LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 400.02 Authorization of Services
 
  PROCEDURES
The 24/7 toll-free ACCESS Center Hotline, 1-800-854-7771, shall be available for providers to make admission notifications and request authorization for inpatient acute psychiatric hospital services and/or to request expedited authorization of an outpatient service requiring pre-authorization.

Concurrent Review for Psychiatric Inpatient Hospital Services, Psychiatric Health Facility Services, Crisis Residential Treatment Services (CRTS) and Adult Residential Treatment Services (ARTS)
  1. Providers must submit requests for concurrent review and authorization for psychiatric inpatient hospital services, psychiatric health facility services, CRTS, and ARTS through a currently approved departmental application in accord with the DMH Organizational Provider’s Manual, Network Provider’s Manual, Policy 401.03 and/or other departmental issued bulletins, alerts, and manuals.
    1. Services beyond the initial authorization shall be reauthorized concurrently with the client’s stay based on the client’s continued need for the service.
    2. DMH Authorizing Staff shall conduct concurrent review of treatment authorizations following the first day of admission. Care shall not be discontinued until the client’s treating provider(s) has been notified of the decision and a care plan has been agreed upon by the treating provider that is appropriate to meet the needs of the client.
    3. Multiple days may be authorized based on the beneficiary’s mental health condition for as long as the services are medically necessary.
    4. For administrative day service claims, the hospital must submit evidence of at least one contact to a non-acute residential treatment facility per day (except weekends and holidays), starting with the day the beneficiary is placed on administrative day status. Once five consecutive contacts have been made and documented, any remaining days within the seven-consecutive-day period from the day the beneficiary is placed on administrative day status can be authorized. Once the five-contact requirement is met, any remaining days within the seven-day period can be authorized without a contact having been made and documented.
      1. DMH may waive the requirements of five contacts per week if there are fewer than five appropriate, non-acute residential treatment facilities available as placement options for the beneficiary. The lack of appropriate, non-acute treatment facilities and the contacts made at appropriate facilities shall be documented to include the status of the placement, date of the contact, and the signature of the person making the contact.
      2. Alternatively, administrative days may be authorized through the Intensive Care Division (ICD) waiver process consistent with the Mental Health Plan (MHP) Contract exhibit A, scope of work, number 8, Exemption from California Code of Regulations Title 9 Section 1820.220(l)(5)(b).
Pre-Authorization for Intensive Home Based Services (IHBS), Day Treatment Intensive (DT), Day Rehabilitation (DR), Therapeutic Behavioral Services (TBS), and Therapeutic Foster Care Services (TFCS)
  1. Providers must submit requests for pre-authorization for IHBS, DT, DR, TBS, and TFCS through a currently approved departmental application in accord with the Organizational Provider’s Manual, Policy 401.03 and other departmental issued bulletins and manuals.
    1. Decisions regarding authorization shall be made within five business days from the receipt of all required information for pre-authorization.
      1. If the need for the service is determined to be urgent (would jeopardize the client’s life or health or ability to attain, maintain or regain maximum functioning), the decision shall be expedited and made no later than 72 hours from the receipt of all required information for pre-authorization.
      2. DMH Authorizing Staff may extend the timeframe for making an authorization decision for up to 14 additional calendar days, if the beneficiary or the provider requests an extension or a need for additional information has been documented by DMH Authorizing Staff.
    2. Enrollment into one of the following programs also establishes initial preauthorization for IHBS:
      1. IFCCS
      2. Full Service Partnership (FSP)
      3. WrapAround
Retrospective Authorization
In the case of Retrospective Authorization as identified in the policy statements, the DMH authorization decision shall be communicated to the client who received services, or designee, within 30 days of the receipt of information that is reasonably necessary to make this determination and shall be communicated to the provider in a manner that is consistent with State requirements from California Health and Safety Code, § 1367.01(a).
  1. Administrative day service claims will be in accord with the above Concurrent Review Procedures.
Grievances and Appeals
  1. Client, or a provider and/or authorized representative, may request an appeal either orally or in writing. Appeals filed by the provider on behalf of the beneficiary require written consent from the beneficiary.
    1. DMH will provide a Problem Resolution Process to all beneficiaries who are dissatisfied with the DMH authorization decision.
    2. A physician shall be available for consultation and for resolving disputed requests for authorization.
    3. All grievances and all requests for appeals, because of a NOABD, will be recorded and resolved, to the extent possible, by the Patients’ Rights Office or other designated DMH administrative division(s).
    4. All grievances and all requests for appeals must be in accord with DMH Policy 200.04.