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California Medical Necessity Review Process – Mental Health

Licensed nurses perform the initial clinical review for pre-service, concurrent and/or post service/retrospective requests consistently using clinical review criteria to determine medical necessity of the mental health care services. All requests that cannot be certified through an initial review are sent to a clinical peer for determination. The reviewer will request only information reasonably necessary to make a determination.

In the case of a review of pre-service or concurrent care, the decision not to approve the service based on medical necessity will be made within 5 business days of receipt of information reasonably necessary to perform the review. A decision regarding services that have been completed will be made within 30 days of receipt of information reasonably necessary to perform the review. Expedited reviews will be performed when the insured’s condition is such that they face an imminent and serious threat to his or her health or could jeopardize the insured’s ability to regain maximum function. An expedited review determination will be completed within 72 hours of receipt of information reasonably necessary to perform the review. The decision will be communicated verbally, by fax or email within 24 hours to the provider and in writing within 2 business days to the insured. Notifications will provide an explanation of the reasons for the decision, a name and number to contact for questions and instructions on how to file an appeal.

In the case of a concurrent review, care shall not be discontinued until the treating provider has been notified of the insurer’s decision and a care plan has been agreed upon with the treating provider that is appropriate for the medical needs of the patient.

The information provided to you is a guideline used by this insurer to authorize, modify, or deny health care benefits for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your insurance plan.

Click here for the Golden Rule Insurance Company California Grievance Procedures.