PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY / PROCEDURE
Policy/Procedure Number: MCUP3057 (previously UP100357)
Policy/Procedure Title: Provider Appeals of Health Services
Administrative Denials
Lead Department: Health Services
☒External Policy
☐ Internal Policy
Next Review Date: 11/18/2016
Last Review Date: 11/18/2015
Original Date: 02/20/2002
Applies to:
☒ Medi-Cal
☐ Healthy Kids
☐ Employees
Reviewing
Entities:
☒ IQI
☐P&T
☒ QUAC
☐ OPERATIONS
☐ EXECUTIVE
☐ COMPLIANCE
☐ DEPARTMENT
☐ BOARD
☐ COMPLIANCE
☐ FINANCE
☒ PAC
Approving
Entities:
☐ CEO
☐ COO
☐ CREDENTIALING
Approval Signature: Robert Moore, MD, MPH
☐ DEPT. DIRECTOR/OFFICER
Approval Date: 11/18/2015
I.
RELATED POLICIES:
A. MCUP3041 TAR Review Process
B. MCUP3124 Referral to Specialists (RAF)
C. MCUG3024 Inpatient Utilization Management
II.
IMPACTED DEPTS:
A. Health Services
B. Claims
C. Member Services
III.
DEFINITIONS:
A. N/A
IV.
ATTACHMENTS:
A. N/A
V.
PURPOSE:
To define Partnership HealthPlan of California (PHC) Health Services departmental policy regarding
administrative denials and other avenues available to providers for resolution of issues.
VI.
POLICY / PROCEDURE:
A. Administrative denials are NOT subject to the provider appeals process.
B. If a provider has received an administrative denial and they believe the information is incorrect, they
should submit a NEW TAR to the Health Services department with the required documentation, within
the timeframes defined for submission, so that the TAR may be processed.
1. The following are reasons that an administrative denial is issued by the Health Services Department:
a. Member is not currently eligible/or was not eligible with PHC at the time of service.
b. Member has other health insurance and the primary carrier is responsible for the service
requested.
c. TAR NOT received timely. Please refer to the PHC policies MCUP3041 TAR Review Process
and MCUP3124 Referral to Specialists (RAF). NO exceptions are made to the policies.
d. Share of Cost (SOC) - It is the provider’s responsibility to clear the share of cost. Members
have no eligibility with PHC UNTIL their SOC has been satisfied.
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Policy/Procedure Number: MCUP3057 (previously
Lead Department: Health Services
UP100357)
☒ External Policy
Policy/Procedure Title: Provider Appeals of Health Services
Administrative Denials
☐ Internal Policy
Next Review Date: 11/18/2016
Original Date: 02/20/2002
Last Review Date: 11/18/2015
Applies to: ☒ Medi-Cal
☐ Healthy Kids
☐ Employees
e.
f.
Other provider must authorize service requested. PHC has delegated other entities to authorize
services for members assigned to them. The appeal is to be directed to the other provider if the
service is delegated to another entity.
Requested documentation/information and or Medical Records were not received timely. Per
PHC policy, providers have 14 days to submit requested additional documentation.
C. If a provider incorrectly submits a TAR on a PHC member to the Medi-Cal field office, PHC applies
timeliness requirements to that request. If the member was eligible with PHC at the time of the request,
TARs submitted beyond the 15 working day requirement are denied for lack of timely submission. If the
member was retroactively granted eligibility with PHC, then the provider must submit the authorization
to PHC within the 60 days of PHC eligibility.
D. If a member has other health coverage and that coverage denies the service and PHC requires a TAR for
the services, the provider must submit evidence of the denial along with a new TAR to the PHC
Utilization Management department within 60 days of the date of the denial by the other carrier for
review and approval.
VII.
REFERENCES:
A. N/A
VIII.
DISTRIBUTION:
A. PHC Provider Manual
B. PHC Department Directors
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services
X.
REVISION DATES: 08/20/03; 09/15/04; 09/21/05; 10/18/06; 10/17/07; 10/15/08; 11/18/09; 05/18/11;
02/20/13; 11/18/15
PREVIOUSLY APPLIED TO:
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In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with
involvement from actively practicing health care providers and meets these provisions:



Consistent with sound clinical principles and processes
Evaluated and updated at least annually
If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be
disclosed to the provider and/or enrollee upon request
The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar
illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits
covered under PHC.
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