CMISP Second Level Medical Specialty Service Appeal


Filing the Second Level Appeal:
If your first level appeal has been denied and you are dissatisfied with the action taken, you have the right to appeal that decision. If you choose to appeal the first level appeal 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 first level 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

MEDICAL INFORMATION:
You are encouraged to submit additional medical information to substantiate the medical need 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 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. You may choose a face-to-face informal hearing with the medical specialist to provide additional information. Please include this request your written appeal letter. Your second level appeal will not be reviewed until the requested time extension has expired.

LATE FILING:
If you file a second level appeal request after the above time period, the second level 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 second level appeal request from being made.

REVIEW PROCESS:
Upon receipt of the second level appeal review request, and once any additional medical information has been received or the time extension has expired (whichever happens first) a medical specialist will be selected and authorized by CMISP to review the medical service request. The specialist will determine whether the requested service is within 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 second level appeal, you will be advised by Medical Case Management with a justification for the denial.

The decision of the medical specialist is the final decision. There is no further appeal available.


 
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