Required Elements for Member Notification Letters
Provider Type
- Participating Physician Groups (PPG)
- Hospitals
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 adverse service authorization decisions. Refer to the Healthcare Industry Collaboration Effort (HICE) 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:
Approvals
- Specify the health care service/s approved
Denials/Modifications
- The decision to deny or modify the request.
- Clear and concise explanation of the reasons for the decision
- A description of the criteria or guidelines used, including a reference to the specific regulation or authorization procedure(s), that supports the decision, as well as an explanation of the criteria or guidelines.
- If the decision was based on medical necessity, the NOA must include a reference to the clinical criteria that has not been met.
- If the denial is related to a member who has a terminal illness, a description of alternative treatment, drug, services or supplies covered by the Plan, if any.
- Notification that the member can obtain a copy of the actual benefit provision, guideline, protocol or criteria on which the denial decision was based.
- Notification to the member that if a medical or vocational expert’s advice was obtained related to their case, they may be provided the identity of these experts, upon request.
- Additional information as required by state or federal regulations including Member “Your Rights" under Medi-Cal Managed Care, Nondiscrimination Notice and Notice of Availability .
- “Your Rights” attachment.
Delays/Deferrals
- The decision to delay or defer the request due to missing information or the need for a same specialty review.
- Specify the additional information requested; requesting only that information which is reasonably necessary to make a decision.
- Provide the anticipated date of decision.
- “Your Rights” attachment.
- PPGs may use the HICE 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.
Additional Requirements
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
If the member’s preferred language is one of the threshold languages in the county of residence, then the NOA must be fully translated at the time of decision per DHCS APL 21-011. The HICE NOA template includes the required DMHC statement. Providers may also refer to the DMHC Required Statement for additional requirements.