CMISP Administrative Appeal


FILING THE ADMINISTRATIVE APPEAL:
If your appeal has been denied based on an administrative decision and you are dissatisfied with the action taken, you have the right to appeal that decision. If you choose to appeal the administrative denial, you must request a review of that decision in writing within TEN (10) WORKING DAYS of the date of the denial letter from Medical Case Management. You must state that you want to appeal the administrative denial decision and tell why you are dissatisfied. The address is as follows:

CMISP Medical Case Management
4600 Broadway, Suite 2500
Sacramento, California 95820
Attention: Appeals

ADMINISTRATIVE DOCUMENTATION:
You must submit information and verification to substantiate the reason your administrative appeal should be re-considered. REMINDER: At this time, the medical merits of your appeal cannot be considered due to the administrative denial decision. If getting the necessary verification will require more than the ten (10) working days allowed, you must request a time extension at the time you file your appeal of the administrative decision (within the ten working days of the administrative denial notification). You may request an extension of up to 30 calendar days. You are responsible for submitting the additional verification within the time limit. Your second level administrative appeal will not be reviewed until the requested time extension has expired.

LATE FILING:
If you file an administrative appeal request after the above time period, the administrative appeal will be denied unless it is found that good cause prevented your making a timely request. You must submit verification that the good cause (such as serious illness, hospitalization, incarceration, or similar reasons) prevented a timely administrative appeal request from being made.

REVIEW PROCESS:
Upon receipt of the administrative appeal review request, and once any additional information and/or verifications have been received or the time extension has expired (whichever happens first) a Department of Health and Human Services Deputy Director will review the requested review on administrative grounds.

APPROVAL:
If the determination is to approve the administrative appeal, the medical appeal will be sent to the appropriate medical professional for medical review.

DENIAL:
If the determination is to deny the administrative appeal, you will be advised by Medical Case Management with a justification for the denial.

The decision of the Department of Health and Human Services Deputy Director is the final decision. There is no further appeal available.


 
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