I.  PURPOSE
 

To provide a process that allows for a formal system of resolving disputes between Los Angeles County Department of Mental Health, the local Mental Health Plan (MHP) and contracted Los Angeles County Medi-Cal managed care plans (MCPs) when traditional communications are unable to resolve disputes.

This policy also clarifies the requirement that medically necessary services will not be delayed during this dispute process.  This policy is aligned with the State of California, Department of Health Care Services, Behavioral Health Information Notice:  21-034 Dispute Resolution Process.

Contracted agencies shall develop an internal policy and associated procedures that are consistent with their organizational practices and meet the requirements set forth in this policy. 
 

II.  DEFINITIONS
 

Managed Care Plan (MCP): State contracted health plan that delivers Medi-Cal benefits to enrollees under a managed care network of providers. 

Member: An eligible Medi-Cal beneficiary who is enrolled in a Medi-Cal Managed Care Plan (MCP).

Mental Health Plan (MHP):  A county Mental Health Plan that is responsible for providing specialty mental health services

Routine Dispute: A formal disagreement between a Medi-Cal MCP and the County MHP regarding the provision of and/or payment for mental health services that has not been resolved through informal measures and occurs when either plan makes a formal written request for a Plan Level Routine Dispute Resolution and/or Department of Health Care Services (DHCS) Routine Dispute Resolution.

Expedited Dispute Resolution Process: When dispute resolution is required within one business day because the Medi-Cal MCP and the MHP determine that the Routine Dispute Resolution timeframe would result in serious jeopardy to the Member’s life, health, or the ability of the Member to attain, maintain or regain maximum function.

Plan Level Dispute Resolution: Good faith efforts, which shall include a meeting to remedy coverage disputes, as formally communicated via written notice by either MCP or MHP to the other party.

Request for Resolution: MHP’s written request to Department of Health Care Services (DHCS) for aid in resolving a dispute between MHP and MCP when the dispute cannot be rectified via the Plan Level Dispute Resolution process.
 

 

1. Guiding Principles:
   1. Emphasis on Timely, Collaborative Resolution
      1. MHP staff will make a good faith effort to agree to resolutions that are in the best interest of Members and are agreeable to all parties involved.
      2. Proactive and timely communication is expected between MHP and MCP.
2. Plan Level Dispute Resolution process is outlined in this policy and referenced in MHP and MCP MOUs:
   1. Regardless of MOU status, MHP shall seek to informally remedy a dispute through discussion and dialogue with MCP. MHPs and MCPs must complete the Plan Level Dispute Resolution process within fifteen (15) business days of identifying the dispute. If the dispute cannot be resolved during that time frame, either the MHP or the MCP must submit a written "Request for Resolution" to DHCS within three (3) business days.
   2. Members will continue to receive medically necessary services while the dispute is being resolved.
   3. The MHP Health Plan Operations team will maintain records of Plan Level Dispute Resolutions consistent with applicable MHP record retention policy.
   4. The Expedited Dispute Resolution Process as outlined in Section 9 below will be followed if a Member has not received disputed services and MHP or MCP determine that the Routine Dispute Resolution timeframe would result in serious jeopardy to the Member’s life, health, or the ability of the Member to attain, maintain or regain maximum function.
3. DHCS Dispute Resolution Process:
   1. The parties are required to document attempts to resolve the disputed issue(s), including results of the Plan Level Dispute Resolution.
   2. If MHP and MCP are unable to resolve a dispute at the Plan Level, MHP or MCP may submit a written Request for Resolution to DHCS signed by the MHP/MCP designee. The Request for Resolution must be submitted within three (3) business days from the completion of the Plan Level Dispute Resolution process that did not result in a satisfactory resolution. A Request for Resolution should be submitted via secure email to the DHCS Managed Care Quality and Monitoring Division (MCQMD), at MCQMD@dhcs.ca.gov.
   3. A Request for Resolution submitted to DHCS must contain all of the following:
      1. Summary of disputed issue(s) and a statement of the desired remedies, including any disputed services that have been or are expected to be delivered to the beneficiary by either party;
      2. History of attempts to resolve the issue with the other party;
      3. Justification for requesting party's desired remedy: and
      4. If applicable, any additional documentation that MHP or MCP deems relevant to resolve the disputed issue(s).

                      The Request for Resolution must be submitted via secure email to CountySupport@dhcs.ca.gov.

4. Within three (3) business days after DHCS’ receipt of a Request for Resolution from MHP or MCP, a copy of the Request for Resolution will be forwarded by DHCS to the other party via secure email (“Notification”).
   1. Both parties will have three (3) business days to submit a response and any relevant documents to support their position; and
   2. If the responding party fails to respond within three (3) business days, DHCS will decide on the disputed issue(s) based solely on the documentation submitted by the requesting party.
5. At its discretion, DHCS may allow both MHP and MCP representatives the opportunity to present oral arguments.
6. Within 20 business days from the third business day of the Notification date, DHCS will issue its final decision and communicate it via secure email to both MHP’s Health Plan Operation Program Manager, or their designee, and MCP Designee.
   1. DHCS’ decision will state the reasons for the decision, the determination of rates of payment (if rates of payment were disputed), and any actions MHP and MCP are required to take to implement the decision.
   2. If DHCS’ dispute resolution determination includes a finding that the unsuccessful party has a financial liability to the other party for services rendered by the successful party, MHP or MCP is required to follow the financial liability criteria outlined in the resolution determination, which specify the provisions regarding financial liability rates and proof of reimbursement.
      1. If necessary, DHCS shall enforce the decision, including withholding funds to meet any financial liability established.
7. The provision of medically necessary specialty and other mental health services, physical health care services, or other services shall not be delayed during the dispute.
8. Expedited Dispute Resolution Process
   1. Either MHP or MCP may seek to enter an Expedited Dispute Resolution Process if a Member has not received a disputed service(s) and MHP or MCP determine that the Routine Dispute Resolution timeframe would result in serious jeopardy to the Member’s life, health, or the ability of the Member to attain, maintain or regain maximum function.
   2. Under this process both MHP and MCP will have one (1) business day to resolve the dispute at the Plan Level.
   3. If MHP and the MCP fail to resolve an Expedited Dispute within one business day, each party must file a Request for Resolution with DHCS, within one (1) business day. The request must include an affirmation of the Member’s stated jeopardy.
   4. If either plan fails to submit a Request for Resolution and/or documentation to DHCS, DHCS will base its decision based upon the documentation submitted.
   5. DHCS will render a decision within one (1) business day upon receipt of said request.
9.  In order to ensure there is no delay in the provision of medically necessary services to a Member during a dispute, the following actions will apply:
   1. When the dispute concerns MHP's contention that MCP is required to deliver physical health care-based treatment of a mental illness, or to deliver prescription drugs or laboratory, radiological, or radioisotope services required to diagnose or treat the mental illness, MHP shall be responsible for providing or arranging and paying for those services to the beneficiary until the dispute is resolved.
   2. When the dispute concerns MCP’s contention that MHP is required to deliver specialty mental health services to a beneficiary either because the beneficiary's condition would not be responsive to physical health care-based treatment or because MHP has incorrectly determined the beneficiary's diagnosis to be a diagnosis not covered by MHP, MCP shall manage the care of the beneficiary under the terms of its contract with the State until the dispute is resolved.
10. Delegation of Plan Level Dispute Resolution
    1. MHP does not delegate the responsibility of MCP and MHP dispute resolution, including the handling of Plan Level Dispute Resolution, to any Subcontractor and as such, is directly responsible for facilitating the Plan Level Dispute Resolution.
    2. Where MHP has delegated responsibility for the provision of Covered Services, consistent with its DHCS Medi-Cal managed care contract, MHP may seek data, documentation, and information from Subcontractors in order to support satisfactory dispute resolution.

IV.  PROCEDURES
 

There are no procedures associated with this policy.

 

V.  AUTHORITIES
 

VI.  ATTACHMENTS
 

No attachments are associated with this policy.