CMISP Appeal Process


When a requested medical services is denied by Medical Case Management, the patient is informed of the appropriate due process available to him/her. A copy of the service denial notification is also sent to the requesting provider. If the patient chooses to appeal the service denial, he/she 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. The letter must state that he/she is requesting an appeal and why he/she is dissatisfied. The patient is encouraged to submit additional medical information to substantiate the medical reason for the requested medical service.

FILING THE APPEAL:
If the request for specialty service has been reviewed and denied by the CMISP Medical Director, and your are dissatisfied with the action taken regarding the requested medical service, you have the right to appeal that decision. If you choose to appeal the service denial, you must request a review of that decision, in writing, within TEN (10) WORKING DAYS of the denial letter from Medical Case Management. You must state that you want to appeal the denial decision and tell why you are dissatisfied. The address is as follows:

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

MEDICAL INFORMATION:
You are encouraged to submit additional medical information to substantiate the medical reason for the requested medical service. If getting the medical information will require more than the ten (10) working days allowed, you must request a time extension at the time you file your appeal (within the ten working days from the date of the denial notification). You may request an extension of up to 30 calendar days. You are responsible for submitting the additional medical information within the time limit. Your appeal will not be reviewed until the requested time extension has expired.

LATE FILING:
If you do not file an appeal request within the above time period, the 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 appeal request from being made.

REVIEW PROCESS:
Upon receipt of the appeal review request, and once any additional medical information has been received or the time extension has expired (whichever happens first) an appeal physician reviewer will review the request to determine whether the requested service is within the CMISP Scope of Services as approved by the Sacramento County Board of Supervisors and whether the requested medical service is medically necessary and appropriate.

APPROVAL:
If the determination is to approve the appealed medical specialty service, the denial is reversed and the service will be authorized and scheduled by CMISP Medical Case Management.

DENIAL:
If the determination is to deny the appealed medical specialty service, you will be advised by Medical Case Management with a justification for the denial. If you are dissatisfied with the action taken, refer to the Medical Specialty Service Appeal Process-Second Level Appeal.

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ADDITIONAL APPEALS PROCESSES


 
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