Service Authorization Request

Healthcare Services

Your doctor can send requests for services on your behalf using one of the following three referral forms:

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 Medicare 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

Continuity of care for an out-of-network provider

As a member of Community Health Group, you will get your health care from providers in Community Health Group’s network. To find out if a health care provider is in the Community Health Group’s network, please see the provider directory published at www.chgsd.com. Providers not listed in the directory may not be in the Community Health Group network.

• You have an ongoing relationship with the out-of-network provider before enrollment in Community Health Group
• You went to the out-of-network provider for a non-emergency visit at least once during the 12 months before your enrollment with Community Health Group
• The out-of-network provider is willing to work with Community Health Group and agrees to Community Health Group’s contract requirements and payment for services
• The out-of-network provider meets Community Health Group’s professional standards
• The out-of-network provider is enrolled and participating in the Medi-Cal program

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.