County of Sacramento
Department of Health and Human Services
Division of Behavioral Health Services
Policy and Procedure
Policy Issuer
(Unit/Program)
Policy Number
Effective Date
Access
02-06
10-24-14
Revision Date
Title:
Functional Area:
Notices of Action
Access
Approved By: Signed version available upon request
Melissa Jacobs, LCSW
Health Program Manager
Kelli Weaver, LCSW
Health Program Manager
Background/Context:
Notices of Action (NOA) are written notifications required by the State Department of Health
Health Care Services (DHCS) and the California Code of Regulations (CCR) Title 9 §
1850.210, Title 22 § 51014.1 and Code of Regulations (CFR) Title 42, Part 438, Subpart F.
The notifications advise Medi-Cal recipients (hereafter referred to as beneficiaries) of their
rights and informs them when the Sacramento Mental Health Plan (MHP) denies mental
health services following assessment; denies or changes a provider’s request for authorization
of payment of services that have not been delivered;or denies authorization for payment to a
provider who has already provided services, when the MHP fails to resolve a grievance or
appeal on time or does not provide timely services.
Purpose:
The purpose of this policy and procedure is to ensure that the Sacramento County MHP is
in compliance with issuing NOA documents as required by DHCS.
Definitions:
NOA – A (Assessment) This notice is used when the MHP or its provider assesses a
Medi-Cal beneficiary and determines that the beneficiary does not meet medical necessity
criteria and specialty mental health services will not be provided.
NOA – B (Denial of Services) This notice is used when a provider requests payment
authorization for a specialty mental health services and the MHP denies or modifies the
provider’s request when the beneficiary did not receive the service.
NOA – C (Post-Service Denials) This notice is used when a provider requests payment
authorization for a specialty mental health service and the MHP denies or modifies the
provider’s request when the beneficiary already received the service. This form reads “this
is not a bill” so that the beneficiary knows that s/he is not responsible for the cost of the
service rendered but then retrospectively denied or modified.
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NOA – D (Delayed Grievance/Appeal Decision) This notice is used when the MHP does
not provide the resolution of a grievance, appeal, or expedited appeal with the required
timeframes.
NOA – E (Lack of Timely Services) This form is used when the MHP does not provide
services in accordance with their own standards for timely services.
Details:
1.
NOA-A. The Access Team will be responsible for the issuance of the NOA-A.
a. A NOA-A will be issued to the beneficiary or authorized representative when it is
determined through a screening assessment the beneficiary is not eligible for
services or does not meet specialty mental health criteria.
b. Evidence to support denial will be documented in Avatar.
c. The beneficiary will be notified of the decision regarding services and told they
will receive a NOA-A, which defines the reasons for denial and the process of
appeal
d. The NOA-A will be hand delivered on the date of the action or mailed to the
beneficiary and provider (as appropriate) within 3 working days of the medical
necessity decision.
e. A copy of the NOA-A will be retained in a central file according to record retention
policies.
2.
NOA-B. The Access Team will be responsible for the issuance of the NOA-B.
a.
When a provider contacts the Access Team to authorize new services or continuing
services and this request cannot be honored, A NOA-B is completed and the original
is sent to the Provider and a copy is sent to the beneficiary.
b. A NOA-B will be issued to the provider and beneficiary or authorized
representative when the provider requests payment authorization for new services
or continuing mental health services and the request cannot be honored. A NOAB is issued under the following circumstances:
i. The provider is not contracted with the MHP.
ii. The documentation for an initial or reauthorization does not support the
need for the level of care requested and the requested service is denied
or modified.
iii. The provider fails to respond to the MHP’s request for more information
when needed to process the provider’s request for reauthorization, within
the 30-day timeframe.
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iv. The provider’s existing authorization is reduced or terminated by the MHP.
c. Before issuance, the designated Access Quality Assurance Clinician will review
the NOA-B for clinical appropriateness.
d. The NOA-B will be hand delivered on the date of the action or mailed to the
beneficiary and provider within 3 working days of the decision to modify, deny,
reduce or terminate services previously authorized.
e. The NOA-B is not required when the MHP modifies the duration of any approved
mental health service as long as the provider requests MHP payment
authorization for additional services before the end of the authorization period for
services.
f.
3.
A copy of the NOA-B will be retained in a central file.
NOA-C. The Inpatient Utilization case mangers and the Access Team will be
responsible for the issuance of the NOA-C.
a. The Utilization Case Managers will issue a NOA-C to the beneficiary or
authorized representative and Provider, when a Provider requests payment for
an unauthorized hospitalization.
b. The Access Team will issue a NOA-C to the beneficiary or authorized
representative and Provider, when a Provider requests payment for an
unauthorized outpatient service.
c. A copy of the NOA-C will be retained in a central file.
4.
NOA-D. The Quality Management Problem Resolution/ State Fair Hearing Staff will
be responsible for the issuance of the NOA-D.
a. The Problem Resolution/ State Fair Hearing staff will send a NOA-D to the
beneficiary or authorized representative and Provider, when the following occurs:
i. Grievance: The issue is not resolved within 60 days from the date of the
receipt of the grievance. If a 14-day extension has been granted, the
NOA-D will not be issued until the 74th day if the issue remains
unresolved.
ii. Standard Appeal: The issue is not resolved within 45 days from the
receipt of the appeal. If a 14-day extension is granted the NOA-D will not
be issued until the 59th day, if the issue remains unresolved.
iii. Expedited Appeal: The issue is not resolved within 3 working days. The
beneficiary will first, if possible, be contacted by telephone and written
notice sent by mail.
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b. The Problem Resolution/ State Fair Hearing staff will retain a copy of the NOA-D
in a central file.
5.
NOA-E. The Access Teams will be responsible for the issuance of the NOA-E
a.
A NOA-E is issued when the MHP does not provide services in a timely
manner according to their own standards for timely services
b.
A copy of the NOA-E will be retained in a central file.
State Fair Hearings:
The MHP shall inform the beneficiary or beneficiary representative of the right to file an Appeal
with the MHP Problem Resolution Process (see PP-BHS-QM-03-01 Problem Resolution ). A
beneficiary may request a State Fair Hearing, regardless of whether a NOA has been received,
when the beneficiary has exhausted the problem resolution process. Assistance in completing
the State Fair Hearing form shall be provided, when needed. Whenever possible, the
beneficiary will be informed verbally, in their primary language, of the contents of the written
notice.
1.
Beneficiary must request a State Fair Hearing within 90 calendar days of receipt of the
NOA to appeal the decision.
2.
Beneficiary requesting a hearing within 10 calendar days of notification or before the
effective date of the change whichever is later, may under certain circumstances continue
receiving services while the hearing is pending.
3.
Detailed instructions for filing a State Fair Hearing are located on the back of each NOA.
Aid (Services) Paid Pending the Outcome of a Fair Hearing:
Beneficiaries receiving a NOA-B, which reduces or terminates an existing authorization in some
circumstances may continue receiving services, pending the outcome of a fair hearing. The
appeal must be filed or called into DMH within10 days of receipt of the NOA-B or before the
effective date of the change, whichever is later.
Related Policies:
PP-BHS-QM-02-01 Notices of Action
PP-BHS-QM-03-01 Problem Resolution
Distribution:
Enter
X
DL Name
Enter
X
DL Name
X
Mental Health Staff
X
Mental Health Service
Providers
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Contact Information:
Kathy Burlingame, MFT, Access Program Coordinator, 916 876-5541,
[email protected]
Cosette Telesford, LCSW, Access Program Coordinator, 916 874-9403,
[email protected]
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