST-STABILIZATION CARE OR DURING THE COMMENCEMENT OF SAID CARE.
Legislative Authority The CCS program is mandated by the Welfare and Institutions Code and the California Code of Regulations (Title 22, Section 51013) to act as an “agent of Medi-Cal” for Medi-Cal beneficiaries with CCS medically eligible conditions. Medi-Cal (and its MCP) is required to refer all CCS-eligible clients to CCS for case management services and authorization for treatment. The statute also requires all CCS applicants who may be eligible for the Medi-Cal program to apply for Medi-Cal. Source: http://www.dhcs.ca.gov/services/ccs/Pages/ProgramOverview.aspx
MCPs must continue to provide case management of all services until eligibility has been established with the CCS program (MMCD Policy Letter 96-10.)
Case management for the Medi-Cal eligible population includes:
The determination of medical eligibility
The determination of the most appropriate provider(s) to provide care
The authorization of medically necessary services and
Linkage and coordination of the child’s care with the authorized provider(s) and agencies in the community. (Numbered Letter 10-1096) (*THIS CANNOT TAKE PLACE IF THE PATIENT HAS ALREADY BEEN DISCHARGED.)
Plans shall ensure that providers are informed of CCS paneled providers and approved hospitals within the plan’s network to ensure continuity of care during the time it takes to determine eligibility. (MMCD Policy Letter 96-10.)
If the MCP referred their member to CCS prior to discharge: Go to Question 3
3. Did CCS determine the patient has a CCS eligible condition?
CCS determined patient does not have a CCS eligible condition: The MCP is still responsible for children referred to but not determined to be eligible for the CCS program
CCS determined the patient’s medical condition is CCS eligible: CCS assumes case management responsibility of the CCS eligible condition
CCS authorizes medically necessary care to be reimbursed on a fee for service basis by the Medi-Cal program
Go to Question 4
CCS program has the sole authority to make CCS program eligibility decisions, NOT MCP’s. (MMCD Policy Letter No. 96-10)
4. Is your facility CCS paneled?
Yes Contact CCS for approval. If it is for emergency services, you must contact CCS by the next business day.
No CCS receives requests for authorization of acute emergency services related to trauma from physician
providers and hospital facilities that do not have CCS approval but may be the nearest facility or provider to the client at the time of trauma. (Numbered Letter No 10-0806)
CCS CANNOT DENY SERVICES IF THE PATIENT WAS NOT STABLE FOR TRANSFER OR THERE WERE NO AVAILABLE BEDS AT THE OTHER FACILITY.
DHCS Policies have consistently required (See NL: 03-0206) that the infant’s life will not be endangered by the transport for surgery to a hospital that is CCS approved and that there is a bed available
The Path to Righteousness: Non-Paneled CCS ER Denials
presents
When a patient is admitted, ask these questions:
Did the patient show a “CCS Eligible” condition?
Did the MCP refer their member to CCS prior to discharge?
Did CCS determine that the patient is not CCS eligible?
Refer patients under 21 that may have a CCS-eligible to the county CCS office (they will decide if they are CCS-eligible).
(CCR § 41515.2 through 41518.9)
MCP remains responsible for providing services and case management for the patient.
(MCP’s responsibility for providing medically necessary health care and case management only changes when CCS eligibility is determined by the CCS program.)
(MMCD Policy Letter No 96-10)
CCS assumes case management responsibility of the CCS eligible condition and authorizes medically necessary care to be reimbursed on a fee for service basis by the Medi-Cal program.
The MCP is still responsible for children referred to but not determined to be eligible for the CCS program. (MMCD Policy Letter No 96-10)
*MCP = Managed Care Plan
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Is your facility CCS paneled? 4.
Contact CCS for approval. If it is for emergency services, you must contact CCS by the next business day.
CCS receives requests for authorization of acute emergency services related to trauma from physician providers and hospital facilities that do not have CCS approval but may be the nearest facility or provider to the client at the time of trauma.
(Numbered Letter No 10-0806)
Infographic Resource:
Remember, CCS cannot tell you they are not authorizing services simply because you are not CCS paneled.
But you must document daily efforts to transfer the child.
WELFARE AND INSTITUTIONS CODE § 14104.3 (3):
“Bills for service under this chapter shall be reviewed and rejected or processed for payment within an average of 18 days from receipt of evidence establishing validity of the bill for payment in the office of the contractor……Ninety percent of all bills submitted to the contractor and under the contractor's control, as set forth in the request for proposal, shall be processed and paid in 30 days and 99 percent of all claims submitted to the contractor and under the contractor's control, as set forth in the request for proposal, shall be processed and paid in 90 days……If it is determined by the contractor that additional evidence of validity is required, the evidence shall be requested within 18 days from the date the bill is received by the contractor. In any event, notice shall be given within 30 days from the date the bill is received concerning the status of the bill submitted if the bill is held for peer review by the contractor beyond 18 days……In no event, shall the number of bills not processed for payment within 30 days of receipt exceed 9 percent of the total bills inventory.”
(For MCP claims, see Health and Safety Code §1371.35)
When you use administrative laws in the revenue and appeal cycle:
You strengthen California’s healthcare delivery system
You defend public health and safety
You protect our emergency safety net.
Together, we will build an enforcement program in the State of California that works.
Patient Advocacy Hotline:
(714)995-6900 Ext 6921
Email: [email protected]
Claim Representation Helpdesk:
(714)995-6900 Ext 6935
Email: [email protected]
Member Services Helpdesk:
(714)995-6900 Ext 6913
Email: [email protected] Call us to report unfair payment practices or concurrent denials of
medically necessary care.
Key Contacts
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QUESTIONS? NEED MORE INFORMATION?
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ERN/NCRA/TRAF
5856 Corporate Ave. #110
Cypress, CA 90630
(714) 995-6900 ext. 6926
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