Required Elements for Member Notification Letters
- Participating Physician Groups (PPG)
Communications regarding decisions to approve requests must state the specific health care service approved. The notice of action (NOA) letters, developed by the California Department of Health Care Services (DHCS) as required by SB 59 (1999, Chapter 539), are to be used when notifying Medi-Cal managed care members of service authorization decisions. Refer to the Industry Collaboration Effort (ICE) website at www.iceforhealth.org/library.asp to view the NOA templates located under Approved ICE Documents.
Member notification letters indicating a denial, delay modification or termination of service must include:
- A clear and concise explanation of the reasons for the decision
- A description of the criteria or guidelines used, including a citation of the specific regulations or participating physician group (PPG) authorization procedures supporting the action
- The clinical reasons for the decisions regarding medical necessity
- Member rights information
PPGs may use the ICE NOA templates for provider notifications, in which case the NOAs are modified to include the name and direct telephone number of the health care professional responsible for the decision to deny, delay, modify, or terminate requested services.
Member notification letters to Medi-Cal managed care members are subject to additional requirements following the decision by the federal district court in Jackson v. Rank (E.D.Cal.1986).
In addition to the requirements stated above, member notification of deferral, denial, modification, or termination of requests for prior authorization for payment of services must inform the member of the following:
- The member's right to, and method for obtaining, a state hearing to contest the denial, deferral or modification action
- The member's right to self-representation at the state hearing, or to be represented by legal counsel, friend or other spokesperson
- The action taken by Health Net or PPG on the request for prior authorization and the reason for such action, including the underlying contractual basis or Medi-Cal authority
- Health Net's name and address of the health plan and the state toll-free telephone number for obtaining information on legal service organizations for representation
The ICE NOA template includes the required DMHC statement. Providers may also refer to the DMHC Required Statement for additional requirements.