Healthcare Services

Process for reviewing requests received by Healthcare services for Medi-Cal and Mental Health Services

  1. CHG confirms you are a member.
  2. CHG reviews the request to see if it needs an approval.  Items listed below don’t need an approval.
    1. Emergency care.
    2. Urgent care.
    3. Services labelled as “sensitive” and/or “freedom of choice” by the Medi-Cal program. These services include:
      • Family planning
      • Sexually transmitted disease (STD)
      • Abortion
      • HIV testing
      • Routine OB/GYN services and basic prenatal care through network providers
      • Preventive care
      • Out-of-Area renal dialysis services

What CHG will do:

  1. CHG will review the urgency of the request. CHG reviews urgent requests within 72 hours. It reviews routine ones within 5 working days for Medi-Cal members & 14 calendar days for CMC members.
  2. A referral specialist will first review the request. If the referral specialist is able to make a decision with the notes sent, they will process the request. If not, they will send the request to a nurse for review.
  3.  A nurse will review the request and medical notes sent by your doctor to make a decision. If the nurse sees that the notes do not have the information that justifies the request, they will send your request to our doctor for review.
  4. A referral specialist will not process requests that are not complete.
  5. CHG uses the following member information to reach a decision:
    1. Your health condition (Diagnosis)
    2. Severity
    3. Treatment tried, failed, or not recommended (contraindicated)
    4. Age
    5. Other health conditions you may have
    6. Complications
    7. Progress of treatment
    8. Your emotional and social situation
    9. Your home environment, when appropriate
    10. How urgent the condition is
    11. Benefit structure
  6. CHG also uses its provider network and practice standards to reach a decision.
  7. For members enrolled in CHG’s Medi-Cal plan, CHG applies established Medi-Cal guidelines before any others.
  8. CHG applies current California Children Services (CCS) referral guidelines when appropriate for requests for services for children and young adults under 21 years of age enrolled in Medi-Cal.
  9. If the member has primary Medicare coverage, CHG applies appropriate Medicare guidelines.
  10. If the request is for behavioral health services, CHG applies MCG (Milliman Care Guidelines).  Where –MCG criteria does not exist, CHG will apply guidelines it develops.
  11. After applying the criteria that is specific to your plan, CHG applies MCG criteria.
  12. CHG applies its disease management protocols before benefit coverage or MCG criteria, when available.
  13. If there aren’t any applicable, plan-specific, MCG criteria, CHG may use the following to decide if something is medically necessary:
    1. Criteria developed and agreed upon by peers (doctors who practice in the same field)
    2. Standard quality markers (such as those developed by the National Committee for Quality Assurance (NCQA) or the Health Plan and Employer Data and Information Set (HEDIS))
    3. American Medical Association (AMA) specialty guidelines and state or county medical association guidelines
    4. Length of Stay (LOS) by Diagnosis and Operation, United States (developed by HCIA, Inc.)
    5. Governmental agencies, such as Centers for Disease Control, Food and Drug Administration, Agency for Healthcare Research and Quality, National Institutes of Health
    6. Local or regional agencies (such as state and county health departments)
    7. Non-profit health care organizations (such as the American Heart Association, American Diabetes Association, American Lung Association)
    8. Peer-reviewed periodicals and journals
    9. Consultation with doctors who are in practice and who teach at universities, work at research foundations and/or are members of recognized specialty societies.
    10. Standards of Practice for Case Management of the Case Management Society of America (CMSA).
  14. CHG reviews requests for non-formulary medicines or formulary medicines that need prior authorization as mentioned above.
  15. Once CHG has made a decision, it will notify your doctor immediately through the provider portal.  CHG will notify members in writing of the decision to deny, delay or modify the request.   

 

Continuity of care

If you now go to providers who are not in the Community Health Group network, in certain cases you may get continuity of care and be able to go to them for up to 12 months. If your providers do not join the Community Health Group network by the end of 12 months, you will need to switch to providers in the Community Health Group network.

Providers who leave Community Health Group

If your provider stops working with Community Health Group, you may be able to keep getting services from that provider. This is another form of continuity of care. Community Health Group provides continuity of care services for:

  • An acute condition

  • A serious chronic condition

  • Pregnancy (available for the duration of pregnancy and immediate postpartum care)

  • Terminal illness

Community Health Group provides continuity of care services if:

  • Member is a child from birth to 36 months of age, or,

  • Member has gotten an approval within 6 months of either the doctor contract termination or the effective date of coverage for a newly covered member, as applicable, for surgery or another procedure as part of a documented course of treatment; and,

  • The member requested the completion of care

Community Health Group does not provide continuity of care services if no agreement for completion of services is reached between Community Health Group and the non-contracted provider, Community Health Group is not obligated to provide the completion of services with the non-contracted provider. In that case, Community Health Group will cover the completion of medically necessary services with a contracted provider as needed to ensure continuity of care is not interrupted.

To learn more about continuity of care and eligibility qualifications, call Customer Service at 1-800-224-7766 (TTY users please call 1-855-266-4584 or 711).

 

IMPORTANT:

Community Health Group (CHG) does not reward doctors (practitioners) or other individuals for issuing denial of coverage or services. Financial incentives for utilization management (UM) decision makers do not encourage decisions that result in under-utilization.  CHG does not reward doctors or other decision makers for denying requested services.