Second Level Out Patient Hospital Emergency Appeal Process


FILING THE SECOND LEVEL APPEAL:
If your first level out-patient medical service was 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
9616 Micron Avenue, Suite 670
Sacramento, California 95827
Attention: Appeals

MEDICAL INFORMATION:
You are encouraged to submit additional medical information to substantiate the medical necessity for the out-patient 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 the appeal (within ten working days of the denial notification letter). 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 in your written appeal letter. Your appeal will not be reviewed until the requested time extension has expired.

LATE FILING:
If you do not file a second level appeal request within 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 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) an independent medical consultant in the community will be authorized to review all of the available medical information to determine whether the condition treated at the hospital emergency department met the CMISP definition of emergency.

APPROVAL:
If the determination is to approve the appealed out-patient emergency department service, the denial is reversed and the service will be authorized by CMISP Medical Case Management. Both you and the hospital will be notified of the approved service status.

DENIAL:
If the determination is to deny the second level appealed outpatient emergency department service, you will be advised by Medical Case Management with a justification for the denial. The decision at the second level appeal is the final decision. There is no further appeal available.


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