1. Denial or limited authorization of a requested service, including determinations based on the type or level of service, medical necessity, appropriateness, setting, or effectiveness of a covered benefit;
2. The reduction, suspension, or termination of a previously authorized service;
3. The denial, in whole or part, of payment for a service;
4. The failure to provide services in a timely manner;
5. The failure to act within the required timeframes for standard resolution of grievances and appeals; or,
6. The denial of a beneficiary’s request to dispute financial liability.

Pre-authorization is required for the following services:

• Intensive Home Based Services (IHBS)
• Day Treatment Intensive (DT)
• Day Rehabilitation (DR)
• Therapeutic Behavioral Services (TBS), and
• Therapeutic Foster Care Services (TFCS).

Concurrent review is required for the following services:

• Psychiatric Inpatient Hospital Services
• Psychiatric Health Facility Services
• Crisis Residential Treatment Services (CRTS), and
• Adult Residential Treatment Services (ARTS)

Pre-authorization is not allowed for the following services:

• Crisis Intervention
• Crisis Stabilization
• Mental Health Services
• Targeted Case Management
• Intensive Care Coordination, and
• Medication Support Services

Retrospective Authorization may only occur in the following situations:

• Retroactive Medi-Cal eligibility determinations in accordance with California Code of Regulations Title 9 Section 1820.215;
• Inaccuracies in the Medi-Cal Eligibility Data System;
• Authorization of services for clients with other health care coverage pending evidence of billing, including dual-eligible clients; and/or
• Client’s failure to identify payer.

The designated DMH administrative divisions are responsible for reviewing all requests for authorizations of SMHS in accord with Department of Health Care Services (DHCS) mandates. Directly Operated and Contracted providers may not authorize services that require authorization unless an exception is approved by DHCS and allowed by DMH.

The designated DMH administrative divisions shall authorize SMHS that require authorization in a sufficient amount, duration, and/or scope to treat SMHS consistent with current clinical practice guidelines, principles, processes and regulatory guidelines. 

Providers have an affirmative responsibility to submit sufficient documentation in as timely a manner as possible and in accord with the applicable DHCS guidelines in order to support medical necessity and the authorization of services.

• Incomplete requests without proper documentation will not be considered.

The designated DMH administrative divisions shall not arbitrarily deny or reduce the amount, duration, and/or scope of medically necessary covered SMHS solely because of diagnosis, type of illness, or condition of the beneficiary.

Decisions to approve, modify or deny provider requests shall be communicated by the designated DMH administrative division to the affected provider, including the hospital and treating practitioner if applicable, in writing, within 24 hours of the decision.

DMH authorizing staff within the designated DMH administrative divisions must notify the requesting provider in writing and give the beneficiary written notice of any decision to deny a service authorization request, or to authorize a service in an amount, duration, and/or scope that is less than requested. The notice to the beneficiary shall meet the requirements pertaining to notices of adverse benefit determinations (NOABD) in accord with DMH Policy 200.04.

• Decisions cannot be made by the designated DMH administrative divisions based upon insufficient information submitted. Therefore, in these circumstances no action will be taken by the administrative division to approve or deny the authorization request and the request is not subject to NOABD.

Policy and procedures will be available to DHCS, DMH providers, beneficiaries and members of the public upon request.