22-440m Submit Request for a Withdrawal or Dismissal Using Member Notification Templates
Date: 06/10/22
This information applies to Participating Physician Groups (PPGs).
Use the new member notification templates to request that an authorization be withdrawn or dismissed
Effective January 1, 2022, the Centers for Medicare and Medicaid Services (CMS) released new guidelines on handling a request to withdraw or dismiss an authorization request. CMS believes that this change will reduce confusion and promote consistent and proper handling of withdrawals and dismissals.
Withdrawal vs dismissal
- Withdrawal – A withdrawal of a request is when the party that initiated the request voluntarily decides that a decision on their request is no longer needed, and the party communicates that desire to the plan (or delegate) to stop consideration of the request for determination (or reconsideration).
- Dismissal – A dismissal of a request is when a plan (or delegate) decides to stop consideration of a request before issuing a decision.
Use approved notification templates
CMS requires the use of a standard templates to notify the requestor of the decision to approve a withdrawal or dismissal. The templates vary by line of business and scenario. The templates can be found on Health Industry Collaboration Effort (HICE) > Library> Approved HICE Documents> UM Templates & Tools.
When should a request be withdrawn or dismissed?
Requests for a withdrawal or dismissal can be submitted verbally or in writing. The following four scenarios are the only times a withdrawal or dismissal should be executed.
Type | Scenario |
|---|---|
Dismissal | The individual or entity making the request is not permitted to request an organization determination and there is no appointment of representation (AOR) form. |
The Medicare Advantage (MA) organization determines the party failed to make a valid request for an organization determination. | |
An enrollee or the enrollee's representative files a request for an organization determination, but the enrollee dies while the request is pending, and both of the following apply: a. The enrollee's surviving spouse or estate has no remaining financial interest in the case. b. No other individual or entity with a financial interest in the case wishes to pursue the organization determination. | |
Withdrawal | A party filing the organization determination request submits a timely request for withdrawal of their request for an organization determination with the MA organization. |
Report withdrawals and dismissals in your data submissions
Providers should report withdrawals and dismissals as part of your monthly source data submissions to Health Net on the standard Medicare template (ODAG_OD) or Cal MediConnect template (SARAG_MSAR). These options are available in your data dictionary. Under the “Request Determination” field, there will be an option for “withdrawal” and “dismissed.”
For more information on reporting withdrawals and dismissals, refer to your Medicare or Cal MediConnect reporting templates.
Additional information
Providers are encouraged to access Health Net’s provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center within 60 days.
Medicare (individual & employer group)
(Wellcare By Health Net) - 800-929-9224
Cal MediConnect
Los Angeles County – 855-464-3571
San Diego County – 855-464-3572